Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record, staff interview, and policy review, the facility failed to ensure an admission skin
assessment was completed, and failed to ensure wound treatments were entered into the electronic
medical record and completed per physician orders. This affected one (Resident #79) of three residents
reviewed for pressure ulcers. The facility census was 78.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #79 revealed an admission date of 09/23/23 and a discharge
date of 10/15/23. Diagnoses included sepsis, encephalitis and encephalomyelitis, enterocolitis due to
clostridium difficile, acute kidney failure, type two diabetes mellitus, chronic systolic heart failure, chronic
kidney disease stage three, atrial fibrillation, and atherosclerosis of coronary artery bypass graft.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had
intact cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, and
toileting. The resident had an unstageable pressure ulcer present on admission. The resident was at risk for
skin breakdown.
Review of hospital documentation dated 09/21/23 revealed Resident #79 had an unstageable pressure
ulcer to the sacrum measuring 6.2 centimeters (cm) in length, 7.5 cm in width with a depth of 0.1 cm.
Review of the admission physician orders revealed an order to apply Triad hydrophilic wound dressing
paste daily and as needed to the sacral wound.
Review of the admission assessment for skin dated 09/23/23 revealed Resident #79 had abnormal findings
for the sacrum. There was no description of the wound and no wound staging.
Review of a weekly wound note dated 09/25/23 at 3:00 P.M. revealed Resident #79 was admitted with a
unstageable pressure ulcer to the coccyx. The wound measured six cm in length, five cm in width, with an
undetermined depth. The wound base was not visible with 100% slough/necrosis present with a moderate
amount of thin tan colored drainage.
Review of a physician order dated 09/25/23 at 3:00 P.M. revealed a new order to cleanse the coccyx wound
with normal saline, pat dry, apply foam dressing, change daily and as needed.
Review of the Nurse Practitioner (NP) wound progress note dated 09/25/23 revealed Resident #79 was
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
365535
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
365535
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2023
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
admitted from the hospital on [DATE] with an unstageable pressure injury of the coccyx. The resident was
on a turning schedule and had a low air loss mattress in place. The NP noted honey gel and dry dressing
was being utilized. The wound measured six cm in length, five cm in width and unable to determine depth.
There was no undermining or tunneling, no odor and the periwound was normal. The wound bed was 100%
soft yellow slough with light to moderate serosanguinous drainage. The NP ordered to cleanse the injury
with normal saline, apply medical honey and dry dressing daily and as needed.
Review of the NP wound progress note dated 10/05/23 revealed the wound status was improved. The
wound measured six cm in length by four cm in width with an undetermined depth. The wound was 100%
slough with light to moderate serosanguinous drainage. There was no undermining, no tunneling, no odor
and the periwound was normal. The NP noted to cleanse injury with normal saline, apply medical grade
honey and dry dressing daily and as needed.
Review of the NP wound progress note dated 10/12/23 revealed the wound status was improved. The
wound measured 5.5 cm in length by 4.5 cm in width, with an undetermined depth. The wound bed was
50% slough and 50% granulation tissue with light to moderate serosanguinous drainage. There was no
tunneling, no undermining and no odor. The periwound was normal. The NP debrided the wound and post
debridement measurement remained unchanged. Post debridement appearance was 75% red granulation
tissue and 25% yellow adherent nonviable tissue. The NP noted to cleanse the injury with normal saline,
apply medical honey and dry dressing daily and as needed.
Review of the Treatment Administration Record (TAR) from 09/25/23 through 10/14/23 revealed the wound
was cleansed with normal saline, patted dry, and a foam dressing was applied. There were no
documentation treatments were completed on 10/01/23, 10/03/23 and 10/10/23. Further review of the TAR
revealed the wound treatment ordered by the NP on 09/25/23 (cleanse the injury with normal saline, apply
medical honey and dry dressing daily and as needed) was never entered as a treatment order and
therefore was not completed from 09/28/23 through 10/14/23.
Interview on 12/04/23 at 9:55 A.M. Unit Manager Licensed Practical Nurse (LPN) #113 verified no wound
assessment was completed until 09/25/23 (two days after admission). LPN #113 revealed the nurses
should measure the wound upon admission. Further interview on 12/04/23 at 11:01 A.M. LPN #113 verified
there were no documented treatments on 10/01/23, 10/03/23 and 10/10/23. LPN #113 also verified the
incorrect treatment was completed from 09/28/23 through 10/14/23. LPN #113 revealed she used the
medihoney on the wound but never entered the correct order in the electronic medical record.
Interview on 12/05/23 at 10:15 A.M. Registered Nurse (RN) #118 revealed she used medihoney for a
treatment on the Resident #79's coccyx wound.
Interview on 12/05/23 at 11:59 A.M. Nurse Practitioner (NP) #120 revealed the resident's wound had
improved. NP #120 revealed staff were likely using the medihoney as something worked to soften the
slough in order for her to debride the wound. NP #120 revealed the resident received the medihoney
treatment after the three times she had assessed the wound. NP #120 revealed medihoney would not work
fast but the wound was cleaning up nicely.
Review of the policy Skin Care Management, last revised 06/08/22 revealed residents with identified skin
breakdown would have a documented skin assessment weekly. There were no guidelines for
documentation of a skin assessment upon admission. Further review of the policy revealed wound
treatments would be completed as ordered.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365535
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
365535
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2023
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
This deficiency is an example of non-compliance investigated under Complaint Number OH00148231.
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:
365535
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the December 5, 2023 survey of THREE MEADOWS POST ACUTE?
This was a inspection survey of THREE MEADOWS POST ACUTE on December 5, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THREE MEADOWS POST ACUTE on December 5, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.