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. (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 4 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 11/12/2024 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)