Inspection·June 27, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and hospice staff interviews, review of medication information from Medscape and facility medication administration policy, the facility failed to ensure blood pressure medication was administered in accordance with physician orders. This resulted in a significant medication error when one resident received an anti-hypertensive blood pressure medication outside of physician prescribed administration parameters. This affected one (#1) of five sampled residents reviewed for the administration of medications. The facility census of 85. Residents Affected - Few Findings include: Resident #1 admitted to the facility on [DATE] with the diagnosis including, cardiomyopathy, congestive heart failure, atrial fibrillation, coronary artery disease, ventricular tachycardia, cardiac pacemaker, seizure disorder, pulmonary hypertension, pleural effusion, left clavical fracture, and cerebral vascular accident affecting left non-dominant side with hemiplegia and hemiparesis. According to the minimum data set assessment dated [DATE] Resident #1 was assessed with intact cognition and dependent on staff for the completion of activities of daily living. Resident #1 was coded as receiving antibiotic and antiplatelet medications. Review of Resident #1 Hospice Patient Medication Profile dated 05/23/24 noted as Resident #1 admission physician orders revealed an order for Metoprolol Succinate 25 milligram tablet extended release (ER) ordered on 04/25/24 to be given by mouth as needed (PRN) for hypertension. Give one tablet once daily as needed for systolic blood pressure (SBP) above 130. Starting on 04/26/2024. According to Electronic Medical Record noted a physician order dated 05/26/24 for Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour. Give one tablet by mouth at bedtime for hypertension. No documentation was provided indicating the physician order was obtained by the hospice physician. Review of Medication Administration Records (MAR) dated 05/26/24 and 05/27/24 at 9:00 P.M. noted the residents SBP readings as follows: 05/26/24- 115 and 05/27/24-119. The medication Metoprolol Succinate 25 mg documented to be administered. On 06/27/24 at 7:38 A.M. telephone interview with hospice Registered Nurse (RN) #201 during review of Resident #1's medication orders confirmed Metoprolol Succinate 25 milligram tablet extended release ordered on 04/25/24 to be given by mouth as needed (PRN) for hypertension. Give one tablet once daily as needed for systolic blood pressure (SBP) above 130. Starting on 04/26/2024. Hospice RN #201 confirmed the physician order was unchanged from the date of the initial order of 04/25/24 and the medication was not to be administered unless Resident #1 SBP was above 130. RN #201 also verified the (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 2 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 06/27/2024 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)