Inspection·May 31, 2023

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on medical record review, staff interview, policy review, and review of the medication information from Medscape, the facility failed to ensure a resident was free from unnecessary psychotropic medication usages when the facility failed to have an adequate indication of use for an antipsychotic medication. This affected one (#132) out of three residents reviewed for psychotropic medication usage. Facility census was 129. Findings include: Review of the medical record for Resident #132 revealed an admission date of 05/03/23. Diagnoses include unspecified head injury, concussion, repeated falls, hypertensive chronic kidney disease, depression, and restless leg syndrome (RLS). The medical record revealed Resident #132 was discharged on 05/16/23. Review of the medical record for Resident #132 revealed an admission Minimum Data Set (MDS) 3.0, dated 05/10/23, which indicated Resident #132 had severe cognitive impairment and required limited assistance with bed mobility, toileting, and transfers. The MDS indicated Resident #132 received an antipsychotic medication routinely. Review of medical record for Resident #132 revealed a physician order dated 05/05/23 for haloperidol (antipsychotic medication) 10 milligram (mg) by mouth daily at bedtime routinely for agitation. Review of medical record for Resident #132 revealed a medication administration record (MAR) for May 2023 which revealed Resident #132 received haloperidol 10 mg daily at bedtime routinely from 05/06/23 to 05/16/23 for agitation. Review of the medical record for Resident #132 revealed a behavior monitoring assessment, dated 05/06/23 at 11:28 P.M., which stated Resident #132 was agitated, anxious, had continued pacing, fighting, restless and wandering. The assessment stated staff provided one on one supervision, changed positions, removed the resident from the environment, toileted resident, and redirected resident which were all ineffective. Further review of the assessment revealed the documentation was initiated on 05/06/23 but was not completed until 05/26/23. Review of the medical record for Resident #132 revealed a nursing progress note dated 05/06/23 at 11:28 P.M., which stated Resident #132 was ordered haloperidol 10 mg by mouth daily at bedtime routinely due to agitation. (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 05/31/2023 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)