Health inspection·February 20, 2019

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of facility policy, the facility failed to serve resident meals in a homelike environment. This affected four residents (#3, #5, #35 and #40) who dine in the assisted dining room. The census was 81. Findings include: 1. Review of record for Resident #3 revealed an admission date of 08/03/18 with diagnoses which included dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required limited assistance with eating. 2. Review of record for Resident #5 revealed an admission date of 10/11/16 with diagnoses which included dementia without behavioral disturbance and depression. Review of the MDS assessment dated [DATE] the revealed resident was cognitively impaired and totally dependent on staff for eating. 3. Review of record for Resident #35 revealed an admission date of 08/10/17 with diagnoses which included dementia and dysphagia. Review of the MDS assessment, dated 12/13/18, revealed the resident was cognitively impaired and was totally dependent on staff for eating. 4. Review of record for Resident #40 revealed an admission date of 12/08/15 with diagnoses which included dementia and dysphagia. Review of the MDS assessment dated [DATE] revealed the resident was cognitively impaired and required staff supervision with eating. Observation of lunch on 02/04/19 at 12:30 P.M. and of breakfast on 02/05/19 at 8:30 A.M. in the assisted dining room revealed Residents #3, #5, #35 and #40 were served their meals on large trays. The staff had not removed the plates from the trays for the meal service. The television in the dining room was playing throughout the meals. Interview with Activities Director (AD) #101 and State Tested Nursing Assistant (STNA) #31 on 02/04/19 at 12:35 P.M. confirmed meals were always served on trays without removing the plates from the trays for the meal service, and the television was usually playing throughout meals. AD and STNA were not sure why the meals were served on trays in the assisted dining room. Interview with STNA #9 on 02/05/19 at 12:30 P.M. confirmed meals were always served on trays without removing the plates from the trays for the meal service, and the television was usually playing throughout meals. STNA #9 confirmed the plates were not removed from the trays for meal service in the assisted dining room for the convenience of the staff. Page 1 of 17 366000 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Director of Nursing (DON) and Administrator on 02/07/19 at 5:00 P.M. confirmed the findings. Review of facility policy dated 12/28/18 titled Resident Dining Meal Service Program revealed the facility would endeavor to increase resident satisfaction with meal service and that the assisted dining room was in place to provide increased attention to meet the residents' needs. 366000 Page 2 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility's transfer and discharge policy, the facility failed to give written notification of transfer and failed to notify the State Long-Term Care Ombudsman Office when a resident was transferred to the hospital. This affected two (#43 and #83) of two residents reviewed for hospitalization. The facility census was 81. Findings include: 1. Review of Resident #83's closed medical record revealed an admission dated of 11/08/18. Diagnoses included jaundice, altered mental status and chronic obstructive pulmonary disease. Further review revealed Resident #83 was discharged to the hospital on [DATE], 12/15/18, and 01/02/19. The record was silent for any written notification of the resident's transfer to the hospital to the resident and/or resident's representative on these three dates. 2. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of right femur, subsequent encounter for closed fracture with healing, altered mental status, unspecified dementia with behavioral disturbance, Alzheimer's disease, and metabolic encephalopathy. Further review of Resident #43's medical record revealed on 11/27/18 the resident was sent to the hospital for evaluation. The medical record was silent of verification, that a notification of transfer was provided in writing to Resident #43 and/or representative. The facility was unable to provide any documentation of the State Long-Term Care Ombudsman office was being notified of Resident #83 and #43 transfers to the hospital. During an interview on 02/06/19 at 3:50 P.M. Administrative Coordinator (AC) #137 confirmed that written notices of discharges were not given to Resident #43 and #83 or their representatives and that the State Long-Term Care Ombudsman Office was not notified of their discharge/transfers. Review of the facility's policy titled Transfer and Discharge, dated 2018, revealed that transfer notices would be provided to the resident and representative as soon as practicable. Notices of resident transfers/discharges would be provided to the State Long-Term Care Ombudsman Office via a monthly list. 366000 Page 3 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's bed hold policy, the facility failed to give written notice of the facility's hold policies to two residents when they were transferred to to the hospital. This affected two (#43 and #83) of two residents reviewed for hospitalization. The facility census was 81. Findings include: 1. Review of Resident #83's closed medical record revealed an admission dated of 11/08/18. Diagnoses included jaundice, altered mental status and chronic obstructive pulmonary disease. Further review revealed Resident #83 was discharged to the hospital on [DATE], 12/15/18, and 01/02/19. The record was silent for any documentation of the resident or resident's representative was provided a written notice of the facilities bed hold policies for transfers on 12/01/18, 12/15/18 and 01/02/19. 2. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of right femur, subsequent encounter for closed fracture with healing, altered mental status, unspecified dementia with behavioral disturbance, Alzheimer's disease, and metabolic encephalopathy. Further review of Resident #43's medical record revealed on 11/27/18 the resident was sent to the hospital for evaluation. The record was silent for any documentation of the resident or resident's representative was provided a written notice of the facilities bed hold policies for transfers on 11/27/18. During an interview on 02/06/19 at 3:50 P.M., Administrative Coordinator (AC) #137 confirmed that bed hold policies were not given to Resident #43 and #83 or their representatives when they were transferred to the hospital. Review of the facility's policy titled Bed Hold Notice Upon Transfer dated 2017 revealed that in the event of emergency transfers of a resident, the facility would provide written notice of the facility's bed hold policies to the resident and representative within 24 hours after the transfer. 366000 Page 4 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0641 Ensure each resident receives an accurate assessment. 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 and staff interview, the facility failed to accurately assess the use of side rails as a restraint. This affected one (#14) of one resident reviewed for physical restraints. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record review for Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified lack of coordination, muscle weakness and Alzheimer's disease. Review of physician orders, dated 05/22/18, revealed Resident #12 was to have two transfer assist bars to assist with bed mobility and function. Review of the quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the resident had a physical restraints as indicated she used the bed rail daily. On 02/06/19 at 10:02 A.M., interview with MDS Coordinator Registered Nurse (RN) #39 revealed Resident #14 should not have had her bed rails coded as a physical restraint. The RN confirmed the bed rail was for used the resident's bed mobility and function. 366000 Page 5 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #16's medical record revealed an admission date of 04/04/15. Diagnoses included Parkinson's disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was moderately cognitively impaired. Review of physician orders revealed an order dated 08/07/18 to discontinue full code status and change it to Do Not Resuscitate Comfort Care (DNRCC). Review of the care plan with a target date of 02/05/19 revealed it stated Resident #16 desired to be a full code. During an interview on 02/06/19 at 12:54 P.M., Registered Nurse (RN) #39 confirmed Resident #16's care plan stated she was a full code and Resident #16 had been a DNRCC since ordered by physician 08/07/18. Based on record review, staff interview, and review of facility policy, the facility failed to ensure resident care plans reflected the residents' advanced directives regarding code status. This affected two (Resident #5 and #16) of three residents reviewed for advanced directives. The census was 81. Findings include: 1. Review of the record revealed Resident #5 was admitted on [DATE] with diagnoses which included dementia without behavioral disturbance and depression. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired Review of code status form in the front of the chart for Resident #5 revealed resident's code status was Do Not Resuscitate/Comfort Care (DNRCC). Review of care plan for Resident #5 initiated 11/10/16 revealed the care plan was silent regarding resident's code status. Interview on 02/07/19 at 10:58 A.M. with Social Services Designee #147 confirmed Resident #5's care plan was silent regarding resident's code status and that the nursing department usually initiated care plans regarding advanced directives. Interview on 02/07/19 at 11:18 A.M. with Registered Nurse #39 confirmed Resident #5's care plan was silent regarding resident's code status and that the social services department usually initiated care plans regarding advanced directives. Review of facility policy dated 2018 titled Care Plan Revisions Upon Status Change revealed resident care plans will be reviewed and revised as necessary to reflect resident's current status. 366000 Page 6 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

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, observation, staff and resident interview, and review of facility policy, the failed failed to assist residents with grooming. This affected one (Resident #50) of one residents reviewed for activities of daily living. The facility identified 72 residents who require assistance from staff or dependent on staff with dressing. The facility census was 81. Residents Affected - Few Findings include: Review of the record revealed Resident #50 was admitted on [DATE] with diagnoses which included diabetes mellitus and hypothyroidism. Review of the Minimum Data Set (MDS) assessment, dated 01/02/19, revealed the resident was cognitively impaired and required extensive assistance of one staff with personal hygiene including shaving. The MDS also revealed Resident #50 was coded negative for behavioral concerns, including refusal of care. Review of care plan, dated 10/12/18, revealed Resident #50 had a self care deficit related to obesity and impaired cognition. Interventions included the staff will assist with hygiene as needed and will encourage resident to do as much for herself as she can. Observation of Resident #50 on 02/04/19 at 12:30 P.M. and on 02/05/19 at 9:27 A.M. revealed the resident had multiple hairs growing from her chin. Observation and interview with Resident #50 on 02/05/19 at 9:27 A.M. confirmed the staff shave her facial hair sometimes when it needs it, but that it doesn't always happen as often as she would like. Resident #50 further confirmed she would like to be shaved daily so that she does not have hairs growing from her chin. The resident was observed to have multiple hairs growing from her chin at this time. Observation and interview with Resident #50 on 02/05/19 at 4:00 P.M. confirmed the staff shaved her facial hair at approximately 3:00 P.M. on 02/05/19. Interview with State Tested Nursing Assistant (STNA) #9 on 02/05/19 at 4:32 P.M. confirmed she had shaved Resident #50's facial hair at approximately 3:00 P.M. on 02/05/19. STNA further confirmed that female residents with facial hair should be shaved daily as needed and that Resident #50 was not able to shave herself. Review of policy dated 2019 titled Grooming a Resident's Facial Hair revealed the facility would assist residents with grooming facial hair to help maintain hair to help maintain proper hygiene 366000 Page 7 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interview, and policy review, the facility failed to ensure adequate supervision and resident education to prevent accidents related to resident operation of motorized wheelchairs. This affected one (Resident #59) of five residents reviewed for accidents. The facility identified three residents who utilize a motorized wheelchair. The facility census was 81. Findings include: 1. Review of the record revealed Resident #59 was admitted on [DATE] with diagnoses which included end stage renal disease and aftercare following surgical amputation. Review of Minimum Data Set (MDS) assessment, dated 01/09/19, revealed the resident was cognitively intact and was totally dependent on staff for activities of daily living and used a wheelchair for mobility. Review of care plan for Resident #59, dated 01/12/19, revealed the resident had bilateral above the knee amputations and the resident used a power wheelchair for mobility. Review of physical therapy evaluation for Resident #59, dated 06/21/17, revealed the resident used a power wheelchair and the resident demonstrate functional mobility with powered wheelchair within facility at supervision level. Review of therapy screening for Resident #59 dated 01/17/18 revealed the resident uses a power wheelchair independently. Review of record for Resident #59 revealed record does not include a motorized wheelchair assessment. 2. Review of record revealed Resident #21 was admitted [DATE] with diagnoses which included cerebral infarction and hemiplegia. Review of the MDS assessment, dated 11/15/18, revealed the resident was cognitively intact, required extensive assistance with activities of daily living and used a manual wheelchair for mobility. Observation on 02/05/19 at 9:28 A.M. revealed Resident #59 maneuvered his power wheelchair down the hall to his room. Resident #21 was seated in his manual wheelchair and was holding onto to the back of Resident #59's power wheelchair and was pulled down the hallway by Resident #59. Resident #59 pulled Resident #21 from the dining room to their room, a distance of approximately one hundred feet. Interview on 02/05/19 at 9:30 A.M. with Residents #59 and #21 confirmed Resident #59 used his motorized wheelchair to pull Resident #21 in his manual wheelchair down the hallway and said they do this almost daily. They stated that neither resident had sustained any accidents or injuries related to the practice. Both residents also confirmed they had not been educated of the possible hazards related to the practice. Interview with Licensed Practical Nurse (LPN) #135 on 02/05/19 at 9:45 A.M. confirmed he had witnessed Resident #59 pulling Resident #21 down the hallway. Interview also confirmed that he had not witnessed this behavior before 02/05/19, and that the practice of a resident in a motorized wheelchair pulling another resident in a manual wheelchair was unsafe. 366000 Page 8 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interviews with Registered Nurse (RN) #69 on 02/07/19 at 11:09 A.M. and with RN #4 at 11:11 A.M. confirmed they had witnessed Resident #59 pulling Resident #21 down the hallway multiple times, although they could not give specific dates and times. Both RNs confirmed they felt this practice was safe for the residents, provided Resident #59 didn't propel the motorized wheelchair with excessive speed. Interview with Rehab Manager #80 on 02/07/19 at 12:22 P.M. stated she had not witnessed Resident #59 pulling Resident #21 down the hallway on 02/05/19 at 9:28 A.M., but that she had witnessed Resident #59 pulling Resident #21 down the hallway multiple times in the past. The Rehab Manager confirmed the practice of a resident in a motorized wheelchair pulling another resident in a manual wheelchair was unsafe. The Rehab Manager confirmed Resident #59's record did not include a motorized wheelchair assessment and/or documentation of resident education on safe operation of a motorized wheelchair. Interview with the Administrator and Director of Nursing on 02/07/19 at 5:00 P.M. confirmed the findings. Review of facility policy titled Electric or Motorized Wheelchair Policy undated revealed the residents using motorized wheelchairs should be assessed annually for safety and that staff would monitor the resident for safety when using the motorized wheelchair. 366000 Page 9 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on record review, staff interview, and policy review, the facility failed to ensure nurse staffing information was posted daily. This had the potential to affect all 81 residents residing in the facility. Residents Affected - Many Findings include: Review of posted daily staffing information on 02/04/19 at 1:10 P.M. revealed form was dated 02/01/19. Interview with the Administrator on 02/04/19 at 1:15 P.M. confirmed daily staffing information posted in facility on 02/04/19 was dated 02/01/19. Administrator confirmed that daily staffing should be posted daily at the beginning of each day. Review of facility policy titled Nurse Staffing Posting Information dated 2018 revealed nurse staffing information will be posted on a daily basis at the beginning of each day. 366000 Page 10 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, interview with facility staff, the attending physician and a nurse practitioner, review of laboratory (lab) testing results, review of the facility policy titled Laboratory Services and Reporting, and review of the Medscape Guidelines 2019, the facility failed to ensure adequate monitoring was completed for one resident (Resident #43) who received the oral anticoagulant (blood thinning) medication, Coumadin. The failure to monitor the anticoagulant therapy resulted in Immediate Jeopardy and serious-life threatening harm to Resident #43 when the resident required transportation to the local emergency room (ER) with a critically elevated International Normalized Ratio (INR) level (used to monitor therapeutic levels of blood clotting) of 16.3 with urethral bleeding noted. This affected one (#43) of four residents who received anticoagulant medication. The facility identified three residents currently receiving anticoagulant medication at the time of the survey. The facility census was 81. Residents Affected - Few On 02/07/19 at 1:30 P.M., the Administrator, Regional Consultant #142, and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/16/18 when the facility failed to obtain a physician ordered lab (INR) test to monitor Resident #43's Coumadin level. The resident continued to receive Coumadin five milligrams (mg) without any INR monitoring until 11/27/18 when Licensed Practical Nurse (LPN) #64 discovered no lab monitoring had been done. LPN #64 obtained orders for the labs for the INR to be done the morning of 11/27/18. The lab results on 11/27/18 at 7:31 A.M. revealed Resident #43 had a critically elevated INR level of 16.3 (normal therapeutic range 2.0 to 3.0). The resident was sent to the local ER on [DATE] with a repeat INR level of 18.6 and received three doses of 2.5 mg of Vitamin K in an attempt to reverse the effects of the Coumadin medication. The ER nursing staff member also found signs and symptoms of Coumadin toxicity with blood in the resident's ureter. The Immediate Jeopardy was removed on 11/27/18 when the medical records of the remaining two residents receiving anticoagulant medications (#189 and #192) revealed the residents had INR levels within acceptable therapeutic ranges, were receiving appropriate laboratory monitoring, and no signs and symptoms of bleeding were noted. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/20/19, when the facility implemented the following corrective actions: • On 11/27/18, Resident #43 was sent to the hospital ER for evaluation and treatment. • On 11/27/18, the DON reviewed the medical records of the two other residents (#189 and #192), who were currently receiving anticoagulant medications, in the facility to ensure their INR levels were within acceptable therapeutic ranges and laboratory monitoring was being completed as ordered by the physician. There were no further issues identified. • On 11/28/18, Resident #43 returned from the hospital with a physician order to discontinue the anticoagulant medication, Coumadin. 366000 Page 11 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0757 • Level of Harm - Immediate jeopardy to resident health or safety On 02/07/19, Residents #58, #68 and #346 were identified by the facility as receiving Coumadin. The DON audited all three resident's medical records and verified physician ordered INR lab tests were being completed as ordered. Residents Affected - Few • On 02/07/19 at 1:15 P.M., in-service education was initiated by the DON, Registered Nurse (RN) Unit Managers #04, #69, #188 and RN Minimum Data Set (MDS) #04 for licensed facility nurses to reinforce the facility's lab policy and ensure physician ordered lab tests including Coumadin monitoring labs were completed as ordered. All education was completed for all licensed nurses working in the facility on this date at 2:18 P.M. Starting on 02/07/19 at 1:15 P.M., any licensed nurse or agency nurse who was not working or on leave will complete the in-service education prior to starting their next shift. • On 02/07/19 at 2:00 P.M., a Quality/Continuity of Care Worksheet was completed for all three residents on Coumadin in the facility (Residents #58, #68, and #346). All residents in the facility have current monitoring per physician orders. The worksheet will be completed by the DON or designee daily for four weeks, then twice a week for four weeks then weekly for four weeks. If issues are noted, the DON or designee will take appropriate action at the time the concern is noted. Results of the worksheet will be reported to the Quality Assurance (QA) committee for a determination of the need for further on-going formal monitoring. • On 02/07/19 at 2:15 P.M., a QA meeting was held with Medical Director #450, the DON, Administrator, Licensed Nurses, Activity Director, Dietary Manager, and Dietician to review the facility's Coumadin policy, Coumadin Monitoring, and to discuss the plan of correction. Action plans to address the deficiency as well as review the policy and overall system were reviewed and approved by the QA committee. On 02/08/19, a second full QA meeting will be held to review the plan of correction and to review initial audit findings. At that time, the committee will determine if the plan implemented is effective. The QA committee will continue to monitor through the usual committee process and make recommendations if indicated. • On 02/07/19 from 3:00 P.M. to 4:00 P.M., nursing staff interviews were conducted with LPN #01, LPN #03, LPN #19 and RN #04, RN #26, and RN #69 who were employed by the facility. All LPN's and RN's interviewed verified recent education on anticoagulants including Coumadin, using the monitoring tool to track Protime (PT)/INR levels, Coumadin orders and lab orders. • On 02/07/19, review of current medical records of the three residents (#58, #68 and #346) currently receiving anticoagulant medications, and five closed medical records of residents (#188, #189, #190, #191 and #192) who received anticoagulants while in the facility were conducted to ensure the 366000 Page 12 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0757 residents were receiving the accurate dosage of the medication and had INR monitoring as ordered by the physician from 11/16/18 through 02/07/19. There were no other issues identified with these eight records. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On 02/20/19, review of medical records for two residents (#58 and #68) revealed there was evidence the residents were receiving the accurate dosage of the medication and the INR was completed as ordered by the physician. • On 02/20/19, the facility had completed all Coumadin administration and INR level audits on a daily basis and there were no issues identified. Findings include: Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of right femur, subsequent encounter for closed fracture with healing, difficulty walking, unsteadiness on feet, altered mental status, unspecified dementia with behavioral disturbance, Alzheimer's disease, type two diabetes mellitus and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment and was totally dependent on staff for bed mobility and transfers. Review of the anticoagulant plan of care, dated 11/01/18, revealed interventions to give medications as ordered and to monitor and document for side effects and effectiveness. Additional interventions included to monitor laboratory values to monitor and document the effect of anticoagulant therapy, and report values outside desired range. Review of the medical progress notes revealed on 11/14/18 at 1:00 P.M., LPN #12 documented the resident was seen by the wound nurse and ordered a venous Doppler (an ultrasound examination of the veins) for his right lower extremity due to increased swelling. Review of the results of the Venous Doppler dated 11/14/18 revealed the resident had an acute nonocclusive Deep Vein Thrombosis (DVT) in the right lower extremity. Review of the physician orders revealed an order dated 11/15/18 for the anticoagulant Coumadin five mg once a day for DVT to right lower extremity. A PT/INR value to be drawn on Friday, 11/16/18. There was no evidence the PT/INR lab value was completed as ordered by the physician from 11/16/18 through 11/26/18. Review of the physician orders, dated 11/27/18, revealed Nurse Practitioner (NP) #800 ordered a PT/INR lab value to be completed. Review of laboratory results dated [DATE] at 7:30 A.M. revealed the resident's INR level was critically high at 16.3. NP #800 was notified and ordered Resident #43 to be sent to the hospital for evaluation and treatment. Review of the nursing progress notes from 11/15/18 to 11/27/18 revealed no negative findings of the effects of the anticoagulant medication. 366000 Page 13 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the Medication Administration Record (MAR) from November 2018 for Resident #43 revealed the resident received five mg of Coumadin as ordered at 5:00 P.M. daily from 11/15/18 to 11/26/18 until the resident was sent to the hospital for evaluation and treatment on 11/27/18. Review of the hospital discharge summary revealed Resident #43 was admitted on [DATE] due to significant, elevated INR level of 16.3., repeat blood work was done in the hospital ER and revealed an elevated INR level of 18.6. The assessment and plan revealed the resident had severe coagulopathy secondary to Coumadin with an INR level of 18.6 status post Vitamin K 2.5 mg oral for three doses. Hemoglobin and Hematocrit were stable at 12.1 and a repeat INR level of 4.7. Resident #43 was given three doses of Vitamin K 2.5 mg orally to reverse the effects of Coumadin and the INR improved to the level of 4.7. There were no active signs of bleeding noted except for mild urethral bleeding. The hospital discharged the resident back to the facility on [DATE]. The physician ordered to discontinue Coumadin and continue Lovenox (blood thinner) 40 mg injection daily for DVT prophylaxis. Interview on 02/07/19 at 9:59 A.M., with the DON and RN Unit Manager #69 verified the physician ordered PT/INR level for 11/16/18 was not completed. The order was put into the electronic system, but the lab order was missed. RN #69 stated she was notified by LPN #64 the morning of 11/27/18 when she discovered it and obtained orders for the PT/INR to be drawn that morning. Telephone interview on 02/07/19 at 2:00 P.M. with the attending Physician #680 revealed he recalled being notified by NP #800 that Resident #43 had critically elevated PT/INR lab results and was sent to the hospital for evaluation and treatment. Telephone interview on 02/07/19 at 3:00 P.M. with NP #800 revealed the facility notified her of the critical lab results on 11/27/18, and she ordered the facility to send the resident to the hospital for evaluation and treatment. An attempt to interview LPN #64 during the survey was unsuccessful. Review of the facility policy titled, Laboratory Services and Reporting, dated November 2017, revealed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with the state law. Review of the medication information titled Medscape Guidelines 2019 revealed Coumadin was an anticoagulant and used as treatment of deep vein thrombosis, myocardial infarction, pulmonary embolism, rheumatic heart disease with heart valve damage, prosthetic heart valves and chronic atrial fibrillation. Under black box warning it indicated Coumadin can cause major or fatal bleeding; bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR greater that 4), and age sixty-five years or older. Regular INR monitoring of INR should be performed on all treated patients; those at high risk for bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR and a shorter duration of therapy is recommended. 366000 Page 14 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to maintain accurate medical records regarding resident code status. This affected two (Resident #5 and #43) of three residents reviewed for advanced directives. The facility census was 81. Findings included: 1. Review of record revealed Resident #5 was admitted on [DATE] with diagnoses which included dementia without behavioral disturbance and depression. Review of code status form in the front of the chart for Resident #5 revealed resident's code status was Do Not Resuscitate/Comfort Care (DNRCC). Review of Medication Administration Record (MAR) for Resident #5 for February 2019 for Resident #5 revealed resident's code status was full code. Review of monthly physician order summary for Resident #5 for February 2019 revealed resident was listed both as a full code and as DNRCC. Review of telephone order dated 01/15/19 for Resident #5 revealed resident was a DNRCC. Review of the face sheet for Resident #5 revealed resident was a full code. Review of care plan for Resident #5 initiated 11/10/16 revealed the care plan was silent regarding resident's code status. Interviews with Licensed Practical Nurse (LPN) #19 on 02/05/19 at 4:13 P.M., with LPN #6 at 4:14 P.M., and LPN #28 confirmed resident code status can be found under the advanced directive tab in the resident's hard chart and that it also can be found on the face sheet, the MAR, the monthly physician orders, and the resident's care plan. LPN interviews further confirmed that the code status listed in multiple places of the residents' records should always match. LPN #28 confirmed that DNRCC was the correct code status for Resident #5. Interview with the Administrator and the Director of Nursing (DON) on 02/07/18 at 5:00 P.M. confirmed the findings. 2. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of right femur, subsequent encounter for closed fracture with healing, altered mental status, unspecified dementia with behavioral disturbance, Alzheimer's disease and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment, and was totally dependent on staff for bed mobility and transfers. Review of the residents medical record revealed physician orders dated November 2018 with Resident 366000 Page 15 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #43's advanced directive code status listed as Full Code. Further review of Resident #43's medical record revealed resident had a signed DNR identification form indicating his wished to be Do Not Resuscitate Comfort Care (DNRCC) dated 07/18/17. On 02/05/19 at 4:41 P.M., during an interview with Registered Nurse (RN) Unit Manager #28 confirmed Resident #43's February 2019 physician orders did not match the DNR identification form indicating his wishes to be Do Not Resuscitate Comfort Care (DNRCC) dated 07/18/17. Review of facility policy dated 2018 titled Communication of Code Status revealed that the resident's code status should be included in the hard copy of the record under the tab titled advanced directives and also in the electronic medical record. Review of policy also revealed that the purpose of the policy is to accurately communicate the resident's code status to the staff. 366000 Page 16 of 17 366000 02/20/2019 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, and review of facility checklist, the facility failed to ensure the dryers used for resident clothing were maintained in safe operating condition. This had the potential to affect all 81 residents residing in the facility. Findings include: Observation on 02/07/19 at 11:24 A.M. revealed there was a heavy buildup of lint accumulated in the lint traps for both dryers in the facility laundry. One dryer was running and the other dryer was empty and not running at the time of the observation. Observation on 02/07/19 at 11:26 A.M. revealed Laundry Aide #130 removed the heavy accumulation of lint from both dryers using a dust pan and broom. Interviews on 02/07/19 at 11:26 A.M. with Laundry Aide #123 and at 11:28 A.M. with Laundry Aide #130 confirmed there was a heavy accumulation of lint in the traps for both dryers and that the lint traps were supposed to be cleaned at the end of each shift. Interviews also confirmed that the lint traps should have been cleaned at the end of second shift at approximately 10:30 P.M. on 02/06/19. Interview on 02/07/19 at 11: 35 A.M. with Maintenance Director #133 confirmed that the lint traps to the dryers should be cleaned at the end of every shift. Interview further confirmed that the laundry aides did not utilize the laundry checklist to track and document cleaning of the lint traps and that he had no record of the last time the lint traps to the dryer had been cleaned. Review of checklist undated titled Laundry Checklist revealed the lint traps to the dryers should be cleaned at the end of every shift. The checklist had a box for staff to document the cleaning of the lint traps. 366000 Page 17 of 17