Health inspection·February 24, 2022

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 complete Minimum Data Set (MDS) assessments for three (#29, #33, and #34) of 12 residents in the survey sample. The census was 42. Residents Affected - Few Findings include: 1. Review of Resident #34's medical record revealed an admission date of 02/24/20. Diagnoses included chronic diastolic heart failure, type II diabetes mellitus, atrial fibrillation, and anemia. Review of a annual MDS assessment, dated 11/08/21, revealed Resident #34 was coded as receiving an anticoagulant medication for seven days of the look back period. Review of a quarterly MDS assessment, dated 02/02/22, revealed Resident #34 was coded as receiving an anticoagulant medication for seven days of the look back period. Review of medication administration records (MARs) for November 2021 through February 2022 revealed no documentation of Resident #34 receiving an anticoagulant medication. Interview on 02/24/22 at 8:56 A.M., Licensed Practical Nurse (LPN) #157 confirmed Resident #34's MDS assessments an 11/08/21 and 02/02/22 were coded incorrectly for anticoagulant medication use. 2. Review of the medical record of Resident #29 revealed an admission date of 11/10/21. Diagnoses included reduced mobility, diabetes mellitus type II, and peripheral vascular disease. Review of the quarterly MDS assessment, dated 01/17/22, revealed the resident had three unhealed pressure ulcers. Review of the skin grid pressure assessment, dated 12/20/21, revealed the wounds on the resident's right foot, second and third toes, were documented as healed, unstageable wounds. Interview on 02/24/22 at 9:26 A.M. with LPN #157 provided verification of the incorrect MDS data being coding identifying Resident #29 to have unhealed pressure ulcers. 3. Review of the medical record of Resident #33 revealed an admission date of 01/28/22. Diagnoses include quadriplegia, pressure ulcers, and depression. Review of the 5-day MDS assessment, dated 001/28/22, revealed Resident #33 was cognitively intact and received hospice services while a resident. (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: 366033 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 02/24/2022 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)