Health 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 Page 1 of 8 366116 366116 01/10/2019 Springfield Masonic Community 3 Masonic Drive Springfield, OH 45501

F 0623 written notice for transfer and bed hold notification to Resident #51 and /or their representative in writing. Level of Harm - Minimal harm or potential for actual harm 4. Review of Resident #90's medical record revealed an admission date of 11/13/18 with diagnoses including congestive heart failure, pleural effusion, and adult failure to thrive. The resident was hospitalized on [DATE] due to complaint of hip pain and returned to the facility on [DATE]. Residents Affected - Some 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 #90 and /or their representative in writing. 366116 Page 2 of 8 366116 01/10/2019 Springfield Masonic Community 3 Masonic Drive Springfield, OH 45501

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to issue a bed hold notification, 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, 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 on 12/05/18. The medical record was silent of verification, that a bed hold notification, was provided to Resident #85 and/or representative. Interview conducted on 01/08/19 at 4:12 P.M., the Administrator verified Resident #85 was transferred out of the facility on 12/03/18 and no notification of bed hold 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. Review of Resident #57's medical record revealed he was 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 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 Alzheimer's disease, heart failure, and abdominal aortic aneurysm. The resident was 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 Administrator verified the facility failed to issue written notice for transfer and bed hold notification to Resident #51 and /or their representative in writing. 4. Review of Resident #90's medical record revealed an admission date of 11/13/18 with diagnoses including congestive heart failure, dementia, and adult failure to thrive. The resident was noted to have been hospitalized on [DATE] due to complaint of 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 366116 Page 3 of 8 366116 01/10/2019 Springfield Masonic Community 3 Masonic Drive Springfield, OH 45501

F 0625 written notice for transfer and bed hold notification to Resident #90 and /or their representative in writing. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 366116 Page 4 of 8 366116 01/10/2019 Springfield Masonic Community 3 Masonic Drive Springfield, OH 45501

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interview the facility failed to correctly code the minimum data set (MDS) assessment for one (#58) of one resident reviewed for hospice services. The facility census was 110. Findings include: Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD), dementia without behavioral disturbances, and rheumatoid arthritis. Review of physician orders for Resident #58 revealed the resident had hospice services initiated on 05/07/18 for terminal diagnosis of late effect cerebral vascular accident. Review of Resident #58's most recent quarterly MDS assessment dated [DATE] revealed the resident did not have a condition or chronic disease the may result in a life expectancy of less that 6 months, however section O revealed the resident was receiving hospice services. Interview on 01/09/19 at 3:30 P.M., with MDS Registered Nurse (RN) #550 confirmed the MDS was coded incorrectly. 366116 Page 5 of 8 366116 01/10/2019 Springfield Masonic Community 3 Masonic Drive Springfield, OH 45501

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure a resident had a plan of care developed for the use of oxygen. This affected one (#93) of 22 residents reviewed for care plans. The facility census was 110. Findings include: Review of the medical record and admission orders for Resident #93 revealed an order dated 12/07/18 for the resident to use O2 at two to three liters, per nasal cannula due to the diagnosis of congested heart failure (CHF). The order revealed to keep the resident's oxygen saturation greater than 90%. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was using oxygen. There was no evidence a plan of care was developed for the use of O2 or CHF. Review of Resident #93's vital signs from 12/28/18 through 01/09/19 revealed the resident had used O2, 19 times. Observation on 01/08/19 at 9:00 A.M., revealed Resident #93 was using O2. Interview on 01/10/19 at 2:00 P.M., with Licensed Practical Nurse (LPN) #620 verified a plan of care had not been developed for Resident #93 regarding the use of O2 for the resident's diagnosis of CHF. 366116 Page 6 of 8 366116 01/10/2019 Springfield Masonic Community 3 Masonic Drive Springfield, OH 45501

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to complete a pressure ulcer dressing change per the physician's orders. This affected one resident (#90) of four reviewed for pressure ulcers. The facility census was 110. Residents Affected - Few Findings include: Review of Resident #90's medical record revealed an admission date of 11/13/18 with diagnoses including congestive heart failure (CHF), dementia, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had severe cognitive impairment. Review of Resident #90's physician's orders revealed an order dated 12/20/18 for a coccyx dressing change to include for the wound to be cleansed with normal saline, Medihoney (wound gel) applied, calcium alginate (help promote moist wound bed) and then Mepilex border lite (a topical foam dressing). The dressing change was to be completed every other day, and as needed. Observation on 01/10/19 at 1:05 PM., of Resident #90s' dressing change revealed the Licensed Practical Nurse (LPN) #600 did not use calcium alginate. Interview with the LPN a the time of the observation confirmed she did not use the calcium alginate and it was part of the treatment order. Interview on 01/10/19 at 1:05 P.M., with Wound Certified Nurse Practioner (CNP) #599 verified the dressing order was to contain the calcium alginate after the Medihoney was applied and before the Mepilex was applied. 366116 Page 7 of 8 366116 01/10/2019 Springfield Masonic Community 3 Masonic Drive Springfield, OH 45501

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and facility staff interview, the facility failed to ensure ordered laboratory tests were completed for one (#12) of five residents reviewed for un-necessary medications. The facility census was 110. Residents Affected - Few Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, and type two diabetes. Review of Resident #12's physician orders revealed the resident was ordered to have a hemoglobin A1C completed every three months in February, May, August and November. There was no evidence the laboratory test was completed in November 2018. Interview with Registered Nurse (RN) #500 on 01/10/19 at 3:30 P.M., confirmed Resident #12 did not have a hemoglobin A1C completed in November 2018 as ordered. 366116 Page 8 of 8