Inspection·November 6, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, review of the facility policy, and record review, the facility failed to ensure fall interventions were in place for a resident who had a history of falls and was at a fall risk. This affected one (Resident #84) of three residents reviewed for falls. The facility census was 125. Findings include: Review of the medical record for Resident #84 revealed an admission date of 06/23/21. Diagnoses included senile degeneration of the brain, chronic obstructive pulmonary disease, respiratory failure dementia and cognitive communication deficit. Review of the care plan dated 08/08/24 revealed Resident #84 was at risk for falls with interventions to assist resident as needed, ensure wheelchair was locked and bed was stable prior to transferring, keep floor free of clutter, use tilt dump wheelchair seat, low bed, non-skid socks, encourage to be in common areas, visual cues to bedside (added 10/21/24), and fall mats to bedside (added 10/21/24). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 had significant cognitive impairment and required partial moderate assistance for bed mobility and transfers. Resident #84 had two or more recent falls during the review period. Review of the quarterly fall risk scale dated 09/18/24 revealed Resident #84 three or more falls in previous 90 days and score a 20 on the fall risk assessment indicating increased risk for falls (over 10 was considered at risk) Review of the progress notes dated 10/18/24 revealed Resident #84 had a fall from her bed that was unwitnessed. The facility initiated interventions of fall mats by the bed and visual cues. Review of the fall investigation dated 10/21/24 revealed Resident #84 had a fall on 10/18/24. Resident #84 was found on the floor by staff laying next to her bed with pillow and blanket. New interventions included a visual cue to bedside and fall mats to bedside. Review of the physician orders dated 10/21/24 revealed an order for fall mats to bedside and a second order dated 10/21/24 for visual cues to bedside (for call light reminder). Observation on 11/05/24 at 4:53 P.M. revealed Resident #84 was sitting in her wheelchair in her room. A black rug-like object was on resident's floor. There was no fall mat in Resident #84's room. (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 4 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 11/06/2024 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)