Health inspection·December 12, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to notify the physician and resident representative of the resident's severe weight losses. This affected two (Residents #200 and #500) of six residents reviewed for weight loss. The facility census was 54. Finding: 1. Closed record review for Resident #200 revealed an admission date of 12/09/22. Diagnoses included diabetes mellitus type two, tracheostomy, stage four decubitus ulcer (Full thickness tissue loss with exposed bone, tendon or muscle), systemic cerebral vascular accident, dysphagia, quadriplegia, and gastrostomy tube. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 was cognitively impaired and no behaviors or rejection of care. Resident #200 received 51% or more total calories though tube feeding, had a five percent weight loss, and was not on a physician prescribed weight-loss regimen. Resident #200 was at a high risk for pressure ulcers with one stage four pressure ulcer upon admission. Review of Resident #200's weights revealed a monthly mechanical lift weight on 08/04/23 of 143.6 pounds (lbs.) and 10/05/23 a mechanical lift weight of 134.2 lbs. (A 9.4 weight loss in two months; 7% weight loss) There was no weight recorded for the month of September 2023. The medical record was silent for notification to the physician and resident representative regarding Resident #200's severe weight loss on 10/05/23. Interview on 12/11/23 at 10:30 A.M. with Dietitian #619 verified the facility did not obtain Resident #200's weight for September 2023. Dietitian #619 verified Resident #200 had a seven percent weight loss from August to October 2023. Dietitian #619 stated Resident #200 should have been placed on weekly weights and was unable to locate any weekly weights for October and November 2023. Interview on 12/11/23 at 11:00 A.M. with the Administrator verified the physician and resident representative were not notified of Resident #200's weight loss on 10/05/23. 2. Closed record review for Resident #500 revealed an admission date of 07/26/23. Diagnoses included restlessness leg syndrome, anxiety, depression, osteoarthritis, diabetes, chronic lower leg wound, sepsis, urinary tract infection, and acute metabolic encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #500 (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 3 Event ID: 365595 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 365595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005 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)