Health inspection·October 17, 2024

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 10/16/24 at 2:12 P.M. with MDS Nurse #255 confirmed the quarterly MDS assessments for Resident #2 dated 08/23/24, for Resident #9 dated 08/25/24, and Resident #26 dated 09/07/24 were not completed timely. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual, dated October 2023, revealed, on page 2-35, the MDS completion date must be no later than 14 days after the ARD. Event ID: Facility ID: 366033 If continuation sheet Page 2 of 12 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 10/17/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to CMS as required. This affected one (#94) of 12 residents reviewed for MDS assessments. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #94 revealed an admission date of 01/30/23 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, anemia, hypertension, and moderate protein calorie malnutrition. Review of the medical record for Resident #94 revealed no documentation to support the facility transmitted Minimum Data Set (MDS) assessments timely for an annual MDS assessment dated [DATE], a significant change MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE]. Interview on 10/16/24 at 9:06 A.M. with MDS Nurse #255 confirmed the Resident #94's MDS assessments dated 12/16/23, 02/07/24, 05/01/24, and 07/30/24 were not transmitted to the Centers for Medicare and Medicaid Services (CMS). Review of the CMS Long-Term Care Facility RAI 3.0 User Manual, dated October 2023, revealed, on pages 5-1 through 5-3, revealed all Medicare and/or Medicaid-certified nursing homes and swing beds of those facilities, must transmit required MDS data records to CMS Internet Quality Improvement Evaluation System (iQIES). The RAI manual revealed the required MDS records are those assessments and tracking records that are mandated under the Omnibus Budget Reconciliation Act (OBRA) and Skilled Nursing Facility Prospective Payment System (SNF PPS) which included comprehensive, quarterly, and PPS assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 3 of 12 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 10/17/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interviews, the facility failed to follow physician orders to ensure treatments were in place. This affected one (#9) of one residents reviewed for treatment of skin conditions. The facility census was 39. Residents Affected - Few Findings included: Review of the medical record for Resident #9 revealed an admission date of 06/11/20 with diagnoses of peripheral vascular disease and venous insufficiency. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, was independent with eating and ambulating, required set-up assistance with oral hygiene, required supervision with bed mobility and transfers, and required partial assistance with toileting hygiene, bathing, dressing, and personal hygiene. Review of the care plan, dated 03/04/24, revealed Resident #9 had potential impairment to skin integrity related to decreased mobility with a goal to be free from injury through the review date. An intervention included to ensure socks/compression hose are on before placing shoes on with a dated of 07/09/24. Review of Resident #9's physician order dated 08/26/24 revealed an order to apply black thrombo-embolic deterrent (TED) hose or all cotton elastic (ACE) wraps if not available applied to bilateral lower extremities every morning and remove every evening. Observation on 10/15/24 at 11:06 A.M. revealed Resident #9 was sitting up in a wheelchair with an elasticated tubular-like bandage (Tubigrip) dressing to the left lower leg. Resident #9's right lower leg was uncovered and the resident had no socks, TED hose or ACE wraps in place to the bilateral lower extremities. Observation on 10/16/24 at 9:13 A.M. revealed Resident #9 was up in a wheelchair in the room with a Tubigrip-like dressing to the left lower leg. Resident #9's right lower leg was uncovered and the resident had soft shoes in place. Further observation revealed the resident was wearing no socks and had no TED hose or ACE wraps in place to bilateral lower extremities. Interview on 10/16/24 at 3:55 P.M. with Licensed Practical Nurse (LPN) #244 confirmed Resident #9 did not have black TED Hose or ACE wraps to the bilateral lower extremities on 10/15/24 or 10/16/24. LPN #244 verified Resident #9 had a physician order to have either TED hose or ACE wraps in place every morning and to removed at bedtime. Interview on 10/17/24 at 1:00 P.M. with Administrator #280 confirmed the facility did not have a policy for following physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 4 of 12 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 10/17/2024 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain laboratory testing as ordered by the physician. This affected three (#11, #26, and #28) of three residents reviewed for laboratory values. The facility census was 39. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 08/08/19. Diagnoses include chronic obstructive pulmonary disease, essential hypertension, vascular syndromes of the brain in cerebrovascular diseases, vitamin B12 deficiency anemia, heart failure, major depressive disorder, cerebral atherosclerosis, and cerebral infarction. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of Resident #28's physician order dated 07/06/21 revealed a complete metabolic panel (CMP), lipid panel, and complete blood count (CBC) with differential was to be obtained every six months on the second Tuesday in June and December. Review of the laboratory results for Resident #28 revealed the last blood work results were dated February 2024 and did not include a lipid panel. 3. Review of Resident #11's medical record revealed an admission date of 04/08/22. Diagnoses listed included atherosclerotic heart disease, chronic obstructive pulmonary disease, hemiplegia, hemiparesis, type two diabetes mellitus, and major depressive disorder. Review of a quarterly MDS assessment dated [DATE] revealed Resident #11 was moderately cognitively impaired. Review of physician orders revealed laboratory orders dated 04/13/22 for a CMP, CBC with differential, thyroid stimulating hormone (TSH), and thyroxine (T4) laboratory values to be obtained every six months in April and October every second Tuesday of the month. Further review of Resident #11's medical record revealed no documentation of a CMP, CBC with differential, TSH, or T4 laboratory values being completed in April 2024. Interview on 10/16/24 at 10:40 A.M. with Director of Nursing (DON) revealed when the facility switched laboratory providers at the end of last year the new provider could not pull the laboratory orders from the electronic medical records and some were missed. The DON confirmed the ordered laboratory values for Resident #11, Resident #26, and Resident #28 were not obtained as ordered. The DON stated the facility must now send the orders to the laboratory provider weekly. The issue was discovered two weeks ago and the DON was working on discovering the missing laboratory orders. Interview on 10/16/24 at 1:50 P.M. with the DON revealed the facility had no policy on obtaining laboratory values as ordered. 2. Review of the medical record for Resident #26 revealed an admission date of 11/09/15 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 5 of 12 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 10/17/2024 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical diagnoses of dementia, cerebral infarction, Alzheimer's disease, delusional disorders, and schizophrenia disorder. Review of the medical record for Resident #26 revealed a quarterly MDS assessment, dated 09/07/24, which indicate Resident #26 had moderate cognitive impairment and required substantial/maximum staff assistance with toileting hygiene and bathing and supervision with bed mobility and transfers. Review of the medical record for Resident #26 revealed a physician order dated 07/07/21 for a serum magnesium laboratory value to be drawn annually in August and an order dated 02/15/23 for a CMP, hemoglobin A1c (HbA1c), and a lipid panel every six months in June and December. Review of Resident #26's medical record revealed no documentation to support the facility completed the residents laboratory draw for serum magnesium, CMP, HbA1c, or a lipid panel as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 6 of 12 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 10/17/2024 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 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, and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and food was stored in a safe manner. This had the potential to affect all 38 residents who received food from the kitchen with the exception of one (#05) resident who the facility identified as receiving nothing by mouth from the kitchen. The census was 39. Findings include: Observation on 10/15/24 at 8:37 A.M., during the tour of the kitchen, revealed the ice maker had debris on the outside, top of the ice holding area. Observation inside the ice machine revealed a brownish-red substance was noted above the ice dispensing chute. Observation inside of a small chest freezer, designated to hold residents' private foods, had a moderate amount of ice build-up. The ice extended from the rim to approximately eight inches down and the small inner basket was unable to be moved. The freezer contained five individually wrapped breakfast sandwiches, an opened bag of tater tots, and numerous boxes of various frozen deserts. The food was not dated nor had a resident names. The produce cooler had a small amount of ice build-up on the inside from the rim and down approximately five inches. The cooler also contained a box of approximately 20 whole tomatoes and one of the tomatoes had a visible area of rot and several with soft-appearing indents. Interview on 10/15/24 at 8:40 A.M. with Dietary Manager (DM) #221 verified the debris on top of the ice maker, the brownish-red substance inside the ice machine, the ice build-up inside the small freezer used to store resident personal food and the lack of the food items being properly labeled, and the ice inside the produce cooler. DM #221 further verified the tomatoes in the produce cooler showed rot. Review of the policy titled, Food Brought in From Outside, dated 05/01/22, revealed foods brought in from the community must be dated and labeled with the resident's name. Review of the undated policy titled, Cleaning and Sanitizing Dietary Areas and Equipment, revealed all kitchen areas and equipment shell be maintained in a sanitary manner and be free of build-up of debris. Review of the policy titled, Refrigerators & Freezers Operation, dated 05/01/22, revealed supervisors will inspect freezers monthly for excess condensation and the freezers will be free of debris, clean, and mopped with sanitizing solution on a scheduled basis and as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 7 of 12 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 10/17/2024 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the online verification system of the Board of Executives of Long-Term Services and Supports (BELTSS), review of the Administrator job description, staff interview, and facility corrective action, the facility failed to ensure there was a licensed nursing home administrator (LNHA) with a valid license providing supervision and leadership to the facility. This had the potential to affect all 39 residents residing in the facility. The facility census was 39 residents. Findings include: Interview on [DATE] at with Administrator #280 confirmed she served as the facility LNHA of record since [DATE]. Administrator #280 confirmed she was notified by a BELTSS representative that her LNHA license expired on [DATE]. Administrator #280 confirmed Administrator #285, who was employed by the facility corporation, served as LNHA for the facility from [DATE] until [DATE]. Administrator #280 confirmed she her licensed was renewed and valid on [DATE] and she had been serving as LNHA of record since that date. Administrator #280 confirmed that facility did not have a LNHA with a valid licensed serving from [DATE] to [DATE]. Review of the online license verification system for BELTSS at https://beltss.ohio.gov/licensing.license-to-okup revealed Administrator #280 was issued an Ohio LNHA license on [DATE] with an expiration date of [DATE]. Review of the online license verification system for BELTSS at https://beltss.ohio.gov/licensing.license-to-okup revealed Administrator #285 was issued an Ohio LNHA license on [DATE] with an expiration date of [DATE]. Review of the facility job description titled, Administrator, revealed the Administrator provided overall direction for all activities related to administration, personnel, physical structure, information systems, office management and marketing of the entire facility. The policy revealed the Administrator must have a current State License as a Nursing Home Administrator. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: • On [DATE], Administrator #285 became the LNHA of record for the facility. • On [DATE], Administrator #280 updated her email address with BELTSS to ensure she received communications from them. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 8 of 12 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 10/17/2024 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 0837 On [DATE], Administrator #280 educated the human resource director to perform an annual audit of the renewal date for the LNHA of record for the facility to ensure the license was valid and current. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Many On [DATE], Administrator #280's Ohio license to practice as an Ohio LNHA was renewed through [DATE]. This deficiency represents non-compliance investigated under Complaint Number OH00157797. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 9 of 12 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 10/17/2024 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of Quality Assurance and Performance Improvement (QAPI) attendance logs, staff interview, and policy review, the facility failed to ensure the facility Medical Director or designee attended QAPI meetings quarterly as required. This had the potential to affect all 39 residents residing in the facility. The facility census was 39. Residents Affected - Many Findings include: Review of the facility quarterly QAPI attendance logs revealed the Medical Director or his/her designee did not attend the quarterly meeting on 04/23/24. Interview on 10/17/24 at 3:25 P.M. with the Director of Nursing (DON) confirmed the facility did not have documentation to confirm the Medical Director or his/her designee attended the quarterly QAPI meeting on 04/23/24. Review of the facility policy titled, QAPI Committee Meetings, dated 05/01/24, revealed the meetings are to ensure the facility care practices maintain standards of quality and to improve the delivery of services and resident outcomes, the facility has established an ongoing Quality Assurance/Quality Improvement (QA/QI) program. Further review revealed the QA/QI program was monitored and revised by the QA/QI committee which members included the DON, Medical Director/Physician, Administrator, Director of Housekeeping, Director of Therapy, Director of Social Work, Director of Food Services, Director of Maintenance, and QA Nurse. The policy indicated the QA/QI committee would meet at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 10 of 12 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 10/17/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed appropriately perform hand hygiene to maintain proper infection control practices during dressing changes. This affected one (#12) of one residents reviewed for wound care. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an admission date of 12/07/23 with diagnoses of quadriplegia, cervical disc disorder with myelopathy, unspecified cervical region, and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact and was dependent on staff assistance with eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. Review of Resident #12's physician orders revealed an order dated 12/08/23 to wash around the suprapubic catheter site with soap and water daily and apply a drainage sponge daily. Review of Resident #12's physician orders dated 10/04/24 revealed an order for the left and right sacrum and left ishium to be cleansed with normal saline (NS) and patted dry, apply primary collagen powder, apply a secondary blue Bacteriostatic dressing, and cover with [NAME] super absorbent silicone bordered dressing daily. Observation on 10/16/24 at 2:25 P.M. with Licensed Practical Nurse (LPN) #244 and State Tested Nurse Aide (STNA) #249 revealed the staff members performed wound care on Resident #12. LPN #244 and STNA #249 entered the resident's room, washed their hands and explained the procedure to the resident. LPN #244 cleansed the bedside table, placed a clean cloth on the table, and gathered wound supplies. LPN #244 washed her hands again. Both LPN #244 and STNA #249 applied gloves. LPN #244 removed Resident #12's suprapubic catheter dressing, cleansed the area with NS and a clean gauze, then applied a clean dry split drainage gauze. LPN #244 removed the soiled gloves and applied a new pair of gloves. STNA #249 assisted Resident #12 to reposition onto his left side. LPN #244 removed the dressing to resident's right sacrum, cleansed it with NS, applied collagen powder to her left glove and placed it in the wound bed, applied a secondary blue Bacteriostatic dressing, and covered it with [NAME] super absorbent silicone bordered dressing. LPN #244 removed her gloves and applied clean gloves. LPN #244 removed the dressing to the resident's left sacrum, cleansed it with NS, applied collagen powder to her left glove and placed it in the wound bed, applied a secondary blue Bacteriostatic dressing, and covered it with [NAME] super absorbent silicone bordered dressing. LPN #244 removed her gloves and applied clean gloves. LPN #244 removed the dressing to the resident's left ischium, cleansed it with NS, applied collagen powder to her left glove and placed it in the wound bed, applied a secondary blue Bacteriostatic dressing, and covered it with [NAME] super absorbent silicone bordered dressing. LPN #244 removed all contaminated wound dressing supplies and disposed of it in the trash. LPN #244 and STNA #249 removed their gloves and washed their hands, ensured the resident was comfortable, and exited the room. Interview on 10/16/24 at 3:00 P.M. with LPN #244 confirmed while doing the suprapubic catheter dressing change and wound dressing changes for Resident #12 she did not perform hand hygiene after removing the soiled dressings and before putting on new gloves to apply the new dressings for each wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 11 of 12 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 10/17/2024 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 site. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled, Handwashing, dated 09/09/21 revealed the facility considered hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing / hand hygiene procedures to help prevent the spread of infections to other personnel , residents, and visitors. Staff are to use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before handing clean or soiled dressings, gauze pads, etc., after handling used dressings contaminated equipment, etc., and after removing gloves. The use of gloves does not replace hand washing/hand hygiene and integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. When applying and removing gloves, staff are to perform hand hygiene before and after applying non-sterile gloves. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366033 If continuation sheet Page 12 of 12