Inspection·February 8, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and policy review, the facility failed to notify the physician of medication being unavailable from the pharmacy for administration. This affected one (Resident #76) of three reviewed for medications. The facility census was 70. Findings include: Review of the medical record for Resident #76 revealed an admission date of 12/29/22 with diagnoses including but not limited to chronic kidney disease, hypertensive heart disease, congestive heart failure, type two diabetes, chronic obstructive pulmonary disease (COPD), and asthma. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #76 revealed the resident was cognitively intact and required extensive assistance for activities of daily living. Review of the care plan dated 11/15/22 for Resident #76 revealed the resident had altered respiratory status/difficulty breathing related to COPD. Interventions included administer medications as ordered. Review of physician orders for Resident #76 revealed an order for Dupixent (breathing medication) subcutaneous solution pen-injector 300 milligrams/2 milliliters (ml)- inject 2 ml subcutaneously at bedtime every 14 days. Review of the Medication Administration Record (MAR) for September 2023 revealed Resident #76 did not receive Dupixent on 09/21/23 due to being on order from the pharmacy. Review of the MAR for November 2023 revealed Resident #76 did not receive Dupixent on 11/02/23 and 11/16/23 due to being on order from the pharmacy. Review of progress notes from September 2023 and November 2023 revealed no documentation the physician was notified of medication not being available for administration. Interview on 01/29/24 with the Director of Nursing (DON) and Regional Nurse #710 verified Resident #76 did not receive Dupixent on 09/21/23, 11/02/23, and 11/16/23 and also verified there was no documentation in the resident's medical record regarding physician notification of the medication not being available. Review of policy titled, Medication Administration-General Guidelines, revised December 2019 (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 02/08/2024 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)