Inspection·September 4, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observation, staff interview, and facility policy review, the facility failed to properly store medications. This affected one resident (#78) reviewed for medications left at bedside. The facility census was 81. Findings include: Review of the medical record for Resident #78 revealed she was admitted on [DATE] with diagnoses of hyperlipidemia, polyneuropathy, and history of urinary tract infection (UTI). Review of the current physician orders dated 08/24 for Resident #78 revealed she was prescribed Cranberry 300 milligrams (mg) (used for UTI prevention), Atorvastatin 40 mg (used to control high cholesterol), and Gabapentin 600 mg (used for nerve pain). Review of Resident #78's medication administration record (MAR) reveaeld Cranberry 300 mg was scheduled to be administered at 9:00 A.M., 1:00 P.M., and 9:00 P.M. daily, Atorvastatin 40 mg was scheduled to be administered at 9:00 P.M. daily and Gabapentin 600 mg was scheduled to be administered at 9:00 A.M., 1:00 P.M., and 9:00 P.M. daily. Interview on 08/27/24 at 9:22 A.M. with Resident #78 stated sometimes the nurses will leave my medication on my table if I am sleeping and I take them when I wake up, this is usually the night nurse for my early morning medication. Observation on 08/28/24 at 7:55 A.M. of Resident #78 revealed the resident was sleeping and on her overbed table was a plastic medication cup containing three pills inside the cup, two of the pills were white and oblong and one was a pink capsule. And next to the plastic medication cup was a plastic medication cup with chocolate pudding and a spoon. Interview on 08/28/24 at 7:58 A.M. with the Administrator verified a plastic medication cup with medications was left on Resident #78's overbed table along with a plastic medication cup with chocolate pudding in it on the overbed table. Observation and interview on 08/28/24 at 8:06 A.M. with Licensed Practical Nurse (LPN) #255 compared the medications left at the bedside and those medications in the medication cart for Resident #78. These medications were identified as Atorvastatin, Cranberry, and Gabapentin. Interview on 08/28/24 at 11:12 A.M. with the Administrator stated the facility does not have any (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 09/04/2024 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)