Inspection·February 14, 2019

F 0690 Level of Harm - Minimal harm or potential for actual harm Review of the nurse associate initial orientation skills checklist revealed peri care and catheter care are part of the initial orientation for STNAs. Review of the facility's policy titled Urinary Catheter Care, dated 01/2019, revealed a soapy wash cloth is used from the point of the catheters insertion in the penis, away from the penis, down the catheter tubing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366151 If continuation sheet Page 2 of 6 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 366151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dayspring of Miami Valley Hlth Care Center & Rehab 8001 Dayton Springfield Road Fairborn, OH 45324 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident interviews, staff interviews, and review of facility policies, the facility failed to follow proper isolation precautions and failed to ensure proper cleansing of the whirlpool tub for two (#7 and #81) out of three residents reviewed for isolation precautions. The facility census was 124. Residents Affected - Some Findings include: 1. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses includes dementia with behaviors iron deficiency, anemia, cervicalgia, diabetes type two, hypertension, staphylococcal arthritis of the knee, and cerebral infarction. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/17/18, revealed Resident #7 had impaired cognition. Per the MDS assessment the resident had not been diagnosed with a urinary tract infection. Review of Resident #7's progress notes revealed on 01/29/19 the nurse notified the physician Resident #7 had increased confusion and a urine analysis and culture and sensitivity was ordered. Review of Resident #7's laboratory (lab) results revealed on 01/30/19 a urinary analysis showed and elevated white blood cell count and bacteria in the urine with a culture indicated from results. Review of the urine culture results dated 01/31/19 revealed Escherichia Coli with a count greater than 100,000 was present in the urine sample. Review of physician orders dated 02/01/19 revealed an order for Resident #7 to be placed in contact precautions, receive Augmentin antibiotic 500 milligrams orally twice a day for ten days, and to re-order a urinary analysis with a culture and sensitivity screen in two weeks. Observation on 02/12/19 at 9:13 A.M. of revealed a container with gloves, masks, trash bags, and gowns was located outside of the door to Resident #7's room. A red magnet was observed on the door frame which read See nurse before entering. Observation on 02/13/19 at 11:00 A.M. revealed State Tested Nurse Aide (STNA) #500 observed exiting the room next to Resident #7. This room contained a sign indicating isolation precautions were being followed for one of the residents in the room. STNA #500 entered Resident #7's room without putting on gloves, or putting on a gown before entering the room. Observation on 02/13/19 at 11:06 A.M. revealed Registered Nurse (RN) #600 was observed entering Resident #7's room, administering medications to the resident, and exiting Resident #7's room without any gloves or gown. Interview on 02/13/19 at 11:34 A.M., STNA #500 revealed the aide did not know which resident in Resident #7's room was ordered to be in isolation, or the type of isolation required. Interview on 02/13/19 at 11:38 A.M. , RN #600 revealed the nurse was unsure which resident in Resident #7's room required isolation precautions and what type of precaution was ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366151 If continuation sheet Page 3 of 6 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 366151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dayspring of Miami Valley Hlth Care Center & Rehab 8001 Dayton Springfield Road Fairborn, OH 45324 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/14/19 at 8:30 A.M., the Administrator and the Infectious Control Designee/Assistant Director of Nursing (ADON) verified there were policies in place for isolation precautions and infection control procedures at the facility. Per the ADON the staff have been trained on the proper procedures for all infection preventions protocols. Review of the facility's policy titled Infection Control, Transmission Based Precautions (Airborne, Contact, Droplet) All Staff, dated 04/2015, revealed Transmission-based precautions should remain in effect while the risk of transmission of the infectious agent persists. Under section two, the policy stated, contact precautions is implemented for residents known to be, or are infected with microorganisms that can be transmitted by direct or indirect contact with that resident or with contact with the resident's environment. Precautions stated the use of Personal Protective Equipment (PPE). When entering the room, one is to wear gloves and gown for interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. PPE is to be put on upon entering the room and discarded prior to exiting. 2. Review of the medical record for Resident #81 revealed an admission date of 02/23/18, with a readmission date of 12/27/18. Diagnoses included pressure ulcer of the sacral region stage four, pressure ulcer of the right buttock, dysphagia, urinary tract infection, sepsis due to Escherichia Coli, elevated white blood cell count, adult failure to thrive, cystitis, end stage renal disease, polyneuropathy, osteomyelitis of the vertebra, sacral and sacrococcygeal region, resistance to Vancomycin related antibiotics, type II diabetes mellitus, major depressive disorder, anxiety disorder, peripheral vascular disease, colostomy, acquired absence of the right toe and left leg above the knee and dependence on renal dialysis. Review of the 30-day Minimum Data Set (MDS) assessment, dated 01/22/19, revealed Resident #81 to have no cognitive impairment. The resident required extensive assistance of two or more staff for his activities of daily living (ADL). In addition, the resident was identified to have an indwelling urinary catheter. Review of the current physician's order sheet revealed an order dated 02/08/19 for Resident #81 to be placed in contact precautions related to Extended-Spectrum Beta-Lactamases (ESBL) in his urine. Review of the Resident #81's care plan dated 02/08/19 revealed the resident to be in contact precautions related to a urinary tract infection and ESBL and pseudomonas aeruginosa in his urine. The resident had a multi-drug resistant organism (MDRO). Interventions included among other interventions bag and transport used linen according to facility protocol, educate the family, resident and caregivers regarding the importance of hand washing, mask and face shield to be worn during procedures with the risk of splashes or droplet contamination of bodily fluids. The staff was to follow contact precautions by placing soiled linens in bags marked biohazard. The linens are to be bagged and tightly closed before taking it to the laundry. Observation on 02/12/19 at 11:13 A.M. of Resident #81's room revealed a white three drawer unit with gloves, masks, trash bags, and gowns located outside of the room door. A red magnet was observed on the door frame which read See nurse before entering. Resident #81's room was observed to be located next to Resident #7's room. Interview on 02/12/19 at 1:09 P.M., RN #600 stated Resident #81 was in contact isolation for ESBL in his urine, and just received a new diagnosis of Carbapenem Resistant Pseudomonas (CRP). She stated staff were using full PPE to enter the resident's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366151 If continuation sheet Page 4 of 6 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 366151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dayspring of Miami Valley Hlth Care Center & Rehab 8001 Dayton Springfield Road Fairborn, OH 45324 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/13/19 at 10:04 A.M., Resident #81 stated some of the staff wear PPE when giving him care and some do not. Observation on 02/13/19 at 10:34 A.M. revealed STNA #500 to be carrying the food tray for Resident #81 out of his room. The STNA was observed not wearing any PPE, and the food tray was uncovered and held by ungloved hands. RN #600 was observed telling STNA #500 the food tray should be placed in a bag prior to exiting the isolation room. Interview on 02/13/19 at 10:35 P.M., RN #600 she confirmed items coming out of isolation rooms should be placed in bags before exiting the room. Observation on 02/13/19 at 10:36 P.M. revealed STNA #500 in Resident #81's room. She was observed to pick up the resident clothing and to straighten up the resident's area wearing only gloves. The clothing was observed touching the STNA's clothes. STNA #500 stated she had planned on giving Resident #81 his whirlpool bath today but instead would give a bed bath with catheter care. Observation of catheter care for Resident #81 on 02/13/19 at 10:53 P.M. revealed STNA #500 did not wear a gown while giving a bed bath and catheter care for Resident #81. The STNA was observed wearing only gloves. Observation on 02/13/19 at 11:00 A.M. revealed STNA #500 was leaving Resident #81's room not wearing any gown or gloves. STNA #500 was carrying two clear bags of soiled laundry. STNA #500 was observed throwing the soiled laundry into the soiled linen closet and then re-entering Resident #81's room without putting on any gown or gloves. STNA #500 was then observed exiting Resident #81's room and entering Resident #7's room without washing her hands. Observation on 02/13/19 at 11:06 A.M. revealed STNA #500 entering Resident #81's room without gown or gloves. The STNA was observed at the resident's bedside. Interview on 02/13/19 at 11:18 A.M., STNA #500 stated Resident #81 was not contagious. She denied knowing exactly what Resident #81 was in isolation for, but stated she was told it was in his urine. She stated if the urine didn't get splattered on you it was okay. STNA #500 stated she did not need a gown during Resident #81's care. Interview on 02/13/19 at 11:34 A.M., STNA #500 revealed the aide did not know which resident in Resident #81's room was ordered to be in isolation or which type of isolation was required. Interview on 02/13/19 at 12:49 P.M., the Administrator confirmed the facility policy indicated the staff needed to wear a gown and gloves when working directly with the area of infection. The Administrator confirmed if working with the penis and catheter with a resident who was in contact isolation for ESBL in his urine, then they should wear a gown and gloves during care. Telephone interview on 02/14/19 at 12:00 P.M., Medical Director #215 stated he expected the staff to adhere to the isolation precaution policy. He stated he did not necessarily want gowns to be worn when entering the room, but gloves and mask must be put on prior to entering a contact isolation room. He also stated items should never be carried outside of a contact isolation room. Additionally, review of the nursing notes for Resident #81 dated 01/13/19, documented Resident #81 having received a whirlpool bath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366151 If continuation sheet Page 5 of 6 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 366151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dayspring of Miami Valley Hlth Care Center & Rehab 8001 Dayton Springfield Road Fairborn, OH 45324 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/13/19 at 3:49 P.M., the Director of Nursing (DON) stated whirlpool baths are disinfected between residents. She stated the surface is sprayed and rinsed off. The DON denied that the whirlpool is disinfected throughout the internal jet system. Interview on 02/13/19 at 4:02 P.M., Resident #81 stated he received whirlpool baths once to twice per week. Interview on 02/13/19 at 4:05 P.M. , Licensed Practical Nurse (LPN) #236 confirmed Resident #81 had been receiving whirlpool baths for approximately one month, once to twice per week. Interviews on 02/13/19 between 4:08 P.M. and 4:15 P.M., STNA #305 and STNA #363 confirmed they have given Resident #81 whirlpool baths. Both STNAs stated they sprayed disinfectant on the inner sides of the tub, then used water to rinse the tub. The STNAs denied using anything to disinfect the inner parts of the whirlpool bath. Interview on 02/13/19 at 4:29 P.M., ADON #298 confirmed Resident #81 had ESBL in a pressure ulcer wound located in his sacral region. She stated he was in contact precaution for this organism from 01/11/19 through 01/22/19. Interview on 02/14/19 at 2:54 P.M., Medical Director #214 stated she was unaware Resident #81 was receiving whirlpool baths. She confirmed whirlpool baths should be disinfected both internally and externally prior to use by a different resident. She stated she had conferred with Infectious Disease Specialist #425 and stated the concern with contact isolation is the consistent use of hand hygiene and glove use for any resident contact. Review of the facility's policy titled ARJO Tub and Lift Cleaning, dated 10/2009, revealed the ARJO tub cleaning procedure included: drain whirlpool, spray tub with hose labeled disinfectant, place ARJO tub lift in tub and spray the lift with the disinfectant, disinfect for three minutes, use a gloved hand and washcloth to scour debris from whirlpool as needed and spray tub and lift with water hose to rinse out the disinfectant. Review of the facility's policy titled Infection Prevention and Control Program (IPCP), dated 10/2018, noted the facility will provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366151 If continuation sheet Page 6 of 6