Health inspection·May 9, 2019

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of monthly MAR for April 2019 documented Resident #36 had a current physician order for Aspirin and Plavix (antiplatelet) medication and was administered the medication for the whole month of April 2019. Further review lacked any documentation of Resident #36 receiving any anticoagulation medication. Interview on 05/07/19 at 11:56 A.M. with MDS Nurse #120 verified she coded the use of anticoagulants inaccurately on the MDS assessments for Residents #11, #14 and #36. She revealed the Resident Assessment Instrument (RAI) manual documents to not code the antiplatelet medications. She further verified Aspirin and Plavix are both antiplatelet medication not anticoagulants. 4. Review of the medical record of Resident #32 revealed an admission date of 06/04/08 and a readmission date of 01/16/17. Diagnoses included schizoaffective disorder, chronic obstructive pulmonary disease, essential hypertension, acute kidney failure, chronic systolic (congestive) heart disease, other forms of chronic ischemic heart disease, other sequelae following unspecified cerebrovascular disease and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the April physician orders revealed an order for Plavix 75 milligrams (mg), an antiplatelet agent, originally ordered 08/28/18. Review of the April 2019 medication administration record revealed the medication was given as ordered. Review of the annual minimum data set assessment dated [DATE] revealed Resident #32 received anticoagulant seven days of the look back period. Interview on 05/07/19 at 11:56 A.M. with MDS Nurse #120 verified she coded the use of anticoagulants inaccurately on the MDS assessments for Residents #32. She revealed the Resident Assessment Instrument (RAI) manual documents to not code the antiplatelet medications. She further verified Aspirin and Plavix are both antiplatelet medication not anticoagulants. 5. Review of the medical record for Resident #25 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, bipolar disorder, chronic atrial fibrillation, osteoarthritis, chronic obstructive pulmonary disease, major depressive disorder, lymphedema, and anxiety disorder. Review of the medication administration record (MAR) dated 04/19, revealed Resident #25 was administered the medication Keflex (antibiotic) on five days (04/09/19, 04/10/19, 04/11/19, 04/12/19, and 04/13/19) of the seven day reference period. Continued review of the MAR revealed the resident was administered the medication Apixaban (anticoagulant) on seven days (04/07/19, 04/08/19, 04/09/19, 04/10/19, 04/11/19, 04/12/19, and 04/13/19) of the seven day reference period . Further review of the MAR dated 04/19, revealed Resident #25 was administered the medication Norco (opioid) on five days (04/07/19, 04/09/19, 04/10/19, 04/11/19, and 04/12/19) of the seven day reference period. Review of a quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #25 received anticoagulant medication on zero days of the seven day reference period, received opioid medication on three days of the seven day reference period, and received antibiotic medication on zero days of the seven day reference period. Interview on 05/08/19 at 9:50 A.M. with MDS #120 verified the quarterly MDS assessment dated [DATE], for Resident #25 was inaccurate. The MDS nurse confirmed Resident #25 was administered anticoagulant medication on seven days of the reference period, opioid medication on five days of the reference (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 2 of 5 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 366033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Sidney 510 Buckeye Ave Sidney, OH 45365 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 0641 period, and antibiotic medication on five days of the reference period. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 3 of 5 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 366033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Sidney 510 Buckeye Ave Sidney, OH 45365 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. Based on medical record review and staff interview, the facility failed to ensure care plans addressed all resident care areas. This affected one resident (#24) of 11 reviewed for care plans. The facility census was 46. Findings include: Review of the medical record of Resident #24 revealed an admission date of 04/02/19. Diagnoses include chronic obstructive pulmonary disease, essential hypertension acute on chronic diastolic heart failure, anemia, and stage four chronic kidney disease. Review of the care plan dated 04/04/19 revealed it to be silent of any dialysis care. Review of the physician order dated 04/10/19 revealed an order for Resident #32 to be transported to dialysis center on Tuesday, Thursday and Saturday. Interview on 05/08/19 at 10:43 A.M. provided verification of the lack of dialysis care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 4 of 5 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 366033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Sidney 510 Buckeye Ave Sidney, OH 45365 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, policy review and staff interview, the facility failed to maintain an effective Legionella Control procedure. This had the potential to affect all 46 residents residing in the facility. Residents Affected - Many Findings include: Review of an undated facility form titled Identifying Buildings at Increased Risk revealed if the facility answered yes to any questions one through four, they should have a water management program for the building's hot and cold water distribution system. The facility checked yes to questions one, two, and three. Question one-Is your building a healthcare facility where patients stay overnight or does your building house or treat people who have chronic and acute medical problems or weakened immune systems? Question 2-Does your building primarily house people older than 65 years? Question 3-Does your building have multiple housing units and a centralized hot water system? Review of the Legionella Control procedure revealed no monitoring of the water temperatures, water sanitizer or disinfectant levels were documented. Interview on 05/09/19 at 1:00 P.M. with the Corporate Clinician (CC) #150 provided verification the facility did not have a water management program in place to monitor for Legionella. She verified the facility risk assessment indicated the facility required a water management program. She verified the facility did not have a flow sheet to identify potential areas of concern and the facility and was not completing any water testing protocols. Review of the facility policy titled Legionella dated 06/02/17 revealed the purpose of the procedure was to reduce the risk of Legionella in healthcare facility water systems and to prevent cases and outbreaks of Legionnaire's disease. The facility will monitor water temperatures, sanitizer levels, and disinfectant levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 5 of 5