Meadowbrook Manor: Missed Doses, No Alerts - OH
The resident, identified in inspection records as Resident 51, was admitted to the facility in October 2025 while being treated for C-difficile, a bacterial infection that can cause severe intestinal damage and, in vulnerable patients, death. He had been prescribed fidaxomicin, taken by mouth twice a day for five days. His last dose before admission had been given at the hospital on the morning of October 16.
He never received that evening's dose. Or the next morning's. Or that evening's. Or the following morning's.
Four missed doses. No alert to his physician. No documentation that anyone had noticed.
The Regional Nurse, the Director of Nursing, and the Infection Control nurse all confirmed the gaps during an interview with inspectors on April 21. They verified the facility had no documentation that Resident 51's primary care physician had been told about the missed doses at any point, until the resident's daughter grew alarmed and asked that he be taken to the ER.
The administrator told inspectors the facility should have been prepared before admitting him, including knowing the cost of his medication and ensuring it could be given on time. She said she had not known about the missed doses until the daughter raised the alarm.
A second resident's case followed a similar pattern, with a different cause.
Resident 39, a woman with chronic obstructive pulmonary disease, schizoaffective disorder, and bipolar disorder, was examined on March 27 by a nurse practitioner who found sinus pressure, nasal congestion, and an acute cough. The nurse practitioner ordered Augmentin, an antibiotic, twice a day for seven days, and documented the order in her progress note that same afternoon.
The facility did not act on it.
An order was eventually written the next morning, March 28, and entered into the medication administration record. But the spaces for the March 28 morning and evening doses are blank. So are the spaces for March 29, morning and evening. Resident 39 did not receive her first dose of Augmentin until March 30, two full days after the order was written and three days after the nurse practitioner had documented the need.
When inspectors asked the Director of Nursing and the Infection Control nurse to explain, they said the nurse practitioner had put the order in her progress note on March 27 but "the facility was not aware." They then pointed to the weekend staffing arrangement: Meadowbrook Manor routinely fills weekend shifts with agency nurses, and those agency nurses do not have access to the facility's emergency medication box, which contains common antibiotics including, as it turned out, Augmentin.
The Augmentin was in the box the entire time. The agency nurses either did not know to check, did not contact the pharmacy, or did not follow through. The Director of Nursing told inspectors the lapse was "most likely because it was the weekend."
Resident 39 told inspectors she had no concerns about how her medications were handled. She was not aware of the gap.
The facility's own medication policy, in place since 2001, requires medications to be administered in a safe and timely manner as prescribed, within one hour of the scheduled time unless a physician specifies otherwise. Inspectors noted the policy contains no requirement to notify a physician when doses are withheld or missed.
That gap in the policy is part of what inspectors found: no mechanism requiring staff to tell a doctor when a patient stops receiving a prescribed medication. In Resident 51's case, the C-diff treatment window was five days. He lost nearly two of them before anyone with authority to act even knew.
His daughter knew. She was the one who made the call.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowbrook Manor from 2026-04-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
MEADOWBROOK MANOR in FOWLER, OH was cited for violations during a health inspection on April 28, 2026.
He had been prescribed fidaxomicin, taken by mouth twice a day for five days.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.