Health inspection·November 12, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Based on medical record review, staff interviews, and policy review, the facility failed to ensure a resident was permitted to stay in the facility once payer source changed from Medicare Part A to private pay. This affected one (#100) out of the three residents reviewed for discharges. The facility census was 98. Finding includes: Review of the medical record for the Resident #100 revealed an admission date of 09/15/24 with medical diagnoses of nontraumatic subarachnoid hemorrhage, cirrhosis, hepatic encephalopathy, anorexia, and congestive heart failure. Review of the medical record for Resident #100 revealed a discharge date of 11/10/24. Review of the medical record for Resident #100 revealed an admission Minimum Data Set (MDS) assessment, dated 09/21/24, indicated Resident #100 had moderately impaired cognition and required partial/moderate staff assistance with eating, bed mobility, and transfers, was dependent upon staff for toilet hygiene, and required substantial/maximum staff assistance for bathing. Review of the medical resident #100 revealed a Social Service note dated 11/05/24 which stated Resident #100's daughter was notified the Medicare services would be exhausted on 11/06/24 and Resident #100 would be private pay. The note stated Resident #100's daughter asked the facility to begin the Medicaid process. The note stated Social Service notified Resident #100's daughter that Resident #100 did not have a power of attorney (POA) and because Resident #100 was severely cognitively impaired the facility would ask for a statement of expert evaluation from the physician prior to starting the Medicaid process. Review of the medical record for Resident #100 revealed no documentation to support the facility issued Resident #100 a 30-day discharge notice. Interview on 11/12/24 at 1:42 P.M. with Social Service Director (SSD) #202 stated she spoke with Resident #100's daughter on 11/06/24 about starting the Medicaid process and informed the daughter that Resident #100 did not have a POA, so the facility needed to get guardianship before the Medicaid application process started. SSD #202 stated she completed the paperwork for Resident #100's expert evaluation and placed the paperwork into the physician's mailbox to review and sign. SSD #202 stated before the physician could review the paperwork, Resident #100's family took Resident #100 with home health. SSD #202 confirmed Resident #100 would have been private pay until Medicaid application was approved but Medicaid would pay the Resident #100's balance from the date of the Medicaid application. Page 1 of 4 366000 366000 11/12/2024 Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/12/24 at 2:45 P.M. with Administrator stated Resident #100 had exhausted her Medicare A days and she would become private pay on 11/07/24. Administrator stated she informed Resident #100's daughter that the facility did not have a long-term care bed available, so the facility would assist with transferring Resident #100 to another facility. Administrator confirmed all facility beds were dually certified Medicare and Medicaid. Administrator stated the facility had not issued any 30- day discharge notices in the past six months. Administrator confirmed the family chose to take Resident #100 home instead of transferring to another facility. Review of the facility policy titled. Resident Transfer-Discharge Rights from the Facility, revised October 2022, stated the facility shall permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility, the transfer or discharge was appropriate because the resident's health has improved sufficiently so the resident on longer needs the services provided at the facility, the resident's urgent medical needs necessitated an immediate transfer, the safety or health of individuals in the facility was endangered due to the clinical or behavioral status of the resident, the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility or the facility ceases to operate. The policy stated transfers and discharges are permitted to take place even if a Medicaid application is pending, if the application is similar to a previous one, which was denied. This deficiency represents non-compliance investigated under Complaint Number OH00159674. 366000 Page 2 of 4 366000 11/12/2024 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. Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure wound care was documented in medical record. This affected one (#80) out of the three residents reviewed for wound care. The facility census was 98. Findings include: Review of the medical record for Resident #80 revealed an admission date of 08/19/23 with medical diagnoses of respiratory failure, diabetes mellitus with chronic kidney disease, chronic venous hypertension, congestive heart failure, and schizoaffective disorder. Review of the medical record for Resident #80 revealed a quarterly Minimum Data Set (MDS) assessment, dated 10/30/24, which indicated Resident #80 had moderately impaired cognition and was dependent for bathing, toileting hygiene, and transfers. The MDS indicated Resident #80 was always incontinent of bladder and bowel. Review of the medical record for Resident #80 revealed a weekly wound progress note, dated 11/04/24, which stated Resident #80 had moisture associated skin damage (MASD) to right buttock and unstageable pressure ulcer to right distal buttock which was acquired 09/02/24. Review of the medical record revealed weekly skin assessments were completed and treatment orders were in place. Review of the medical record for Resident #80 revealed a physician order dated 05/01/24 to cleanse, pat dry and to apply remedy skin cream 1.5% to bilateral buttocks two times per day, an order dated 05/13/24 for low air loss mattress, and an order dated 10/31/24 to cleanse right distal buttock with normal saline, pat dry, apply calcium alginate, apply gauze, and cover with island bordered dressing daily and as needed. Review of the medical record for Resident #80 revealed the November 2024 Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) did not contain documentation to support the facility completed wound care to right distal buttock wound as ordered from 11/01/24 to 11/11/24. Interview on 11/12/24 at 1:07 P.M. with Resident #80 confirmed he received wound care to his right buttock daily but stated at times he would refuse cares. Interview on 11/12/24 at 2:16 P.M. with Director of Nursing (DON) confirmed Resident #80's medical record did not contain documentation to support wound care to right distal wound was completed as ordered 11/01/24 to 11/11/24. DON stated the order for the treatment was not entered into the electronic health record (EHR) correctly but stated the staff had completed the wound care as ordered because Resident #80 had the wound for a long time and staff was aware that the wound care needed completed daily. Interview on 11/12/24 at 3:25 P.M. with Licensed Practical Nurse (LPN) #210 confirmed she provided care for Resident #80 and performed wound care on 11/06/24 and 11/07/24. LPN #210 stated Resident #80 would require multiple dressing changes in one day due to incontinence. LPN #210 denied any concern that Resident #80's wound care to right distal buttock was not changed at least daily from 11/01/24 to 11/11/24. 366000 Page 3 of 4 366000 11/12/2024 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 Interview on 11/12/24 at 3:28 P.M. with LPN #211 confirmed she worked 11/08/24 and 11/09/24 on night shifts and completed wound care to Resident #80's right distal buttock. LPN #211 stated Resident #80 had the wound for a while and she knew that treatment needed to be done. LPN #211 stated she was not aware the order was entered into the EHR incorrectly or that staff had not been documenting wound care completion. LPN #211 stated Resident #80's dressing to right distal buttock would be changed more than one time per shift because of bowel incontinence. LPN #211 denied any concern that Resident #80 wound care to right distal buttock was not changed daily from 11/01/24 to 11/11/24. Interview on 11/12/24 at 3:41 P.M. with Registered Nurse (RN) #212 stated she provided care for Resident #80 between 11/01/24 and 11/11/24. RN #212 stated she was not aware the order for treatment to the right distal buttock was not entered into the EHR correctly but stated staff knew Resident #80 had the wound to his right buttock and completed the treatment as ordered. RN #212 denied any concern that Resident #80's wound care to right distal buttock was not completed daily. Review of the facility policy titled, Skin Preventive Measures, stated staff would verify treatment orders after evaluation and documentation of wound. This deficiency represents non-compliance investigated under Complaint Number OH00159674. 366000 Page 4 of 4