Health inspection·March 5, 2020

F 0580 not administered to the resident on 02/19/20 and 02/20/20. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366000 If continuation sheet Page 2 of 5 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 366000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, staff interview, policy review and review of medication information from Medscape, the facility failed to ensure a resident was free from unnecessary medications when the staff failed to follow physician ordered parameters regarding the administration of a cardiac medication. This affected one (#29) of five residents reviewed for unnecessary medications. The facility census was 88. Residents Affected - Few Findings included: Medical record review for Resident #29 revealed an admission date of 08/30/19. Medical diagnoses included hypertension and cerebrovascular accident with impairment to left side. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed she cognitively intact. Functional status was total dependence for bed mobility and transfers with two-person assistance. She was total dependence for toilet use with one-person assistance and supervision for eating with set-up help. Review of physician orders dated 08/31/19 revealed Cardizem 24-hour to give 240 milligrams (mg) by mouth in the morning for hypertension and hold if pulse was less than 70 beats per minute (bpm). Review of Medication Administration Record (MAR) from 12/01/19 through 12/31/19 for Resident #29 revealed there were nine dates the Cardizem was administered where the pulse was less than 70 bpm. Those dates were 12/10/19, 12/11/19, 12/14/19, 12/15/19, 12/16/19, 12/24/19, 12/27/19, 12/28/19 and 12/29/19. Further review of the MAR from 01/01/20 through 01/31/20 revealed there were ten dates the medication was administered with a pulse documented less than 70 bpm. Those dates were 01/01/20, 01/02/20, 01/04/20 ,01/06/20, 01/07/20, 01/10/20, 01/11/20, 01/12/20, 01/14/20, and 01/31/20. Review of the MAR from 02/01/20 through 02/29/20 revealed there was ten times the medication was given with a pulse less than 70. Those dates were 02/02/20, 02/06/20, 02/08/20, 02/12/20, 02/15/20, 02/19/20, 02/20/20, 02/22/20, 02/26/20 and 02/27/20. Interview with the Director of Nursing (DON) on 03/05/20 at 10:28 A.M. verified the above mentioned dates the Cardizem was given during the time frame to the resident with a pulse of less than 70. Review of policy entitled Change of Condition revised 06/01/15 revealed the facility staff will reported identified significant changes in resident's status. Documentation of the condition will be noted in the nursing notes or interdisciplinary charting. The resident's physician will be notified of significant changes in the resident's condition. Review of medication information from Medscape revealed Cardizem is a cardiac medication used to treat angina (chest pain), hypertension, paroxysmal supraventricular tachycardia (fast heart beat) and atrial fibrillation/flutter FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366000 If continuation sheet Page 3 of 5 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 366000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342 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 0760 Ensure that residents are free from significant medication errors. 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, cubex (emergency medication box) supply list review, staff, Nurse Practitioner and physician interviews, policy review and review of medication information from Medscape, the facility failed administer medications as ordered by the physician resulting in significant medication errors. This affected one (#17) of five residents review for unnecessary medication. The census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE] at 5:07 P.M. Diagnoses include seizures, idiopathic epilepsy, venous thrombosis, protein calorie malnutrition, chronic respiratory failure, dysphagia, malformation of brain, disorder of psychological development, repeated falls, hypertension, and, ataxia. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #17 required extensive assist of one person for bed mobility, locomotion, and walking. The resident required extensive assistance of two for transfers and was dependent upon staff for dressing and eating. A brief interview of mental status was not completed because the resident was rarely/never understood. The assessment revealed the resident had long term memory problems and was not able to recall the current season, location of own room, staff names/faces, or the he/she was in a nursing home. Review of a medication administration record (MAR) dated 02/20 revealed the medications prescribed to be administered to Resident #17 on 02/19/20 at 9:00 P.M. were unavailable. The medication identified as unavailable for administration included lacosamide tablet (anticonvulsant) 200 milligram (mg); ativan (anticonvulsant/antianxiety) one mg, Phenobarbital tablet (anticonvulsant) 64.8 mg; phenytoin sodium (anticonvulsant) 100 mg with 30 mg give two capsules (total of 160 mg); Eliquis (anticoagulant) five mg; Losartan potassium (antihypertensive) 25 mg; and Mucinex (expectorant) 600 mg. Continued review of the MAR revealed ativan one mg was not available to be administered on 02/20/20 at 9:00 P.M. Review of a document titled, Cubex Formulary undated revealed the medications Eliquis 2.5 mg (supply of eight), Mucinex 600 mg (supply of 10), Phenobarbital 32.4 mg (supply of 10), phenytoin 100 mg (supply of six), phenytoin 50 mg chew tablet (supply of five), ativan one mg (supply of two), Losartan 25 mg (supply of 10) where listed as available for resident use in the facilities emergency medication supply. The only medication not listed as available in the emergency medication supply was lacosamide. Interview on 03/04/20 at 8:33 A.M. with the Director of Nursing (DON) revealed when a resident was admitted to the facility and had physician ordered medication due for administration, the medications could be obtained from the facilities emergency medication supply. The DON further revealed if a medication was not available in the emergency box supply then the physician would be notified for further direction. Continued interview with the DON revealed the code 16, when documented on a residents MAR, indicated the medication was not available from pharmacy. The DON verified documentation on the MAR dated 02/20 for Resident #17 revealed medications scheduled at 9:00 P.M. on 02/19/20, which included ativan one mg; Phenobarbital 64.8 mg; phenytoin sodium 160 mg; lacosamide 200 mg; Eliquis 5 mg; Losartan potassium 25 mg; and Mucinex 600 mg was not not available from pharmacy. The DON further verified the ativan scheduled on 02/20/20 at 9:00 P.M. was documented as unavailable. The DON confirmed the medications that were documented as unavailable on 02/19/20 and 02/20/20 were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366000 If continuation sheet Page 4 of 5 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 366000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administered to Resident #17. Continued interview with the DON verified six of the seven medications that were documented on the resident MAR as unavailable, were identified on the cubex formulary and available in the emergency medication supply. Interview on 03/04/20 at 8:58 A.M. with Physician #239 (Resident #17 primary care physician) revealed when medication were available in the facilities emergency supply and there was a valid prescription, it would be expect that the medications would be administered. Interview with the physician revealed the only medication that should have been held for Resident #17 on 02/19/20 at 9:00 P.M. was the lacosamide, because it was not available in the emergency box. Continued interview with Physician #239 revealed on this day, 03/04/20, the facility spoke with this physician in regards to the medications that were placed on hold on 02/19/20 by the on call nurse practitioner. The interview revealed it was this physician's professional opinion that the available medications should have been administered as ordered. Interview with the physician revealed the physician was made aware of the 02/19/20 medications being placed on hold on 03/04/20 and the physician was asked to sign the telephone ordered for the held medication on 03/04/20, even though the telephone order indicated the order was signed by this physician on 02/19/20. The physician did not know who documented the sign date as 02/19/20. Interview 03/04/20 at 10:37 A.M. with Nurse Practitioner (NP) #238 (on call for Physician #239 on 02/19/20) revealed facility staff called the NP on 02/19/20, and a verbal order was given to hold unavailable medications until they were available the next morning. Interview with NP #238 revealed the NP was not aware of the facility having an emergency medication supply. Further interview with the NP revealed it was the NP's expectation that any medications which had a valid order and was available in the emergency supply would be administered to Resident #17 and not be held until the next morning. Review of a policy titles, Emergency Boxes and On-Site Stores, dated 06/21/17, revealed the pharmacy supplies an emergency box and other on-site stores of medications to be utilized by he facility in the case of new admissions, urgent new orders received after hours, or when immediate medication administration was required. When receiving a new medication order that needs to be administered prior to the next pharmacy delivery, the nurse obtaining the order should check the on-site store list prior to accepting the order from the physician to see if that medication is available in the facility. If not, the physician should be informed of the available medications to determine if an alternative can be ordered. Review of medication information from Medscape revealed the following: Ativan is used as an antianxiety; Phenobarbital is an anticonvulsant (anti-seizure); Phenytoin sodium is an anticonvulsant; Eliquis is an anticoagulant; Losartan is used to treat hypertension and Mucinex is used to treat a cough. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366000 If continuation sheet Page 5 of 5