Three Meadows Post Acute

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

notified of the x-ray results of the right ankle.Review of the nurse's notes, physician orders, and medication administration record (MAR) for 10/06/25 revealed no documentation the resident had received the intravenous fluids per physician orders. There was also no documentation the physician was notified the intravenous fluids had not been administered. Interview on 12/03/25 at 9:07 A.M., Unit Manager Licensed Practical Nurse (UMLPN) #102 verified there was no documentation Resident #05's representative had been notified of the x-ray results for the right ankle. UMLPN #102 verified there was no documentation the IV had been administered per physician orders. Further interview with UMLPN #102 revealed she was unable to obtain IV access. UMLPN #102 verified there was no documentation of the unsuccessful attempt to initiate the IV and no documentation the physician was notified.Review of the policy Change in a Resident' Condition or Status, revised 02/2021, revealed the facility would promptly notify the attending physician of a need to alter the resident's medical treatment. This deficiency represents non-compliance investigated under Complaint Number 2677336.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Three Meadows Post Acute

10540 Fremont Pike Rd Perrysburg, OH 43551

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, review of the medical record, resident interview, staff interview, and policy review. The facility failed to ensure surgical wound care was completed per physician orders. This affected one resident (#43) of three residents reviewed for wound care. The facility identified five residents with surgical wounds. The facility census was 83. Review of the medical record for Resident #43 revealed an admission date of 09/10/25 and a readmission date of 10/23/25. Diagnoses included pneumonia, anxiety, and surgical aftercare following surgery of the digestive system.Review of the admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had intact cognition. Review of the physician orders dated 11/18/25 revealed the resident had a surgical wound to the right upper quadrant mid abdomen. The orders were to cleanse the wound with wound cleanser, pat dry, apply skin prep to the skin surrounding the wound, apply the antibacterial dressing and foam, change three times per week on Tuesdays, Thursdays, and Saturdays, and as needed. Review of the nurses' notes from 11/21/25 through 11/25/25 revealed no documentation the resident had refused wound care. Review of the Treatment Administration Record (TAR) dated 11/01/25 through 11/25/25 revealed the wound care treatment to the abdomen had been documented as completed on 11/22/25. Interview on 11/25/25 at 1:25 P.M., Resident #43 revealed the facility had not completed the wound care to her surgical wound since the previous week. Resident #43 revealed she had asked the nurse to change the dressing on Saturday 11/22/25 but the nurse never returned to complete the dressing change. Resident #43 also revealed she had to request every week for dressing for her PICC (Peripherally Inserted Central Catheter) line to be changed or it would not have gotten done.Observation on 11/25/25 at 1:25 P.M. of Resident #43's abdominal wound dressing revealed

the dressing was dated 11/20/25. Interview on 11/25/25 at 1:36 P.M., the Assistant Director of Nursing (ADON) #114 verified the wound dressing was dated 11/20/25 and the wound treatment had not been completed on 11/22/25 as documented. ADON #114 revealed she would find someone to change the wound dressing. Review of the facility policy Wound Care, revised 10/2010, revealed wound care would be provided per physician orders and the dated and time the wound care was given would be documented in

the medical record. This deficiency represents non-compliance investigated under Complaint Number

1. 2677336. Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Three Meadows Post Acute

10540 Fremont Pike Rd Perrysburg, OH 43551

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

wound culture was collected on 10/06/25 at 1:00 A.M. and received at the lab at 7:08 A.M. The results were verified on 10/10/25 at 8:44 A.M. with the residents' wound testing positive for methicillin-resistant staphylococcus aureus (MRSA).Review of the progress notes and TAR dated 08/01/25 through 10/05/25 revealed no documentation the resident had refused her compression stockings or of the physician being notified of compression stocking refusals. Review of the TAR dated 09/01/25 through 10/06/25 revealed the nurses had documented completing checks for the left ankle monitor placement and function every shift except during the dayshift on 09/14/25 and 09/18/25. The nurses also documented the completion of checks for ankle monitor placement each shift and function daily except during the dayshift on 09/14/25 and 09/18/25. The TAR did not list the location of the ankle monitor. Further review of the TAR revealed no documentation of the intervention for the heel boots being implemented or completed. Wound treatments for the right malleolus were completed per physician orders. Review of the nurse's notes, physician orders, and Medication Administration Record (MAR) for 10/06/25 revealed no documentation the resident had received the intravenous fluids per physician order. There was also no documentation the physician was notified the intravenous fluids had not been administered. Additional review of the MAR revealed the resident was not administered the protein supplement prior to discharge to the hospital on [DATE REDACTED].Review of hospital documentation dated 10/06/25 through 10/18/25 revealed Resident #05 arrived at the emergency department on 10/06/25 at 8:16 P.M. with hypoglycemia, with an extremely low blood sugar of 26 milligrams[TRUNCATED]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Three Meadows Post Acute

10540 Fremont Pike Rd Perrysburg, OH 43551

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

indicated. A normal bowel pattern was once daily up to once every three days. Further review of the policy revealed to provide medications per physician orders, encourage activity as allowed and tolerated, and encourage fluid intake as allowed and tolerated. Prune juice may be given daily. The Certified Nursing Assistants would document each shift the number the number of bowel movements and size of bowel movements on the resident flow record. The nurse would medication as ordered by the physician or obtain

a physician's order for residents on the bowel care list including a suppository, milk of magnesia or lactulose. The nurse would follow up on those residents on the bowel care list for results and documentation should include size and consistency of the bowel movement.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Three Meadows Post Acute

10540 Fremont Pike Rd Perrysburg, OH 43551

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview on 12/02/25 at 9:03 A.M., LPN #140 revealed Resident #51 was the only current resident with an ankle monitor. LPN #140 revealed she would check and make sure the ankle monitor was not too tight. LPN #140 revealed Resident #51's ankle monitor would alarm if the resident's family took the resident out of the unit. LPN #140 revealed she had worked in the facility for about a year. LPN #140 revealed she was unaware of any device used to check the function of an ankle monitor. LPN #140 looked for a device to check function at the nurse's station and found the device in a bottom drawer. LPN #140 verified she had been documenting she had checked the function and placement of the resident's ankle monitor when in fact

she had not known how. LPN #140 could not get the device monitor to turn on. LPN #140 then consulted with UMLPN #108 who then opened the battery compartment on the device revealing no batteries were present. UMLPN #108 then left the unit to find batteries. Further observation revealed UMLPN #108 replaced the battery and instructed LPN #140 on how to use the device monitor to check the function of the ankle monitor. LPN #140 then checked Resident #51's ankle monitoring sensor for function and placement.

Review of the facility policy Charting and Documentation, revised 07/2017 revealed all services provided to

the resident, progress toward care plan goals, and changes in condition shall be documented in the resident's medical record. Documentation in the medical record would be objective, complete, and accurate.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Three Meadows Post Acute

10540 Fremont Pike Rd Perrysburg, OH 43551

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, review of the medical record, staff interview, and policy review, the facility failed to ensure enhanced barrier precautions were maintained during wound care. This affected one (#05) of four residents reviewed for wound care. The facility identified 29 residents with enhanced barrier precautions. The facility census was 83. Review of the medical record for Resident #05 revealed an admission date of 06/14/23.

Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with late onset, dementia, hypertension, repeated falls, anemia, peripheral vascular disease, orthopedic aftercare following surgical amputation, Methicillin susceptible staphylococcus aureus infection, occlusion and stenosis of carotid artery, and unstageable pressure ulcer of sacral region, acquired absence of right leg above knee, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #05 had severe cognitive impairment. The resident was at risk for developing pressure ulcers/injuries. The resident used a wheelchair and could not ambulate. The resident required the substantial/maximal assistance of staff for toileting, bathing, bed mobility, and transfers. Review of a physician order dated 10/21/25 revealed the resident was ordered enhanced barrier precautions for high contact resident care including wound care.Review of a nurse ' s note dated 10/21/25 at 2:00 P.M. revealed Resident #05 had returned from the hospital on [DATE REDACTED] and a second skin check was completed. The resident had an above the knee amputation of the right leg with the incision well approximated with 16 sutures. The resident had an unstageable pressure ulcer to the coccyx, and unstageable pressure ulcer to the left heel, a deep tissue injury of the left lateral foot and left malleolus.

Observation on 11/25/25 at 2:00 P.M. of Resident #05 revealed a sign outside the resident ' s door indicating the resident required enhanced barrier precautions (gown and gloves) when providing high contact care. Licensed Practical Nurse (LPN) #103 and the Unit Manager Licensed Practical Nurse (UMLPN) #102 provided wound care treatment for the resident ' s unstageable sacral wound per physician orders. LPN #103 and UMLPN #102 had not donned a gown prior to providing wound care for the resident.

The uniform tops of both LPN #103 and UMLPN #102 touched the resident while turning and repositioning

the resident during wound care. Interview on 11/25/25 at 2:16 P.M., LPN #103 and UMLPN #102 verified

the resident required enhanced barrier precautions during wound care. LPN #103 and UMLPN #102 verified they had not worn gowns while providing wound care for the resident. Review of the facility policy Enhanced Barrier Precautions, revised 03/2024, revealed enhanced barrier precautions (EBPs) were utilized to reduce the transmission of multidrug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities including wound care.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet