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. Page 1 of 5 366033 366033 02/24/2022 Momentous Health at Sidney 510 Buckeye Ave Sidney, OH 45365

F 0641 Review of the record revealed no documentation of Resident #33 receiving hospice services. Level of Harm - Minimal harm or potential for actual harm Interview on 02/24/22 at 9:24 A.M. with LPN #157 verified Resident #33's MDS was inaccurately coded for hospice. Residents Affected - Few 366033 Page 2 of 5 366033 02/24/2022 Momentous Health at Sidney 510 Buckeye Ave Sidney, OH 45365

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR)was completed. This effected one (#7) of two residents reviewed for PASRR. The facility census was 42. Residents Affected - Few Findings include: Review of the medical record of Resident #7 revealed an admission date of 11/10/21 and a readmission date of 12/16/21. Diagnoses included unspecified dementia with behavioral disturbance and bipolar type schizoaffective disorder. Review of the Preadmission Screening and Resident Review (PASRR) Identification Screen dated 12/14/21 and signed by a Catholic Social Service assessor revealed a no response was documented for the diagnosis of dementia. A negative response was also indicated for a diagnosis of any mental disorder. Interview on 02/24/22 at 9:37 A.M. with Licensed Practical Nurse (LPN) #7 provided verification of the inaccurate assessment. 366033 Page 3 of 5 366033 02/24/2022 Momentous Health at Sidney 510 Buckeye Ave Sidney, OH 45365

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, review of dishwasher logs, and review of the facility Dish Machine Guidelines, the facility failed to ensure the dishwasher was operating correctly. This had the potential to effect all 41 residents who recieved food from the kitchen. Resident #2 did not receive food from the kitchen. The facility census was 42. Findings include: Observation on 02/22/22 at 9:00 A.M. revealed the dishwasher was a high-temperature sanitizer. The rinse cycle revealed a high temperature of 170 degrees Fahrenheit (F). A second observation at 9:05 A.M. with Dietician #161 revealed the rinse cycle attained a temperature of 172 degrees F. Review of the dish machine temperature logs for 01/22/ and 02/22 revealed 31 entries with a rinse temperature less than 180 degrees F. Interview on 02/22/22 at 9:10 A.M. with Dietary Personnel (DP) #107 revealed the temperature of the rinse cycle should be above 180 degrees F and she records the temperature with breakfast trays and lunch trays. DP #107 stated she does not inform anyone if the temperature is below 180 degrees F. Interview on 02/22/22 with Dietician ##161 provided verification the rinse temperature did not reach 180 degrees F and informed the kitchen personnel they would have to use disposable service until the machine is repaired. Interview on 02/23/22 at 7:55 A.M. with Dietician #161 revealed the dishwasher uses high-temperature water to sanitize the dishes and is not attached to any sort of quaternary solution. The documentation on the Dish Machine Log appears to be for the three sink system. As the dishwasher does not have any chemical sanitization. Interview on 02/23/22 at 8:02 A.M. with DP #123 revealed the dishwasher was tested each meal with a quaternary solution test strip. She added she had told Dietary Supervisor #118 on 12/21 of the low temperatures recorded on the dishwasher. Review of the Dish Machine Guidelines undated, provided by Dietician #161 and Administrator revealed the proper rinse temperature is 180 F. 366033 Page 4 of 5 366033 02/24/2022 Momentous Health at Sidney 510 Buckeye Ave Sidney, OH 45365

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure staff appropriately removed personal protective equipment (PPE) when exiting the room of a resident under transmission precautions (TBP). This affected one (#30) of three residents reviewed for TBP and had the ability to affect 15 residents (#1, #2, #6, #12, #13, #16, #18, #19, #20, #22, #28, #37, #38, #43, and #195) residing on the 200 hall. The census was 42. Residents Affected - Some Findings include: Review of Resident #30's medical record revealed an admission date of 10/15/21. Diagnoses included bipolar disorder, schizophrenia, major depressive disorder, and acute bronchitis. Resident #30 was assessed as being cognitively intact and requiring limited assistance to supervision with activities of daily living (ADLs). Review of physician order dated 02/21/22 revealed Resident #30 was to be on droplet isolation related to left infiltrate and contact isolation to left infiltrate every shift until 03/04/22. Observation on 02/23/22 at 8:41 A.M. revealed Licensed Practical Nurse (LPN) #112 was entering Resident #30's room with medications. LPN #112 was wearing a blue gown, gloves, facemask, and goggles. At 8:42 A.M. LPN #112 exited Resident #30's and went to the medication cart. LPN #112 was still wearing the blue gown and gloves. LPN #112 did not removed the blue gown and gloves before exiting Resident #30's room. LPN #112 removed gloves while at the medication cart, but kept the blue gown on. Interview with LPN #112 at 02/23/22 at 08:49 A.M. confirmed she had exited Resident #30's room while still wearing the blue gown and gloves she had entered his room wearing. LPN #112 confirmed the Resident #30 was in contact and droplet isolation. LPN #112 confirmed that there was a receptacle located inside Residents #30's to dispose of personal equipment. Observation of signs on Resident #30's door revealed signs designating he was in contact and droplet precautions. Instructions on the signs included that staff should remove gown and gloves before exiting the room. Review of the facility policy titled Contact Isolation Precautions Best Practice, revised November 2017, revealed staff should removed PPE and perform hand hygiene before leaving the resident room. Resident #1, #2, #6, #12, #13, #16, #18, #19, #20, #22, #28, #37, #38, #43, and #195 resided on the same hall as Resident #30 and would have received care from LPN #112 366033 Page 5 of 5