Inspection·January 31, 2019

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (# 93 and # 43) of 44 residents reviewed during the annual survey. The total facility census was 139. Residents Affected - Few Findings include: 1. Review of Resident #93's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, encephalopaty, altered mental status, pain, chronic kidney disease, gout, and partial traumatic transphalangeal amputation of left middle finger. Review of the admission assessment, dated 12/28/18, revealed the resident had left middle finger amputation, left index finger dark area tip of finger and right index finger red and non blanchable. Review of hospital transfer orders, dated 12/28/18, revealed Resident #93 had no pressure ulcers and the resident had wounds to the finger tips. Review of the plastic surgeon note dated 12/28/18, revealed the resident had a an amputation of the distal phalanx of his left, long finger after thromboembolic ischemia to the tip of the finger on 11/19/18. The area had delayed healing and the site currently was covered in eschar. The resident also has wounds to left ring finger tip consistent with previous thromboembolic ischemia. Review of admission MDS assessment, dated 01/04/19, revealed the resident was coded as having cognitive impairment. The resident was coded as having two deep tissue pressure ulcers that were present on admission. The resident had a pressure reducing device to the bed and chair and pressure injury care with application of non-surgical dressings with or without topical medications other than to the feet coded. Additionally application of ointment other than to the feet coded as well. Review of the five day MDS assessment dated [DATE] and the 14 day MDS assessment, dated 01/22/19, revealed the resident the resident was coded as having pressure ulcers that were two unstageable deep tissue pressure injuries that were present on admission. Review of plastic surgery note from 01/15/19 revealed the resident has small scattered finger tip eschars, other fingers markedly improved. The resident left long finger post amputation with overlying dark eschar. On 01/14/19 dehiscence of incision but no obvious exposed bone, fingertip still tender. The note documented the resident was two months post-op for left, long finger tip amputation for embolic disease with dry gangrene. Wound dehisced, finger remains ischemic. (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 3 Event ID: 366388 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 366388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonespring of Vandalia 4000 Singing Hills Bvld Dayton, OH 45414 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)