Health inspection·November 18, 2024

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. Based on medical record review, staff interview and review of facility policy, the facility failed to administer medications per physician orders and further failed to ensure Controlled Drug Records (CDR) were maintained. This affected one resident (#10) of three residents reviewed for medication administration. The facility census was 74. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/20/23 with diagnoses of chronic obstructive pulmonary disease, malignant neoplasm of upper-outer quadrant of right female breast, major depressive disorder and secondary malignant neoplasm of bone. Review of the annual Minimum Data Set (MDS) assessment, dated 11/8/24, revealed Resident #10 was cognitively intact. Resident #10 required set-up assistance for eating, required substantial assistance for bathing and bed mobility and was dependent on staff assistance for toileting hygiene, dressing and personal hygiene. Review of the Medication Administration Record (MAR) from 10/01/24 through 10/31/24 revealed Ativan oral tablet one milligram (mg) (Lorazepam), one mg every six hours for anxiety was not administered on 10/07/24 at 6:00 A.M., 10/08/24 at 6:00 P.M., 10/10/24 at 6:00 A.M., 10/13/24 at 6:00 A.M., 10/13/24 at 6:00 P.M. and 10/22/24 at 6:00 P.M. Further review of the MAR revealed Clindamycin HCl oral capsule 150 mg, one capsule four times daily for infection was not administered on 10/07/24 at 6:00 A.M., 10/08/24 at 6:00 P.M., 10/10/24 at 6:00 A.M., 10/13/24 at 6:00 A.M. and 10/22/24 at 6:00 P.M. Additionally, Methocarbamol oral tablet 1000 mg, give 1000 mg by mouth every six hours for pain was not administered on 10/07/24 at 6:00 A.M., 10/08/24 at 6:00 P.M., 10/10/24 at 6:00 A.M., 10/13/24 at 6:00 A.M., 10/13/24 at 6:00 P.M. and 10/22/24 at 6:00 P.M. Lastly, Dilaudid oral tablet two mg (Hydromorphone HCl), one tablet by mouth four times a day for pain was not administered on 10/07/24 at 6:00 A.M., 10/08/24 at 6:00 P.M., 10/10/24 at 6:00 A.M., 10/13/24 at 6:00 A.M., 10/13/24 at 6:00 P.M. and 10/22/24 at 6:00 P.M. Review of the CDR revealed Lorazaepam oral tablet one mg was signed out for the 10/07/24 6:00 A.M. dose, 10/10/24 6:00 A.M. dose, 10/13/24 6:00 A.M. dose and 10/22/24 6:00 A.M dose. There was no evidence of a CDR for Dilaudid oral tablet. Interview on 11/18/24 at 4:00 P.M. with the Director of Nursing (DON) confirmed the facility had no evidence the medications identified above were adminstered as ordered, further stating the nurse who worked those shifts was no longer employed with the facility so she was unable to gather any additional information. Additionally, the DON verified the CDR for Lorazepam indicated the 10/07/24 6:00 Page 1 of 3 365640 365640 11/18/2024 Sycamore Trails Post Acute 450 Oak Ridge Boulevard Miamisburg, OH 45342

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A.M. dose, 10/10/24 6:00 A.M. dose, 10/13/24 6:00 A.M. dose and 10/22/24 6:00 A.M dose were signed out but the MAR did not reflect the medication was administered. Lastly, the DON confirmed the facility was unable to locate a CDR for Dilaudid. Review of the facility policy titled Medication Administration General Guidelines, dated November 2021, revealed the individual who administers the medication dose records the administration on the resident's MAR/electronic MAR (eMAR) directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. This deficiency represents non-compliance investigated under Master Complaint Number OH00159209 and Complaint Numbers OH00159082 and OH00159031. 365640 Page 2 of 3 365640 11/18/2024 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 Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure appropriate hand hygiene was performed following incontinence care. This affected one resident (#20) of four residents reviewed for incontinence care. The facility census was 74. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date of 12/27/20 with diagnoses of idiopathic aseptic necrosis of right femur, obstructive and reflux uropathy, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 9/20/24, revealed Resident #20 had moderate cognitive impairment. Resident #20 required partial assistance with personal hygiene and was dependent on staff assistance with toileting hygiene, dressing, bed mobility and transfers. Observation on 11/18/24 at 9:55 A.M. of incontinence care for Resident #20 and completed by Certified Nursing Assistant (CNA) #190, revealed CNA #190 knocked on the door when entering the room, explained the procedure to the resident, closed the door to the room, gathered the equipment, washed her hands and applied gloves. Resident #20 was positioned by her back. CNA #190 loosened Resident #20's incontinence brief, which was soiled with urine and feces, and tucked it between the resident's legs. CNA #190 used a clean wipe for each swipe down the residents peri-area, ensuring to not cross-contaminate, and used to same process to rinse and dry the peri area. CNA #190 repositioned Resident #20 onto her right side and cleansed the resident's sacrum/coccyx area, using a clean wipe with each swipe, ensuring not to cross-contaminate, and used the same process to rinse and dry the sacrum/coccyx area. CNA #190 continued, with her gloves intact, to change out the bath blanket Resident #20 was laying on with a clean one, per the resident's request. CNA #190 then reapplied Resident #20's top sheet, causing the resident's television (TV) remote to fall into the bed. CNA #190 picked up the TV remote with her gloved hands and handed it to Resident #20. With her gloves still intact, CNA #190 proceeded to place a clean blanket on top of the sheet for the resident. CNA #190 used her gloved hands to use the bed remote to lower Resident #20's bed to the appropriate height. CNA #190 removed her gloves, washed her hands, gathered the dirty linen bag and exited the room. Interview on 11/18/24 at 10:10 A.M. with CNA #190 verified she did not remove her gloves or perform hand hygiene after providing incontinence care for Resident #20, which included a bowel movement, and proceeded to use her soiled gloves while providing the resident clean linen, touching the resident's TV remote and using the bed remote to adjust the resident's bed height. CNA #190 revealed that she feels she completed incontinence care without getting bowel movement on her gloves, so she did not feel there was cross-contamination requiring her to remove her soiled gloves. Review of the facility policy titled Incontinence Care, dated 06/08/22, revealed the purpose was to keep skin clean, dry, free of irritation and odor; identify skin problems as soon as possible so treatment can be started; prevent skin breakdown; and to prevent infection. The procedure included hand hygiene and apply gloves; lower the head and foot of the bed; hand hygiene and apply gloves; drape resident for privacy; wash all soiled skin areas and dry very well; remove gloves and wash hands; and change linen as needed. This deficiency was an incidental finding discovered during the complaint investigation. 365640 Page 3 of 3