Inspection·February 9, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of the facility policy, and record review, the facility failed to ensure pre-admission screening and resident review (PASARR) were updated after changes in diagnosis. This affected two (Residents #20 and #32) of two residents reviewed for PASARR. The facility census was 73. Findings include 1. Review of the medical record for Resident #20 revealed an admission date of 03/08/19. Diagnoses included anxiety and psychosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Review of the PASARR dated 11/28/22 revealed Resident #20 had no mental health diagnoses. This PASARR was completed after a hospital admission. Interview on 02/07/23 at 4:20 P.M. with Administrator revealed the PASARR assessment was completed upon admission and should be updated after a significant change in condition. The Administrator confirmed the PASARR for Resident #20 did not include diagnosis of anxiety or psychotic disorder. The Administrator later revealed the social worker has been checking newly admitted residents to ensure accuracy of PASARR assessments from the hospital. The Administrator started the social worker began in 01/2021. Review of the facility policy titled PASARR Screen Policy, dated 03/17/15, revealed a PASARR would be completed to evaluate for serious mental illness upon admission and after a change in condition. 2. Review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including dementia. Since admission, Resident #32 has been diagnosed with major depressive disorder, anxiety, and psychotic disorder with delusions due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of Resident #32's preadmission screening resident review (PASARR) dated 05/29/19 revealed Resident #32 had dementia no indications of serious mental illness. Further review of Resident #32's PASARR revealed Resident #32 did not have a significant change PASARR upon new diagnoses of serious mental illness. (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 4 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 02/09/2023 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)