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** THE
FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Residents Affected - Some
Based on medical record review, observation, staff interview, review of camera footage, review of facility
investigation, and review of facility in-services, the facility failed to ensure staff practiced proper infection
control practices. This affected one (#01) of three residents reviewed for infection control. This had the
potential to affect six additional residents (#04, #08, #11, #21, #29, and #39) identified as being in
Enhanced Barrier Precautions (EBP). The facility census was 40.
Findings include:
Review of the medical record of Resident #01 revealed an admission date of 12/07/23. Diagnoses include
quadriplegia and a history of pressure ulcers to buttocks.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #01 was
cognitively intact and dependent on staff for personal hygiene and transfers. Resident #01 was assessed as
having an indwelling urinary catheter and incontinence of stool.
Review of the physician order dated 06/19/24 revealed Resident #01 was ordered EBP related to wounds.
Observation of Resident #01's room revealed a sign for EBP and indicating a gown and gloves were to the
donned prior to contact with the resident.
Review of five videos date coded as 04/13/25, 04/15/25, 04/17/25, 04/18/25, and 04/21/25 revealed
numerous staff members providing direct care to Resident #01. The videos were reviewed on 05/21/25 at
1:00 P.M., along with the Administrator and Director of Nursing (DON) to identify the staff and verify the
deficient practice. The video dated 04/13/25, revealed Wound Nurse (WN) #120 and Licensed Practical
Nurse (LPN) #121 providing wound care to Resident #01. Both wore gloves but neither had donned a
protective gown. The video dated 04/15/25, revealed WN #120 and DON providing direct care without
having donned protective gowns. The video dated 04/17/25, revealed Registered Nurse (RN) #122 and
Certified Nursing Assistant (CNA) #123 providing direct care to Resident #01 without donning a protective
gown. The video dated 04/18/25, revealed RN #100 providing direct care to Resident #01 without donning a
protective gown. The video dated 04/21/25, revealed CNAs #105 and #124 providing direct care to
Resident #01 without having donned protective gowns. The DON and Administrator verified the findings in
the videos.
Review of the policy titled, Transmission Based Precautions, dated 05/01/22, revealed Enhanced
(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 2
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
06/02/2025
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
Barrier Precautions indicated the use of gown and gloves when providing high contact care to residents.
Examples of high contact care activities included providing hygiene, changing linens, and wound care.
Level of Harm - Minimal harm
or potential for actual harm
As a result of the incident, the facility took the following actions to correct the deficient practice by 05/13/25:
Residents Affected - Some
•
On 04/17/25, the Quality Improvement Plan started when the DON identified the lack of proper procedure
for EBP.
•
On 04/18/25, the action plan was initiated by instructing all staff to read and sign the EBP policy. By the
DON via staff meeting and paper postings.
•
On 04/30/25, all staff were also instructed to sign and read the policies for contact and droplet precautions.
By the DON via staff meeting and paper postings.
•
On 05/13/25, an all-staff in-service was held and again the EBP procedure was provided to staff. DON and
ADON spoke at the all staff and circulated the hand outs with the sign off sheet.
•
Review of the sign sheets for the training on 04/17/25, 04/18/25, 04/30/25, and 05/13/25, revealed all staff
attended the all-staff in-service or indicated they had read the policy.
•
Random observations on 05/21/25 from 9:00 A.M. to 3:00 P.M., revealed staff to don protective gowns and
gloves prior to entering any of the six rooms identified as requiring EBP.
•
Review of auditing/monitoring dated 04/18/25, 04/21/25, 04/28/25, 04/29/25, 05/05/25, 05/08/25, 05/13/25,
and 05/20/25 revealed staff were following the EBP procedure.
This deficiency represents the noncompliance discovered during the investigation of Complaint Number
OH00165605.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366033
If continuation sheet
Page 2 of 2
