Health inspection·May 21, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 05/21/25 at 12:49 P.M. of the 200-hall main medication room refrigerator, with the Director of Nursing (DON), revealed a plastic container which held eight vials of insulin. There were two vials of Novolog N 100 units per 10 milliliters (U/ml) with expiration dates of 12/31/24 and 01/31/25, a vial of Novolog R 100 U/10 ml with an expiration date of 03/31/25, two vials of Novolog 70/30 with an expiration date of 01/31/25 and one vial of Novolin R 100 U/10 ml with an expiration date of 03/31/25. Interview on 05/21/25 at 1:05 P.M. with the DON revealed the vials of insulin in the mail medication room refrigerator were used by all three halls of the facility for emergency situations, such as residents out of insulin or with new admissions. The DON verified the eight vials of insulin in the main medication room refrigerator were expired. Review of the facility policy titled, Medication Storage in the Facility, dated November 2018, revealed medications were stored safely, securely and properly, following manufactures recommendations or those of the supplier. Further review revealed outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled or without secure closures were immediately removed from inventory. All expired medications would be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Based on observation, staff interview, medical record review and review of the facility policy, the facility failed to ensure medications were not left unattended at a resident's bedside. This affected one (#111) of five residents reviewed for medication administration. In addition, the facility failed to ensure medications were removed from use and disposed of upon expiration. This had the potential to affect eight (#16, #22, #27, #30, #36, #39, #44 and #49) residents identified by the facility as receiving insulin. The facility census was 58. Findings include: 1. Review of the medical record reveal Resident #111 was admitted on [DATE]. Diagnoses included cellulitis of the left lower limb, hypertensive heart and chronic kidney disease, acute on chronic diastolic heart failure, chronic kidney disease stage III, rheumatoid arthritis, type two diabetes mellitus with diabetic neuropathy, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 03/13/25, revealed Resident #111 was cognitively intact and prescribed medications included anticoagulants, antibiotics, opioids, and anticonvulsants. Review of the Medication Administration Record (MAR) for May 2025 revealed on 05/18/25, during the morning medication administration, Resident #111 received the following medications: amiodarone (antiarrhythmic medication) 200 milligram (mg), bumetanide (diuretic) one mg, duloxetine (antidepressant) delayed release 60 mg, Eliquis (anticoagulant) five mg, folic acid (vitamin) one mg, gabapentin (antiseizure/nerve pain) 300 mg, glimepiride (diabetic medication) two mg, Jardiance (diabetic medication) 25 mg, levothyroxine (thyroid medication) 88 microgram (mcg), midodrine (antihypotensive) five mg, multivitamin tablet, oxybutynin chloride (urinary) tablet extended release 10 mg, pantoprazole (proton pump inhibitor) 40 mg, potassium chloride 20 milliequivalent (mEq), prednisone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 2 of 3 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 05/21/2025 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 0761 (corticosteroid) five mg, senna (supplement) 8.6 mg, and spironolactone (diuretic) 12.5 mg. Level of Harm - Minimal harm or potential for actual harm Observation on 05/18/25 at 9:54 A.M. revealed Resident #111 was sitting in her wheelchair, just outside of the resident's room door. Upon entering the resident's room, with the resident, a half full medication cup was observed on the bedside table. Residents Affected - Some Interview on 05/18/25 at 10:00 A.M. with Licensed Practical Nurse (LPN) #283 verified leaving Resident #111's medications unattended at the bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 3 of 3