Inspection·January 10, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to issue written notice for transfer, to the resident and/or representative. This affected four (#51, #57, #85, and #90) of five residents reviewed for hospitalizations. The facility census was 110. 1. Review of Resident #85's medical record revealed an admission date of 06/06/17 with diagnoses including acute kidney failure, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, and chronic kidney disease. On 12/03/18 at 1:42 P.M., the resident was transferred to the hospital for the evaluation of the resident's complaints of abdominal pain and tenderness. The resident returned to the facility on [DATE]. The medical record was silent of verification, that a notification of transfer, was provided to Resident #85 and/or representative. Interview on 01/08/19 at 4:12 P.M., with the Administrator verified Resident #85 was transferred out of the facility on 12/03/18 and no written notification of transfer was provided in writing to the resident and/or representative. 2. Review of Resident #57's medical record review revealed an admission date of 07/30/18 with diagnoses including cerebral infarction due to embolism of left middle cerebral artery, acute kidney failure, congestive heart failure, and sepsis. The resident was noted to have be hospitalized on [DATE] due to a change in condition and returned to the facility on [DATE]. The medical record was silent for verification that a notification of transfer and bed hold notification, was provided to the Resident and/or representative. Interview on 01/10/19 at 4:08 P.M., with the Administrator verified the facility failed to issue written notice for transfer and bed hold notification to Resident #57 and /or their representative in writing. 3. Review of Resident #51's medical record review revealed an admission date of 08/02/18 with diagnoses including muscle weakness, Alzheimer's disease, and abdominal aortic aneurysm. The resident was noted to have been hospitalized on [DATE] due to a complaint of right hip pain and returned to the facility on [DATE]. The medical record was silent for verification that a notification of transfer and bed hold notification, was provided to the Resident and/or representative. Interview on 01/10/19 at 4:08 P.M., with the Administrator verified the facility failed to issue (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 8 Event ID: 366116 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 366116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Masonic Community 3 Masonic Drive Springfield, OH 45501 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)