F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on medical record review, observation, staff interview, resident interview and review of the facility
policy, the facility failed to ensure all medications were stored securely. This affected two (Residents #11
and #22) of seven residents reviewed for medication storage and had the potential to affect four residents
(#41, #48, #68, #72) identified by the facility as being independently ambulatory and cognitively impaired.
The facility census was 97.
Findings include:
1.Review of the medical record for Resident #11 revealed an admission date of 12/14/23 with diagnoses
including displaced fracture of right lower leg and protein calorie malnutrition.
Review of the admission orders for Resident #11 dated 12/14/23 revealed the resident did not want to
self-administer medications.
Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 12/20/23 revealed the resident
had intact cognition.
Review of the physician orders for Resident #11 revealed an order dated 02/07/24 carboxymethylcellulose
sodium one drop per eye two times a day for dry eyes.
Observation of medication administration for Resident #11 on 02/15/24 at 8:24 A.M. per Licensed Practical
Nurse (LPN) #176 revealed the nurse could not locate the resident's eye drops in the medication cart. LPN
#176 asked Resident #11 if he knew where his eye drops were located. Resident #11 reached for his
personal bag on the floor next to his bed and told LPN #176 that someone had given him the eye drops last
night and he had kept them in his bag.
Interview on 02/15/24 at 8:30 A.M. with LPN #176 confirmed Resident #11 did not have an order for
self-administration, and the eye drops should be stored in the medication cart.
2. Review of the medical record for Resident #22 revealed an admission date of 10/04/23 with diagnoses
including end stage renal disease, acute osteomyelitis right foot and ankle, type two diabetes mellitus,
cerebral infarction, Crohn's disease, multiple sclerosis, and peripheral vascular disease.
Review of physician orders for Resident #22 revealed orders dated 10/06/23 for sevelamer carbonate 800
milligrams (mg) give four tablets by mouth with meals for end stage renal disease- may keep at bedside
and PhosLo capsule give one capsule by mouth with meals-may keep at bedside.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
366000
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
02/15/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Review of the MDS assessment for Resident #22 dated 01/08/24 revealed the resident was cognitively
intact.
Observation on 02/13/24 11:04 A.M. revealed a bottle of sevelamer carbonate and a bottle of PhosLo were
sitting on Resident #22's bed side table, and the resident was in the room.
Residents Affected - Few
Interview on 02/13/24 at 11:04 A.M. with Resident #22 confirmed she self-administered sevelamer
carbonate and PhosLo because she needed to take the medications when she ate.
Review of the medication self-administration evaluation for Resident #22 dated 01/06/24 revealed the
resident was able to self-administer PhosLo and sevelamer carbonate. Resident #22 was cognitively intact
and was able to demonstrate secure storage of the medications in her room. The physician gave an order
for the resident to self-administer PhosLo and sevelamer carbonate.
Observation on 02/14/24 at 1:48 P.M. revealed Resident #22's room door was open, and resident was not
in the room. There was a bottle of PhosLo and a bottle of sevelamer carbonate sitting on the resident's
bedside table.
Interview on 02/14/24 at 1:49 P.M. with the Director of Nursing (DON) confirmed Resident#22 was not in
the room and there was a bottle of PhosLo and a bottle of sevelamer carbonate sitting on the resident's
bedside table. The DON confirmed the resident was supposed to lock up her medications in her bedside
dresser when she was not in the room.
Interview on 02/14/24 at 1:59 P.M. with Licensed Practical Nurse (LPN) #200 confirmed Resident #22 had
left her medications unattended on prior occasions and she had spoken to Resident #22 about the need to
ensure her medications were locked up when she was not in the room.
Review of the facility policy titled Medication Storage dated December 2012 revealed the facility would
ensure medications were securely stored in a locked cabinet/cart or locked medication room.
Review of the facility policy titled Self Administration of Medication dated February 2022 revealed residents
had the right to self-administer medications if the Interdisciplinary Team (IDT) had determined it was
clinically appropriate. If a resident requested to self-administer medications the IDT was responsible for
determining if it was safe for the resident to do so.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366000
If continuation sheet
Page 2 of 2
