Health inspection·December 7, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and resident and staff interviews, the facility failed to ensure Resident #37 had access to her call light at all times. This affected one resident (Resident #37) of 19 residents reviewed for accommodation of needs. Residents Affected - Few Finding include: Review of Resident #37's medical record identified admission to the facility occurred on 08/11/14 with medical diagnosis including obstructive hydrocephalus, convulsions, COPD, malignant neoplasm of breast, neoplasm of bone, schizoaffective disorder, dysphasia, panic disorder and low back pain. The [AGE] year old was identified to be wheelchair dependent. Review of the 10/10/22 Quarterly Minimum Data Set (MDS) Assessment identified Resident #37 was dependent on staff for all Activates of daily living. Review of the plan of care for Resident #37 identified Clip to call light to bed and encourage resident to use for help. Interview with Resident #37 occurred on 12/04/22 at 10:02 A.M. in her room. Resident #37 was observed at that time without her call light. Resident #37's tilt-in-space wheelchair was positioned near the bathroom door. The call light was located under Resident #37 and not in reach. Resident #37 identified she could not access the call system from where she is located. Observation on 12/04/22 at 1:19 P.M. revealed the call light remained in the same position and was not accessible to Resident #37. Observation of Resident #37 occurred on 12/07/22 at 7:39 A.M. Resident #37 was positioned in her wheelchair near the bathroom without access to her call light. Interview with Licensed Practical Nurse (LPN #102) occurred on 12/07/22 at 7:39 A.M. LPN #102 confirmed Resident #37 was positioned near the bathroom door and not near her bed. The interview confirmed Resident #37 does not have access to her call light in this position. Page 1 of 6 366024 366024 12/07/2022 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, facility policy review, and staff interview, the facility failed to report an alleged incident of misappropriated narcotics to the State Survey Agency within five working days of the incident. This affects one resident (Resident #37) of six residents reviewed for controlled narcotic medication. Findings include: Review of the medical record for Resident #37 revealed an admission date of 08/11/14. Resident #37's diagnoses included malignant neoplasm of breast, neoplasm of bone and low back pain. Review of Resident #37's physician orders revealed orders for oxycodone 5 milligrams (mg) give 1 tablet by mouth every four hours as needed for pain to low back and may have two tablets every four hours for pain. Review of the missing medications investigation dated 06/22/22 revealed on 06/22/22 during the narcotic reconciliation count with Licensed Practical Nurse (LPN) #102 and LPN #218 there was a discrepancy with Resident #37's oxycodone tablet 5 milligrams (mg) cards in the narcotic drawer. Resident #37 had three cards of oxycodone 5 mg in the narcotic drawer. Card #1 identified with Rx# 26937782 revealed there were 53 pills in the bubble pack. The Controlled Drug Receipt/Record/Disposition Form revealed Card #1 should have had #54 pills. Card #2 identified with Rx# 27335479 revealed there were 59 pills in bubble pack card. The controlled drug receipt/record/disposition form revealed there should have been 60 pills in Card #2. Card #3 identified with Rx# 27684929 revealed there were 58 pills in the bubble pack card. The Controlled Drug Receipt/Record/Disposition Form revealed the card should have had 60 pills in total Resident #37 had five missing oxycodone 5 mg in total. Interview on 12/04/22 at 1:46 P.M. with LPN #102 stated on 06/22/22 she was coming on shift at 7:00 A.M. and was doing narcotic count with LPN #218. LPN #102 stated when she pulled Resident #37 oxycodone card out, she noticed there was a missing pill at the bottom of the card. During the whole narcotic count, it was identified Resident #37 had three cards of oxycodone 5 mg with four pills missing and not accounted for. LPN #102 notified the supervisor. Interview on 12/05/22 at 4:12 P.M. with the Director of Nursing (DON) and Administrator revealed LPN #102 identified a discrepancy in the narcotic count with LPN #218. There were four missing oxycodone not accounted for. The Administrator verified there was a breakdown in documenting medications. The Administrator and DON verified they were not able to physically account for the four missing pills but felt the missing medications were actually a documentation and system breakdown. The Administrator verified she did not feel any misappropriation or diversion had occurred, so she did not report to appropriate authority of the incident. Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16 revealed all investigations should be reported to the administrator, other officialism accordance with state law, including to the State Survey Agency, within five working days of the incident. 366024 Page 2 of 6 366024 12/07/2022 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

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 observations, medical record review, and resident and staff interviews, the facility failed to ensure Resident #37 and Resident #148 received assistance with activities of daily living (ADL). This affected two residents (Resident #37 and Resident #148) of three residents reviewed for ADL. Residents Affected - Few Findings include: 1. Review of Resident #37's medical record identified admission to the facility occurred on 08/11/14 with medical diagnosis including obstructive hydrocephalus, convulsions, malignant neoplasm of Breast and bone, schizoaffective disorder, dysphasia, panic disorder, and low back pain. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed #37 was dependant on staff for ADL, including hygiene and bathing. Interview and observation with Resident #37 on 12/04/22 at 10:02 A.M. revealed she had multiple long hairs across her chin. Resident #37 was asked if the hair on her chin bothered her. Resident #37 confirmed the long hairs on her chin did bother her and she would like it removed. Resident #37 had long fingernails which she confirmed did not bother her. Observation with State Tested Nursing Assistant (STNA #213) occurred on 12/04/22 at 1:19 P.M. The observation confirmed Resident #37 had long chin hairs covering the bottom of her chin. The interview confirmed Resident #37 was dependant on staff for ADL's. 2. Review of Resident #148's medical record identified admission to the facility occurred on 11/16/22 with medical diagnosis which included Alzheimer's disease, need assistance with personal care, high blood pressure, hearing loss, dementia and anxiety. Review of the MDS dated [DATE] revealed Resident #148 was dependent on staff for activities of daily living and was severely cognitively impaired. The assessment identified Resident #148 was totally dependent on staff for bathing/grooming. Review of Resident #148's written plan of care identified Resident #148 required total assistance with grooming including fingernails, shaving and hair. Observations of Resident #148 occurred on 12/04/22 at 9:40 A.M. The observation identified Resident #148 had a significant amount of facial hair and quite long fingernails with brown dirty substance under them. Resident #148 revealed they should be clipped. Observation of Resident #148 occurred with the facility Administrator on 12/05/22 at 1:30 P.M. The Administrator confirmed Resident #148's chin hair and fingernails needed attention. 366024 Page 3 of 6 366024 12/07/2022 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure new pressure ulcer treatment orders were transcribed and completed per physician orders. This affected one resident (Resident #91) of one resident reviewed for pressure ulcers. Residents Affected - Few Findings Include: Review of the medical record for Resident #91 revealed an admission dated 10/04/22. Resident #91's diagnoses included non-pressure ulcer left foot, atrial fibrillation, and pressure ulcer. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation. Review of the physician orders for November 2022 revealed orders to cleanse bilateral buttocks with normal saline, pat dry, apply calcium alginate to excoriated area and cover with foam dressing, change everyday on dayshift and as needed. Review of the wound care nurse practitioner note dated 11/18/22 revealed new order for a buttock pressure wound, to apply medihoney ointment first, pack wound with alginate cover with foam dressing. The order continued to change dressing daily and as needed. Review of the wound assessment dated [DATE], revealed the coccyx (earlier identified as buttock) wound was a stage four pressure ulcer and the area was now a butterfly shaped with characteristic of Kennedy terminal ulcer, which was unavoidable. Review of the November and December 2022 Treatment Administration Reports (TAR) revealed no orders for medihoney, alginate and cover with foam dressing to coccyx. There was an order for calcium alginate and foam dressing to coccyx. Interview on 12/06/22 at 12:12 P.M. with Licensed Practical Nurse (LPN) #116 stated she was the wound nurse for the facility. LPN #116 verified a new order for Resident #91's coccyx was not put into the computer and there was no documentation of order being completed daily. LPN #116 verified the wound order was not transcribed and not completed. Interview on 12/06/22 at 12:30 P.M. with the Director of Nursing (DON) verified the new orders received on 11/18/22 had not been put into the computer and had not been completed per treatment orders. 366024 Page 4 of 6 366024 12/07/2022 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, facility policy and staff interview the facility failed to maintain an accurate reconciliation of narcotic medication for Resident #37. This affected one resident (Resident #37) of six residents reviewed for controlled narcotic medication. Findings include: Review of the medical record for Resident #37 revealed an admission date of 08/11/14. Resident #37's diagnoses included malignant neoplasm of breast, neoplasm of bone and low back pain. Review of Resident #37's physician orders revealed orders for oxycodone 5 milligrams (mg) give 1 tablet by mouth every four hours as needed for pain to low back and may have two tablets every four hours for pain. Review of the missing medications investigation dated 06/22/22 revealed on 06/22/22 during the narcotic reconciliation count with Licensed Practical Nurse (LPN) #102 and LPN #218 there was a discrepancy with Resident #37's oxycodone tablet 5 milligrams (mg) cards in the narcotic drawer. Resident #37 had three cards of oxycodone 5 mg in the narcotic drawer. Card #1 identified with Rx# 26937782 revealed there were 53 pills in the bubble pack. The Controlled Drug Receipt/Record/Disposition Form revealed Card #1 should have had #54 pills. Card #2 identified with Rx# 27335479 revealed there were 59 pills in bubble pack card. The controlled drug receipt/record/disposition form revealed there should have been 60 pills in Card #2. Card #3 identified with Rx# 27684929 revealed there were 58 pills in the bubble pack card. The Controlled Drug Receipt/Record/Disposition Form revealed the card should have had 60 pills in total Resident #37 had five missing oxycodone 5 mg in total. Review of the interview with LPN #102 during investigation dated 06/22/22 revealed on 06/19/22 she worked and had done a thorough narcotic count and all pills were accounted for. On 06/22/22 during the narcotic count, it was identified there were four missing pills. Review of the interview with LPN #116 during the investigation revealed she worked on 06/20/22 and counted narcotics with LPN #218 and at the end of my shift with LPN #147, she pulled the narcotic cards forward to count and the count was correct both times. Review of the interview with LPN #218 during the investigation revealed when doing the narcotic count when she counts narcotic cards, they just flip through the cards to see the last full spot, they do not pull out the card out of the drawer. On 06/22/22 LPN #102 pulled out the cards and noticed a spot with a pill missing and she notified the supervisor. Interview on 12/04/22 at 1:46 P.M. with LPN #102 stated on 06/22/22 she was coming on shift at 7:00 A.M. and was doing narcotic count with LPN #218. LPN #102 stated she pulled the narcotic cards out of the drawer due to the cards being very tight together. When she pulled Resident #37 oxycodone card out, she noticed there was a missing pill at the bottom of the card. During the whole narcotic count, it was identified Resident #37 had three cards of oxycodone 5 mg with four pills missing and not accounted for. LPN #102 stated the supervisor was notified and a full investigation was completed. Interview on 12/05/22 at 4:12 P.M. with the Director of Nursing (DON) and Administrator revealed LPN #102 identified a discrepancy in the narcotic count with LPN #218. A full investigation was 366024 Page 5 of 6 366024 12/07/2022 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few started. There were four missing oxycodone not accounted for. The Administrator verified there was a breakdown in documenting medications. The Administrator and DON verified they were not able to physically account for the four missing pills. Review of the facility policy Administration of Scheduled 2 Controlled Medications, dated 06/21/17 revealed any discrepancies in the individual resident's Controlled Drug Receipt/Record/Disposition Form must be immediately reported to the DON and or per facility policy. This deficiency represents non-compliance investigated under Complaint Number OH00133877. 366024 Page 6 of 6