Inspection·April 23, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, observation and staff and resident interview, the facility failed to ensure medications kept at the resident bedside were ordered by a physician. This affected three residents (#104, #112, #106) of eight residents reviewed for medications. The facility census was 126. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #104 revealed an admission date of 03/22/23. Diagnoses included Amyotrophic Lateral Sclerosis (ALS), depression and hypothyroidism. The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #104 required extensive two person assistance for bed mobility, transfers, one person assistance for toilet use and supervision for eating. Observation on 04/23/23 at 8:54 A.M. revealed Resident #104 had a tube of Orasol (anesthetic gel) and Triamcinolone Acetonide Cream (corticosteroid cream) on her bedside table. This was verified with Licensed Practical Nurse (LPN) #12 who stated she believed it was a nighttime medication and she was not at the facility when it was administered. Review of the physician orders and a follow-up interview on 04/23/23 at 11:03 A.M., with LPN #12 verified there was no order for Orasol gel or Triamcinolone Acetonide Cream for Resident #104. 2. Review of the medical record for Resident #105 revealed admission date of 03/11/22. Diagnoses included alcoholic cirrhosis of the liver, kidney failure, diabetes type II, and depression. The quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #105 required extensive two person assistance for bed mobility, toilet use and was independent for eating. Observation on 04/23/23 at 10:41 A.M. revealed Resident #105 appeared to be sleeping and there was a bottle of Antacids at the bedside. At 10:49 A.M., LPN #14 said she believed there was an order to keep the antacid medication at the bedside. Upon looking in the electronic medical record LPN #14 verified there was no order for the antacid medication for Resident #105. Interview on 04/23/23 at 1:48 P.M., with Resident #105 revealed she bought the antacids from another resident and had them for some time, but she usually kept them in her drawer. She got them out the previous evening because she needed to take some, and she forgot to put them away. (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: 366151 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 04/23/2023 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)