Inspection·April 23, 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 medical record reviews, observations, staff interviews and policy review, the facility failed to ensure fall risk assessments were completed as per policy. This affected three (#11, #20, and #37) out of three residents reviewed for falls. Additionally, the facility failed to ensure fall preventative measures were in place as per the plan of care. This affected one (#37) out of three residents reviewed for falls. The facility census was 45. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 02/01/22 with medical diagnoses of Alzheimer's disease, adult failure to thrive, chronic obstructive pulmonary disease (COPD), schizoaffective disorder, and bipolar disorder. Review of the medical record for Resident #11 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/12/23, which indicated Resident #11 had moderate cognitive impairment and required maximum staff assistance for toilet hygiene and transfers, was dependent upon staff for bathing, and moderate staff assistance for bed mobility. The MDS revealed Resident #11 had two or more falls without injury and one fall with injury since the last MDS assessment. Review of the medical record for Resident #11 revealed an admission observation tool, dated 12/18/23, which included a fall risk assessment. The fall risk assessment indicated Resident #11 was at risk for falls. Further review of the medical record revealed no documentation to support a comprehensive fall risk assessment had been completed since 12/18/23. 2. Review of the medical record for Resident #20 revealed an admission date of 06/15/22 with medical diagnoses of Alzheimer's disease, dementia with behavioral disturbances, pulmonary fibrosis, morbid obesity, seizures, and right-side orbital fracture. Review of the medical record for Resident #20 revealed a quarterly MDS, dated [DATE], which indicated Resident #20 had severe cognitive impairment and was dependent upon staff for showers, required maximum staff assistance for toilet hygiene, and moderate staff assistance with bed mobility and transfers. Further review of the MDS revealed Resident #20 had a fall with major injury since the last MDS assessment. Review of the medical record for Resident #20 revealed a Resident First Meeting assessment, dated 11/15/23, which included a fall risk assessment. Review of the fall risk assessment revealed Resident #20 was at high risk for falls. Further review of the medical record revealed no documentation to (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: 366490 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 366490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vienna Springs Health Campus 2510 Vienna Pkwy Dayton, OH 45459 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)