Inspection·April 2, 2024

F 0689 members present when transferring a resident using a mechanical device. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Mechanical Lift, dated 11/30/23, revealed to safely lift and transfer residents the transfer requires the assistance of two individuals. Residents Affected - Few This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365535 If continuation sheet Page 2 of 6 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 04/02/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview, and review of a facility policy, the facility failed to ensure a dependent resident received timely incontinence care. This affected one (#41) of three residents reviewed for bowel and bladder incontinence. The census was 79. Findings include: Review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis affecting the right side (dominant) after a cerebral infarct, compression of the brain, aphasia, rheumatoid arthritis, dementia, ulcerative colitis, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was assessed with severely impaired cognition, dependent on staff for activities of daily living (ADLs) including transfers and repositioning. Resident #41 utilized a wheelchair propelled by staff for mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development. Review of the care plan dated 02/14/24 addressed Resident #41's bowel and bladder incontinence related to impaired mobility and cognition. Interventions included to check as needed and as required for incontinence, wash, rinse, and dry the perineum, change clothing as needed after incontinence episodes, monitor for skin breakdown, and apply protective skin barrier after incontinence care. An additional care plan dated 02/14/24 addressed Resident #41's impaired mobility and ADLs deficits related to right-sided hemiparesis. An intervention included to provide extensive assistance in bed including mobility. Continuous observation on 04/02/24 at 11:10 A.M. to 11:23 A.M. of incontinence care completed by State Tested Nurse Aide (STNA) #90 revealed Resident #41 was incontinent of both urine and stool. Resident #41's incontinence brief was noted to be saturated with urine as STNA #90 pushed the brief between the resident's thighs and cleansed the perineum. Resident #41 was rolled to the right at which time STNA #90 explained to the resident a spray that may be cold was going to be used to ensure all the stool could be removed easily from the skin as some of the stool was dried to the skin. After wiping away the stool with the brief that STNA #90 could she sprayed Resident #41's buttocks and used four different wipes to clean between the resident's legs and buttocks. STNA #90 removed the brief from under the resident, threw it into the trash can, and placed a clean brief under Resident #41. Interview on 04/02/24 at 11:15 A.M. with Resident #41 stated it had been a long while since the last time the resident was checked and changed. Interview on 04/02/24 at 11:30 A.M. with STNA #90 revealed the shift started at 6:00 A.M. and Resident #41 was checked and changed right after she first arrived, and verified the resident had not been checked or changed for incontinence since. STNA #90 stated residents should be checked and changed every two hours, but could not get to every resident timely because there were five other residents needing assistance to get out of bed. Review of the facility policy titled, Activities of Daily Living, dated 06/08/22, revealed residents who require nursing intervention to maintain their current level of assistance in other bathing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365535 If continuation sheet Page 3 of 6 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 04/02/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm dressing, or grooming skill will receive the support to preserve activities of daily living function, promote independence and increase self-esteem and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00151587. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365535 If continuation sheet Page 4 of 6 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 04/02/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview, and review of a facility policy, the facility failed to ensure the facility was adequately staffed to ensure a dependent resident received timely incontinence care. This affected one (#41) of three residents reviewed for bowel and bladder incontinence. The census was 79. Findings include: Review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis affecting the right side (dominant) after a cerebral infarct, compression of the brain, aphasia, rheumatoid arthritis, dementia, ulcerative colitis, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was assessed with severely impaired cognition, dependent on staff for activities of daily living (ADLs) including transfers and repositioning. Resident #41 utilized a wheelchair propelled by staff for mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development. Review of the care plan dated 02/14/24 addressed Resident #41's bowel and bladder incontinence related to impaired mobility and cognition. Interventions included to check as needed and as required for incontinence, wash, rinse, and dry the perineum, change clothing as needed after incontinence episodes, monitor for skin breakdown, and apply protective skin barrier after incontinence care. An additional care plan dated 02/14/24 addressed Resident #41's impaired mobility and ADLs deficits related to right-sided hemiparesis. An intervention included to provide extensive assistance in bed including mobility. Continuous observation on 04/02/24 at 11:10 A.M. to 11:23 A.M. of incontinence care completed by State Tested Nurse Aide (STNA) #90 revealed Resident #41 was incontinent of both urine and stool. Resident #41's incontinence brief was noted to be saturated with urine as STNA #90 pushed the brief between the resident's thighs and cleansed the perineum. Resident #41 was rolled to the right at which time STNA #90 explained to the resident a spray that may be cold was going to be used to ensure all the stool could be removed easily from the skin as some of the stool was dried to the skin. After wiping away the stool with the brief that STNA #90 could she sprayed Resident #41's buttocks and used four different wipes to clean between the resident's legs and buttocks. STNA #90 removed the brief from under the resident, threw it into the trash can, and placed a clean brief under Resident #41. Interview on 04/02/24 at 11:15 A.M. with Resident #41 stated it had been a long while since the last time the resident was checked and changed. Interview on 04/02/24 at 11:30 A.M. with STNA #90 revealed the shift started at 6:00 A.M. and Resident #41 was checked and changed right after she first arrived, and verified the resident had not been checked or changed for incontinence since then. STNA #90 verified residents should be checked and changed every two hours, but she could not get to every resident timely because there were five other residents needing assistance to get out of bed that morning and there was not enough staff to timely assist everyone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365535 If continuation sheet Page 5 of 6 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 04/02/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled, Activities of Daily Living, dated 06/08/22, revealed residents who require nursing intervention to maintain their current level of assistance in other bathing, dressing, or grooming skill will receive the support to preserve activities of daily living function, promote independence and increase self-esteem and dignity. This deficiency represents non-compliance investigated under Master Complaint Number OH00151730 and Complaint Number OH00151587. Event ID: Facility ID: 365535 If continuation sheet Page 6 of 6