Inspection·December 20, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Review of the electronic charting for Resident #70 revealed a UA was collected on 09/15/23, received on 09/16/23, reported on 09/18/23, and marked as reviewed on 09/20/23 at 9:08 A.M. by the Director of Nursing (DON). The UA documented culture results were positive for greater than 100,000 colonies/milliliter for Proteus Mirabilis (gram-negative bacterium). Residents Affected - Few Review of Resident #70's physician orders revealed no orders for an antibiotic for a positive urine culture. Review of Resident #70's progress notes revealed no documentation a provider had been informed of the UA results reviewed by the DON on 09/20/23. Review of Resident #70's nursing progress notes dated 09/20/23 at 8:01 P.M. revealed respiratory therapy informed the nurse of a decrease in oxygen levels of 80 percent (%) on room air and 90% on the ventilator. Resident #70 was assessed as alert, diaphoretic, abdomen distended with hypoactive bowels sounds. The CNP was updated, and the rescue squad was called for a change in condition. Resident #70 was transferred to the hospital. Review of the hospitalization record of Resident #70 for 09/20/23 through 09/30/23 revealed the resident had diagnoses which included acute hypoxic respiratory failure subsequent to subsegmental pulmonary embolism, and bilateral pleural effusions, Proteus Mirabella's bacteremia secondary to complicated UTI in the setting of left hydronephrosis and left ureteral calculus; urinary retention secondary to left hydronephrosis due to left ureteral calculus status post cystoscopy, left ureteral stent placement 07/23 with sepsis on admission. Further review revealed a Computed Tomography (CT) scan revealed a left nine-millimeter proximal ureteral stone. On 09/23/23, Resident #70 was taken to the operating room for a cystoscopy left retrograde pyelogram and left ureteral stent placement. Interview on 12/19/23 at 3:50 P.M. with Lab Technician #19 revealed Resident #70's UA was finalized on 09/19/23 at 12:19 P.M. and results were faxed to the facility and uploaded into the electronic charting system. Interview on 12/19/23 at 4:03 P.M. with the DON explained the reason Resident #70's electronic charting documented her review of the urine culture result was due to her usual morning routine. The DON stated it was her morning routine to check the electronic charting system for residents who had lab results returned for review, she then clicked reviewed although she did not actually look at the results. The DON stated she would document the resident, and the type of lab containing result on the morning report sheet for the primary nurse to follow up with. The DON confirmed Resident #70's UA results on 09/20/23 showing a UTI were not provided to the physician and the resident subsequently was hospitalized later that evening. Interview on 12/20/23 at 10:30 A.M. with LPN #10 verified she worked on 09/20/23 but did not recall receiving notification of UA results for Resident #70. LPN #10 was able to check SIGNAL (secure messaging system) on 09/20/23 and verified no notification of UA results were messaged to a provider. LPN #10 confirmed Resident #70's UTI was not timely treated and the resident was admitted to the hospital on [DATE]. This deficiency represents non-compliance investigated under Complaint Number OH00149219. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure physician orders for antibiotics were administered as ordered. This affected one (#70) of three reviewed for medication administration. Facility census was 78. Findings include: Review of medical record for Resident #70 revealed admission date of 02/18/10. Diagnoses include hemiplegia following unspecified cerebrovascular disease affecting left non dominant side, depression, chronic respiratory failure, anxiety. Review of Resident #70's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #70 required moderate assistance for eating, dependent for bathing, bed mobility, toileting hygiene and resident refused transfer. Review of Resident #70's hospitalization record dated 09/20/23 through 09/30/23 revealed a discharge order for Amoxicillin (antibiotic) 500 milligrams (mg) take two capsules by mouth in the morning and two capsules before bedtime. Do all this for four days. Review of the physician orders for Resident #70 revealed an order for Amoxicillin (antibiotic) 500 milligrams (mg) take two capsules by mouth, two times a day with a start date of 10/01/23 and an end date of 10/03/23. Review of the October 2023 Medication Administration Record (MAR) for Resident #70 revealed documentation Amoxicillin 500 mg was given twice daily for three days, from 10/01/23 through 10/03/23. The review revealed Resident #70's Amoxicillin was not given for the fourth day per the hospital discharge orders. Interview on 12/20/23 at 11:15 A.M. with Licensed Practical Nurse (LPN) #21 revealed she had gotten in report from the hospital and verified on the discharge paperwork that Resident #70 had received the morning dose of the four day order of Amoxicillin prior at the hospital. LPN #21 verified Resident #70 did not receive the second dose of Amoxicillin on September 30th and instead obtained and entered an order for three days in error. LPN #21 confirmed Resident #70 did not receive the Amoxicillin as per the hospital discharge orders. This deficiency represents non-compliance investigated under Complaint Number OH00149219. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 3 of 3