Health inspection·March 28, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, review of staffing records/schedules and policy review, the facility failed to provide timely Activities of Daily Living (ADL's) assistance. This affected one (#11) out of three residents reviewed for ADL assistance and had the potential to affect 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 and top of the 100 hallway assignment. The facility census was 82. Residents Affected - Some Findings include: Review of medical record for Resident #11 revealed admission date of 05/27/22 with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition on The resident was admitted with diagnoses including anxiety, depression, sleep apnea and stage three kidney disease. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she required extensive two-person assistance for transfers, toileting, one person assistance for bed mobility and supervision for eating. Review of the progress note dated 03/07/24 by Assistant Director of Nursing (ADON) #106 revealed documentation that Resident #11 had requested to take the sit to stand transfer device to her room. Resident #11 was educated she was not able to use the standby herself and the device required two staff members to operate. Interview on 03/28/24 with ADON #106 revealed Resident #11 was upset on 03/07/24 because she needed to use the bathroom and unfortunately each aid was occupied in a room. ADON #106 stated she was unable to assist Resident #11 by herself as the sit to stand device required two staff. ADON #106 stated it took an additional thirty minutes for Resident #11 to be assisted to the bathroom. Interview on 03/28/24 at 1:48 P.M. with Resident #11 revealed she had waited two hours to be provided care on the evening of 03/27/24. Resident #11 stated her State Tested Nursing Assistant (STNA) #111 came into her room around 9:00 P.M. Resident #11 stated she was upset because no one acknowledged her call light was on and at least told her they would be back in to assist her when they were free. Resident #11 stated she also voiced her concern to Human Resource #110. Interview on 03/28/24 at 1:59 P.M. with Human Resource #110 acknowledged he had been informed by Resident #11 that she had her call light on for two hours before STNA #111 entered the room to provide care. Human Resource #110 did not refute her statement, and stated education would be provided to STNA #111. Page 1 of 5 365640 365640 03/28/2024 Sycamore Trails Post Acute 450 Oak Ridge Boulevard Miamisburg, OH 45342

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 03/28/24 at 2:29 P.M. with STNA #111 revealed she did not arrive for her 7:00 P.M. shift until 8:00 P.M., and stated she had previously informed the facility she would be late. STNA #111 stated there was no STNA to receive report from upon her arrival. STNA #111 also revealed she was upset her assignment had the top of the 100-hall added to her 300-hall assignment. STNA #111 verified Resident #11 was on her added assignment. STNA #111 acknowledged Resident #11's call light had been on when she arrived and once she figured out her assignment, she answered it. STNA #111 said Resident #11 had informed her the call light had been on for two hours. STNA #111 stated Resident #11 was incontinent and needed to be taken to the bathroom to be cleaned. Interview on 03/28/24 at 3:24 P.M. with Licensed Practical Nurse (LPN) #112 revealed she worked the evening of 03/27/24. LPN #112 stated Resident #11 was being assisted by staff in the bathroom in getting cleaned up. LPN #112 stated Resident #11 informed her she had her call light on for two hours. LPN #112 shared she did not doubt Resident #11's call light was on for an extended amount of time. LPN #112 shared STNA #111 was late for her shift and upset with her assignment when she did come in, and there was a nurse who was a no call no show and adjustments in the schedule had to be made. The facility confirmed STNA #111 was assigned to 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 hall and top of the 100 hallway assignment. Interview on 03/28/24 at 5:18 P.M. with LPN #114 revealed she worked day shift on 03/27/24 and stayed until about 8:30 P.M. because her replacement nurse was late. LPN #114 shared STNA #111 came into work late and was upset with her assignment, called management and walked off the unit. LPN #114 stated she did not see her return, and she left at 8:30 P.M. LPN #114 acknowledged Resident #11's call light was going off during that time period, but she could not say for how long. Review of the nursing clock in times provided by the facility revealed STNA #111 punched in for her on 03/27/24 at 8:00 P.M. Review of the staffing sheet for STNA #111 revealed STNA #111 was assigned to 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 hall and top of the 100 hallway assignment. Review of the facility policy, Call Light, Use of, last reviewed 11/30/23 documented to answer call lights whether or not you are assigned to the area. This deficiency represents non-compliance investigated under Complaint Numbers OH00152381, OH00152091 and OH00151819 365640 Page 2 of 5 365640 03/28/2024 Sycamore Trails Post Acute 450 Oak Ridge Boulevard Miamisburg, OH 45342

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review, staff and resident interviews, review of staffing records/schedules and policy review, the facility failed to ensure there was sufficient staffing to provide timely assistance with Activities of Daily Living (ADL's). This affected one (#11) out of three residents reviewed for ADL assistance and had the potential to affect 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 and top of the 100 hallway assignment. The facility census was 82. Findings include: Review of medical record for Resident #11 revealed admission date of 05/27/22 with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition on The resident was admitted with diagnoses including anxiety, depression, sleep apnea and stage three kidney disease. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she required extensive two-person assistance for transfers, toileting, one person assistance for bed mobility and supervision for eating. Review of the progress note dated 03/07/24 by Assistant Director of Nursing (ADON) #106 revealed documentation that Resident #11 had requested to take the sit to stand transfer device to her room. Resident #11 was educated she was not able to use the standby herself and the device required two staff members to operate. Interview on 03/28/24 with ADON #106 revealed Resident #11 was upset on 03/07/24 because she needed to use the bathroom and unfortunately each aid was occupied in a room. ADON #106 stated she was unable to assist Resident #11 by herself as the sit to stand device required two staff. ADON #106 stated it took an additional thirty minutes for Resident #11 to be assisted to the bathroom. Interview on 03/28/24 at 1:48 P.M. with Resident #11 revealed she had waited two hours to be provided care on the evening of 03/27/24. Resident #11 stated her State Tested Nursing Assistant (STNA) #111 came into her room around 9:00 P.M. Resident #11 stated she was upset because no one acknowledged her call light was on and at least told her they would be back in to assist her when they were free. Resident #11 stated she also voiced her concern to Human Resource #110. Interview on 03/28/24 at 1:59 P.M. with Human Resource #110 acknowledged he had been informed by Resident #11 that she had her call light on for two hours before STNA #111 entered the room to provide care. Human Resource #110 did not refute her statement, and stated education would be provided to STNA #111. Interview on 03/28/24 at 2:29 P.M. with STNA #111 revealed she did not arrive for her 7:00 P.M. shift until 8:00 P.M., and stated she had previously informed the facility she would be late. STNA #111 stated there was no STNA to receive report from upon her arrival. STNA #111 also revealed she was upset her assignment had the top of the 100-hall added to her 300-hall assignment. STNA #111 verified Resident #11 was on her added assignment. STNA #111 acknowledged Resident #11's call light had been on when she arrived and once she figured out her assignment, she answered it. STNA #111 said Resident #11 had informed her the call light had been on for two hours. STNA #111 stated Resident #11 was 365640 Page 3 of 5 365640 03/28/2024 Sycamore Trails Post Acute 450 Oak Ridge Boulevard Miamisburg, OH 45342

F 0725 incontinent and needed to be taken to the bathroom to be cleaned. Level of Harm - Minimal harm or potential for actual harm Interview on 03/28/24 at 3:24 P.M. with Licensed Practical Nurse (LPN) #112 revealed she worked the evening of 03/27/24. LPN #112 stated Resident #11 was being assisted by staff in the bathroom in getting cleaned up. LPN #112 stated Resident #11 informed her she had her call light on for two hours. LPN #112 shared she did not doubt Resident #11's call light was on for an extended amount of time. LPN #112 shared STNA #111 was late for her shift and upset with her assignment when she did come in, and there was a nurse who was a no call no show and adjustments in the schedule had to be made. The facility confirmed STNA #111 was assigned to 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 hall and top of the 100 hallway assignment. Residents Affected - Some Interview on 03/28/24 at 5:18 P.M. with LPN #114 revealed she worked day shift on 03/27/24 and stayed until about 8:30 P.M. because her replacement nurse was late. LPN #114 shared STNA #111 came into work late and was upset with her assignment, called management and walked off the unit. LPN #114 stated she did not see her return, and she left at 8:30 P.M. LPN #114 acknowledged Resident #11's call light was going off during that time period, but she could not say for how long. Review of the nursing clock in times provided by the facility revealed STNA #111 punched in for her on 03/27/24 at 8:00 P.M. Review of the staffing sheet for STNA #111 revealed STNA #111 was assigned to 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 hall and top of the 100 hallway assignment. Review of the facility policy, Call Light, Use of, last reviewed 11/30/23 documented to answer call lights whether or not you are assigned to the area. This deficiency represents non-compliance investigated under Complaint Numbers OH00152381, OH00152091 and OH00151819 365640 Page 4 of 5 365640 03/28/2024 Sycamore Trails Post Acute 450 Oak Ridge Boulevard Miamisburg, OH 45342

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews and policy review, the facility failed to ensure infection control procedures were followed during wound care. This affected one (#14) of three residents reviewed for wound care. Facility census was 82. Residents Affected - Few Findings include: Review of medical record for Resident #14 revealed admission date of 03/10/24. Diagnoses include diabetes mellitus type two, necrotizing fasciitis, acute osteomyelitis left ankle and foot. The resident remains at the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #14 required extensive one person assistance for toileting and supervision for eating, bed mobility and transfers. Review of Resident #14's physician orders revealed an order to cleanse wound with normal saline, pat dry with non-sterile gauze and reapply wound vacuum negative pressure on Mondays, Wednesdays and Fridays with a start date of 03/25/24. A second order to cleanse external fixator pins with normal saline, pat dry and apply split sponge every sift with a start date of 03/16/24. Observation on 03/17/24 at 3:35 P.M. of wound care by Registered Nurse (RN) #105 for Resident #14 revealed RN #105 removed the old sponge and dressing from the left lateral ankle of Resident #14 and disposed of it in the trash can. Without removing her gloves, she applied normal saline to the wound and patted it dry. RN #105 then opened a new dressing kit, removed and cut the sponge to fit the wound and secured it with tape. A small hole was cut into the tape and the wound vacuum was reapplied and restarted. RN #105 then removed her gloves and grabbed another pair of gloves and applied them without performing hand hygiene. RN #105 then proceeded to clean the external fixator pins. RN #105 cleansed the top two pins with normal saline on a four by four, and patted the area dry. RN #105 then repeated the same procedure to the bottom pins, using the same pair of gloves. After care was completed, RN #105 removed her gloves and washed her hands using soap and water. Interview on 03/17/24 at 4:11 P.M. with RN #105 verified she did not change her gloves after removing the old dressing, or in between the care of two separate wound sites. Review of the facility policy titled, Dressing Change dated 11/30/23 documented after removing and disposing of soiled dressing, dispose of gloves. Also documented was to cleanse wound as prescribed, remove gloves and wash hands or use hand sanitizer. This deficiency represents non-compliance investigated under Complaint Numbers OH00152243 and OH00152091. 365640 Page 5 of 5