Inspection·November 9, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 11/08/22 at 2:21 P.M., Regional Clinical Support (RCS) #481 confirmed Resident #11's medical record did not reflect CHF clinic notification of Resident #11's weight gain on 11/05/22. RCS #481 provided documentation weight increases were faxed to the clinic on 11/02/22 and 11/07/22 but no notification was made on 11/05/22. Review of facility policy titled Notification of Change in Condition, reviewed 12/01/21, revealed the resident representative and provider should be notified of change in condition in a timely manner. Event ID: Facility ID: 365407 If continuation sheet Page 2 of 7 Printed: 05/15/2026 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of facility policy, the facility failed to ensure weights were obtained in a consistent manner to ensure accuracy. This affected one (#11) of three residents reviewed for nutrition. The facility census was 55. Residents Affected - Few Findings include: Review of Resident #11's medical record revealed an admission date of 04/14/22 and a readmission date of 05/20/22. Diagnoses included displaced bimalleolar fracture of right lower leg, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, seizures, cardiomyopathy, asthma, major depressive disorder, anxiety disorder, overactive bladder, morbid (severe) obesity, hypotension, intellectual disabilities, edema and mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/13/22 revealed Resident #11 was severely cognitively impaired, required extensive assistance with activities of daily living (ADLs) and had no weight loss or weight gain. Review of a plan of care, revised 10/26/22, revealed Resident #11 experienced a significant weight gain. Interventions included obtain weight as ordered. Additional review of a plan of care, revised 08/23/22, revealed Resident #11 had a potential for complications related to congestive heart failure (CHF). Interventions included weight as ordered, medications per orders, diet per physician orders and observe for and report complications as needed. Review of a physician order dated 11/02/22 revealed to weigh Resident #11 daily. Additional review revealed to weigh the resident on the spa scale for consistency. Review of weights revealed Resident #11 weighed 350.2 pounds (lbs.) on 11/01/22, 376.4 lbs. on 11/02/22, 356.8 lbs. on 11/03/22, 356 lbs. on 11/04/22, 375 lbs. on 11/05/22, 375.6 lbs. on 11/06/22, and 358 lbs. on 11/07/22. Interview on 11/08/22 at 2:21 P.M. with Regional Clinical Support (RCS) #481 verified significant variances in Resident #11's weights. RCS #481 stated the variances may have been due to staff not subtracting Resident #11's wheelchair on the dates he weighed 375 lbs. RCS #481 confirmed Resident #11's wheelchair weighed 58 lbs. and the weight of the wheelchair exceeded the differences in the Resident's weights. Follow up interview on 11/08/22 at 2:49 P.M., RCS #481 revealed Resident #11 had been weighed on different scales, which likely accounted for the weight variations. RCS #481 confirmed Resident #11's physician orders specified to use the spa scale to ensure consistency with weights and the spa scale and the chair scale were both being used when weighing Resident #11. Interview on 11/09/22 at 9:07 A.M., Licensed Practical Nurse (LPN) #336 revealed she had assisted in obtaining some of Resident #11's weights. LPN #336 stated she was unsure why the resident's weights were so off from each other. LPN #336 stated the spa scale was not wide enough for Resident #11's wheelchair and the only thing she could think was that some staff were pushing the wheelchair onto the spa scale, with the weight not being evenly distributed, resulting in inaccurate weights. Review of facility policy titled Guidelines for Weight Tracking, reviewed 03/16/22, revealed to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 3 of 7 Printed: 05/15/2026 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0692 extent possible, the same scale, same person, same wheelchair (if applicable) should be used to ensure consistency. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 4 of 7 Printed: 05/15/2026 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and review of facility policy, the facility failed to ensure medications were received from the pharmacy in a timeframe to allow for the timely initiation of physician's orders for new medications. This affected two (Resident #15 and #205) of seven residents reviewed for medications. The facility census was 55. Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included type two diabetes mellitus with diabetic chronic kidney disease, abdominal aortic aneurysm without rupture, chronic kidney disease stage 4, vascular dementia with behavioral disturbance, schizoaffective disorder, and hypertension. Review of the physician order, dated 11/04/22, revealed an order for the antibiotic cefadroxil/duricef 500 milligram (mg) twice a day. Review of the progress note, dated 11/05/22 revealed cefadroxil/duricef was not received in tote prior night and was not able to be pulled from Cubex. Pharmacy was contacted and stated it would be in that evening's tote. Facility staff voiced concerns that the medication was put into matrix care before 2:00 P.M. on 11/04/22 so it should have been in the prior night's tote. It was reported the pharmacy will drop ship today's antibiotic doses for Resident #15. Review of Medication Administration Record (MAR), dated November 2022, revealed cefadroxil was not administered on 11/04/22 and 11/05/22. Comments included could not find medication and medication was to be dropped shipped and was not received. Interview on 11/09/22 at 11:59 P.M. with the Director of Nursing (DON) verified Resident #15 did not receive the antibiotic ordered on 11/04/22 until 11/06/22 due to not receiving the antibiotic timely from pharmacy. The DON reported a drop shipment should be received within two hours. 2. Review of the medical record revealed Resident #205 was admitted on [DATE]. Diagnoses included sepsis, acute respiratory failure with hypoxia, acute kidney failure, type two diabetes mellitus without complications, and nicotine dependence. Review of progress note, dated 11/04/22, revealed Resident #205's daughter requested a nicotine patch be ordered due to Resident #205 being a current cigarette smoker of one to two packs per day. Review of the physician order, dated 11/04/22, revealed an order for nicotine patch 24 hour 21 mg/24 hour one patch applied transdermal once a day. Review of the Medication Administration Review (MAR), dated November 2022, revealed on 11/04/22, 11/05/22, and 11/06/22 the nicotine patch 24 hour 21 mg was not administered due to the drug/item not available. Interview on 11/08/22 at 3:48 P.M. with Licensed Practical Nurse (LPN) #412 verified working on 11/06/22. LPN #412 stated he had called the pharmacy due to Resident #205 not receiving nicotine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 5 of 7 Printed: 05/15/2026 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0755 Level of Harm - Minimal harm or potential for actual harm patches as ordered. Pharmacy stated their new system was the reason for delay. LPN #412 verified the nicotine patches were ordered on 11/04/22 and the resident did not receive the patch until 11/07/22. Review of policy titled Medication Ordering and Receiving from Pharmacy, revised January 2017, revealed medications and related products are received from the dispensing pharmacy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 6 of 7 Printed: 05/15/2026 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on review of Quality Assessment and Assurance (QAA) Committee/Quality Assurance Improvement Program (QAPI) meeting sign in sheets, staff interview, and review of a facility policy, the facility failed to ensure QAA Committee/QAPI meetings occurred at least quarterly. This affected all 55 residents residing in the facility. The census was 55. Residents Affected - Many Findings include: Review of QAA Committee/QAPI meeting sign in sheets between December 2021 and October 2022 revealed the facility did not hold a QAA Committee/QAPI meeting in the first quarter (January, February, and March) of 2022. The facility held meetings on 12/09/21, 04/28/22, 07/29/22, and 10/26/22. Interview on 11/09/22 at 12:49 P.M. with Executive Director #402 verified the facility had no documentation of a QAA Committee/QAPI meeting occurring during the first quarter of 2022. Review of a facility policy titled Quality Assessment and Assurance Committee/Quality Assurance and Performance Improvement (QAPI) Program, revised 11/14/19, revealed the Quality Assessment and Assurance Committee shall meet at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 7 of 7