Health inspection·November 13, 2024

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 interview, medical record review, and facility policy review, the facility failed to submit a new Level I Pre-admission screening and resident review (PASARR) when required for one (#4) of one sampled resident reviewed for PASARRs. The census was 39. Findings included: Review of an admission record revealed the facility admitted Resident #4 on 03/30/22. According to the admission record, the resident had a medical history that included diagnoses of anxiety disorder (onset 09/16/22), dementia (onset 10/01/22), major depressive disorder (onset 09/21/23), and delusional disorders (onset 11/06/24). Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/07/24, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS assessment revealed the resident had active diagnoses to include anxiety disorder, depression, and psychotic disorder. Review of Resident #4's medical record revealed no evidence to indicate a level I PASARR screening was completed after the resident received new mental illness diagnoses. During an interview on 11/13/24 at 10:51 A.M., Social Worker (SW) #250 indicated she was responsible for resident PASARRs and indicated a resident review was done if there was a significant change or if a mental health diagnosis was added. SW #250 stated the resident review was for updates on the PASARR identification screening form. SW #250 indicated if the resident obtained a new mental health diagnosis, then a new resident review was completed at that time. SW #250 stated she completed a resident review for Resident #4 on 11/12/24 because the resident's prior PASARR did not have the resident's current mental illness diagnoses on it. SW #250 indicated the dates the resident obtained the mental health diagnoses were on the chart on the medical diagnoses list. SW #250 indicated the PASARR should have been resubmitted when the resident was diagnosed with the mental health diagnoses. During an interview on 11/13/24 at 12:27 P.M., the Director of Nursing (DON) indicated SW #250 was responsible for the PASARR process. The DON indicated she did not know much about the PASARR protocols, but if there was a regulation then she expected it to be followed. During an interview on 11/13/24 at 12:56 P.M., the Administrator indicated SW #250 was responsible for the resident PASARRs. The Administrator stated she expected for a Level I PASARR to be submitted when a resident obtained a new mental illness diagnosis. (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 5 Event ID: 366223 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 366223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Notre Dame Health Center 699 East Columbia Avenue Cincinnati, OH 45215 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)