Inspection·September 12, 2024

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 observation, resident interview, staff interviews and record review, facility failed to ensure a resident received adequate Activities of Daily Living (ADLs) care. This affected one resident (#27) of one reviewed for personal care. Facility census was 125. Residents Affected - Few Findings include Review of the medical record for Resident #27 revealed an admission date of 11/18/19. Diagnoses included contracture of left hand, monoplegia of left upper extremity, anxiety, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition and was dependent on staff for showering and bathing as well as personal hygiene and stated, helper does all of the effort, resident does none of the effort to complete the activity. Review of the plan of care dated 07/29/24 revealed Resident #27 had a self care performance deficit related to contracture of the left hand, impaired mobility and limited range of motion, confusion and non compliance with behaviors with interventions of bathing and showering total dependence of two staff, encourage resident to participate in ADLs to the fullest extent possible, trim and clean finger nails on bath day and as necessary, contracture of left hand to provide skin care every shift and use of palm protector at all times. The care plan revealed resident had a behavioral problem including irritability, mood swings and delusions with interventions to anticipate needs. Review of shower sheets revealed resident did not refuse any showers in 08/2024 or 09/2024. Resident had nail care and hair washed checked off on 08/30/24 and 09/06/24 and documentation of bed baths given with no hair washing or nail care marked on 09/04/24 and 09/10/24. Observation and interview on 09/09/24 at 11:35 A.M. of Resident #27 revealed long fingernails with about 1/4 inch to 1/2 inch growth from the nail bed. Resident had a black/brownish dirt substance under all nails. Resident revealed a staff member trimmed a hangnail a few days ago, but reported they did not trim or clean her nails at that time. She revealed her nails had looked dirty for a few weeks. Residents left hand had a contracture with a splint in place and nails on her contracted hand were also very long with dirt and grime underneath them. Resident also reported she wanted her hair washed and revealed staff have not provided hygiene and bathing for several weeks. Resident revealed she felt dirty and felt her hair was greasy and matted. Residents hair appeared greasy and was stringy from scalp to the ends and her hair also appeared matted and knotted in the back. When resident lifted her head off the pillow or turned her head from side to side during discussion, her hair stayed in place and had no flow or movement. (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 9 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 09/12/2024 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)