F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review and staff interview, the facility failed to accurately code Minimum Data Set
(MDS) assessments for Resident #4. This affected one (#4) of 20 residents reviewed for accuracy of the
MDS assessments. The facility census was 108.
Residents Affected - Few
Findings include:
Review of Resident #4's medical record revealed an admission date of 07/22/14. Diagnoses included
hypertension, congestive heart failure, coronary artery disease and depression.
Review of the quarterly MDS assessments, dated 02/12/19, 08/14/19, and 11/13/19, revealed Resident #4
was coded for daily restraint use per bed rails. However, there was no documentation of restraint use for
those time periods in the resident's medical record
Interview with Registered Nurse (RN) #620 on 02/27/20 at 10:45 A.M. verified restraints were not used for
Resident #4 during the look-back periods of the quarterly MDS assessments dated 02/12/19, 08/14/19, and
11/13/19. The RN verified the quarterly MDS assessments were coded incorrectly for restraint use on
02/12/19, 08/14/19, and 11/13/19.
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:
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
02/27/2020
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)
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
record review and staff interview, the facility failed to develop care plans for a resident receiving wound care
for Moisture Associated Skin Damage (MASD) and for the resident's Meibomian eye gland disease. This
affected one (Resident #39) of twenty residents reviewed for the development and implementation of care
plans. The facility census was 108.
Findings include:
Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] with diagnoses
including ischemic cardiomyopathy, congestive heart failure, cognitive communication deficit, type two
diabetes mellitus and dementia.
Review of the wound progress note, dated 02/20/20, revealed Wound Nurse Practitioner (NP) #480
documented Resident #39 had MASD bilateral buttocks.
Review of the physician orders, dated 02/2020, revealed an order for Minocycline (antibiotic) 50 milligram
(mg.) once daily for Meibomian eye gland disease.
Review of the resident's care plans revealed the resident did not have a care plan for MASD and antibiotic
for the resident's Meibomian eye gland disease.
Interview with the Director of Nursing (DON) on 02/27/20 at 10:37 A.M. verified Resident #39's care plan
did not address the resident's MASD or Meibomian eye gland disease.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366116
If continuation sheet
Page 2 of 3
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
02/27/2020
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)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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 physician interview, the facility failed to ensure a medication was used for an
appropriate diagnosis. This affected one (Resident's #39) of five residents reviewed for unnecessary
medications. The facility census was 108.
Residents Affected - Few
Findings include:
Record review for Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses
included ischemic cardiomyopathy and unspecified dementia. Review of the quarterly Minimum Data Set
(MDS) assessment, dated 01/02/19, revealed the resident had moderate cognitive impairment.
Review of the physician orders, dated 02/2020, revealed an order for Minocycline (antibiotic) 50 milligram
(mg.) once daily for antibiotic prophylaxis, indefinite treatment.
Interview with the Medical Director (MD) #550 on 02/27/20 at 8:52 A.M. revealed Resident #39 was ordered
Minocycline (antibiotic) 50 milligram (mg.) once daily for Meibomian eye gland disease, not for antibiotic
prophylaxis for recurrent eye infections. MD #550 stated she contacted the resident's ophthalmologist and
confirmed the antibiotic was prescribed for the resident's eye gland disease not for not for recurrent eye
infections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366116
If continuation sheet
Page 3 of 3
