Inspection visit

Health inspectionApril 24, 2023

MOMENTOUS HEALTH AT VANDALIACMS #36603521 citations on this visit

21 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 21 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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, observations, resident interview, staff interviews and policy review, the facility failed to ensure a resident was assessed to self-administer medications. This affected one (#78) of one random resident observed. The census was 103. Residents Affected - Few Findings include: Medical record review for Resident #78 revealed and admission on [DATE], with diagnoses including pneumonia, chronic obstructive pulmonary disease, chronic respiratory failure, hypertension, anxiety disorder, solitary pulmonary nodule, and dementia with other diseases. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #78 revealed an impaired cognition. Resident #78 was coded with delusions during the assessment period. Resident #78 required limited assistance for bed mobility, supervision for transfers, eating and toileting. Review of the plan of care for Resident #78 revealed I have potential for altered respiratory status, difficulty breathing related to congestive obstructive pulmonary disease. Interventions include administer my medication or puffers as ordered, observe for effectiveness and side effects, elevate the head of my bed to assist me with breathing, maintain a clear airway by encouraging me to clear my own secretions with effective coughing, monitor for signs and symptoms of respiratory distress and report to physician, observe and report abnormal breathing patterns to my doctor and use oxygen as ordered. Review of the electronic health record assessment tab for Resident #78 was silent for medication self-administration assessment. Review of the monthly physician orders for April 2023 revealed no orders for self-administration of medications. Observation on 04/17/23 at 7:39 P.M., of Resident #78 sitting on his bed in his room. On Resident #78's bedside stand was a med nebulizer machine with a medication cup. Inside the medication cup was an open and full vial of clear solution, labeled albuterol. Staff were not present in the room when the observation was made. Interview on 04/17/23 at 7:40 P.M., with Resident #78 stated the nurse brought the medication in for me a little bit ago. Resident #78 stated he used it with the med nebulizer for his breathing. Interview on 04/17/23 at 7:50 P.M., with Licensed Practical Nurse (LPN) #47 stated if she has worked here, they have kept the medication in his room for him to use. LPN #47 verified the orders do not state that the resident can administer his own medication via a medication nebulizer. LPN #47 Page 1 of 35 366035 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0554 stated she left the medication in the room for Resident #78. Level of Harm - Minimal harm or potential for actual harm Interview on 04/18/23 at 6:25 P.M., with Assistant Director of Nursing (ADON) verified medication should not be left in resident's room unsupervised. Residents Affected - Few Review of the policy titled Medication Administration, dated 05/01/22 revealed residents may self-administer medications only if the physician in conjunction with the interdisciplinary care planning team has determined that have the decision-making capacity to do so. 366035 Page 2 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and resident interview, the facility failed to ensure a resident was treated with dignity and respect. This affected one (#47) of 25 residents reviewed for care and treatment. The census was 103. Findings included: Review of Resident #47's medical record revealed an admission date of 06/14/22. Medical diagnoses included puerperal psychosis, cancer, heart failure, peripheral vascular disease, diabetes, bilateral below the knee amputation (BKA), Schizophrenia, and obstructive uropathy. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Her functional status was extensive assistance or bed mobility and toilet use. She was dependent on staff for transfers, and supervision for eating. She has an indwelling Foley catheter. Review of care plan dated 10/05/22 revealed Resident #47 has a behavior problem and will make false allegations towards staff to get them in trouble. Interventions were to approach her and speak to her in a calm manner. Divert her attention and remove her from a situation as needed. Review of progress note dated 01/19/23 through 04/19/23 revealed no concerns related to behaviors. Interview on 04/18/23 at 9:07 A.M., with Resident #47 revealed State Tested Nursing Aide (STNA) #113 who is taking care of her today is sarcastic, and the nurse treats her like hell and told her she was going to send her to the Nut House Observation on 04/18/23 at 9:30 A.M., of STNA #113 revealed the aide was getting supplies ready for catheter care and yelled from the bathroom inside of the resident's room, to STNA #102 in the hallway, that the resident was jackknifed in the bed and the aide couldn't provide the care to the resident like this. The roommate (Resident #87) was lying in bed in the room when this was spoken. During the observation, of catheter care and a bath, the tone of the aides voice was direct and ordering the resident to lift her arm and wash her face. Interview on 04/18/23 at 10:20 A.M., with STNA #113 confirmed she was disrespectful to Resident #47 during the catheter care. STNA #113 stated she felt her tone was ok she used with the resident. Observation on 04/18/23 at 2:15 P.M., of Resident #47 revealed she was in her room in her wheelchair and STNA #113 had her voice raised saying you are going to have to wait a minute till I get the Hoyer lift to get you back to bed. Interview on 04/18/23 at 2:42 P.M., with STNA #113 said the tone and the way she spoke to Resident #47 was the way she always talked to her. STNA #113 stated she did not have any discord with the resident. STNA #113 stated she was not going to baby talk to Resident #47. STNA #113 stated she had to be stern with Resident #47 because the resident will cuss you out and talk about your whole family. STNA #113 continued to state, Resident #47 is one of those type people who will be disrespectful to the staff, and she doesn't do me that way. STNA #113 stated she treats all the residents the same. 366035 Page 3 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/18/23 at 4:10 P.M., with the Resident #47 revealed STNA #113 came into her room and stated she knew everything the resident said to the surveyor, and she was not going to get her up again and left the room and went home. Interview on 04/18/23 at 4:34 P.M., with LPN #66 revealed she and STNA #113 both demanded respect from Resident #47 and that she has told Resident #47 that she needs to think about how she treated people. LPN #66 reported Resident #47 threatens staff all the time, but they never refuse her care and always re-approach her. LPN #66 stated she won't put up Resident #47 talking mean and doesn't expect her girls (STNA #113) to deal with it. This deficiency represents the noncompliance in Complaint Number OH00141826. 366035 Page 4 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and policy review, the facility failed to notify Medicaid recipient residents when they had exceeded the Medicaid eligible personal fund limit. This affected 15 (#36, #18, #86, #25, #23, #46, #37, #14, #72, #45, #88, #2, #29, #19, and #15) of 15 Medicaid residents with personal funds accounts reviewed. The facility census was 103. Residents Affected - Some Findings include: Review of the facility census list revealed Residents #36, #18, #86, #25, #23, #46, #37, #14, #72, #45, #88, #2, #29, #19, and #15 were Medicaid eligible recipients. Review of Resident Fund Log dated 04/19/23, revealed Residents #36, #18, #86, #25, #23, #46, #37, #14, #72, #45, #88, #2, #29, #19, and #15 were over the Medicaid $2,000.00 limit in their personal fund account. Resident #72 was over the Medicaid eligibility limit by $10,624.17; Resident #86 was over the limit by $13,957.88 and Resident #88 was over the limit by $14,196.27. Interview on 04/20/23 at 11:30 A.M., with Business Office Manager (BOM) #9 verified the residents receiving Medicaid should be notified when reaching $200.00 of the $2,000.00 limit amount in their personal funds account. BOM #9 stated residents who are over the Medicaid limit of $2,000.00 could lose their Medicaid eligibility. BOM #9 verified she had no documentation of notification to Residents #36, #18, #86, #25, #23, #46, #37, #14, #72, #45, #88, #2, #29, #19, and #15 of surpassing the Medicaid limit in their personal funds' accounts. BOM #9 stated she had no documentation of a plan or previous attempts to assist Residents #72, #86 or #88 to spend down their personal funds accounts to prevent the residents from losing their Medicaid eligibility. Review of the policy titled, Resident Funds, dated 05/01/22 revealed the facility protects the residents' funds managed by the facility. 366035 Page 5 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 04/18/23 at 8:23 A.M., revealed on the wall behind Resident #30 bed board, a four foot by four-foot wall area with multiple half inch deep cuts in the wall. This exposed a non-cleanable wall surface. Interview on 04/18/23 at 8:23 A.M., with Resident #30 stated the wall had the exposed area and cuts since admission on [DATE]. He stated he did not like how the wall looked. Interview on 04/20/23 at12:00 P.M., with Maintenance Director #81 verified the wall behind Resident #30 bed board had large scrapes and deep cuts which was not a cleanable surface. The Maintenance Director #81stated he was unsure how long the wall had been in disrepair. Review of the policy titled Homelike Environment dated 05/01/22 revealed the facility will provide a safe, clean, comfortable and homelike environment. 4. Observation on 04/18/23 at 8:59 A.M., revealed Resident #39 to be in his bed. The left side of Resident #39's bed was observed to be up against the wall with a circular baseball sized hole in the wall next to his bed and chipped paint on the wall next to his bed that was approximately 12 inches long by 5 inches wide. Interview on 04/18/23 at 8:59 A.M., with Resident #39 verified the hole and chipped paint next to his bed but he did not know how long the hole or chipped paint had been next to his bed. Observation on 04/19/23 at 3:56 P.M., of Resident #39's room, revealed Resident #39 to be in his bed. The left side of Resident #39's bed was observed to be up against the wall with a circular baseball sized hole in the wall next to his bed and chipped paint on the wall next to his bed that was approximately 12 inches long by 5 inches wide. Interview on 04/19/23 at 3:56 P.M., with Maintenance Director #81 verified the circular hole and chipped paint next to Resident #39's bed. Maintenance Director #81 stated he was not aware how long the hole had been next to his bed, but stated the hole appeared to be from a previously installed grab bar. Based on observation, resident interviews, staff interview and policy review, the facility failed to maintain the resident's environment a safe and sanitary operating condition. This affected five (#89, #33, #78, #30, and #39) of 103 resident rooms observed for a homelike environment. The census was 103. Findings include: Observation on 04/19/23 at 4:08 P.M. to 4:30 P.M., revealed the following identified concerns: 1. In Resident #89's bathroom, the floor baseboard was separated from the wall and laying on the floor. 2. Resident #33's right sided wheelchair arm rest was cracked and peeling; and the left side wheelchair arm rest was missing a screw and misaligned. 366035 Page 6 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0584 Level of Harm - Minimal harm or potential for actual harm 3. Resident #78's nebulizer was sitting on the bedside stand and had black marks on the front and side of the nebulizer. Interview at the time with Resident #78 stated the machine needed to be cleaned. Interview on 04/19/23 at 4:30 P.M., with Maintenance Director #81 verified the above findings. Residents Affected - Some 366035 Page 7 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and resident interview and policy review, the facility failed to ensure a resident was free from verbal abuse. This affected one (#47) of four residents reviewed for potential abuse. The census was 103. Findings included: Review of Resident #47's medical record revealed an admission date of 06/14/22. Medical diagnoses included puerperal psychosis, cancer, heart failure, peripheral vascular disease, diabetes, bilateral below the knee amputation (BKA), Schizophrenia, and obstructive uropathy. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Her functional status was extensive assistance or bed mobility and toilet use. She was dependent on staff for transfers, and supervision for eating. She has an indwelling Foley catheter. Review of care plan dated 10/05/22 revealed Resident #47 has a behavior problem and will make false allegations towards staff to get them in trouble. Interventions were to approach her and speak to her in a calm manner. Divert her attention and remove her from a situation as needed. Review of progress note dated 01/19/23 through 04/19/23 revealed no concerns related to behaviors. Interview on 04/18/23 at 9:07 A.M., with Resident #47 revealed State Tested Nursing Aide (STNA) #113 who is taking care of her today is sarcastic, and the nurse treats her like hell and told her she was going to send her to the Nut House Resident #47 identified the nurse as a tall blonde, out at the medication cart, and stated License Practical Nurse (LPN) #66's name. Observation on 04/18/23 at 2:15 P.M., of Resident #47 revealed she was in her room in her wheelchair and STNA #113 had her voice raised saying you are going to have to wait a minute till I get the Hoyer lift to get you back to bed. Interview on 04/18/23 at 2:42 P.M., with STNA #113 said the tone and the way she spoke to Resident #47 was the way she always talked to her. STNA #113 stated she did not have any discord with the resident. STNA #113 stated she was not going to baby talk to Resident #47. STNA #113 stated she had to be stern with Resident #47 because the resident will cuss you out and talk about your whole family. STNA #113 continued to state, Resident #47 is one of those type people who will be disrespectful to the staff, and she doesn't do me that way. STNA #113 stated she treats all the residents the same. Observation and interview on 04/18/23 at 4:02 P.M., with the LPN #66 revealed LPN #66 was telling Resident #47 she could not get out of bed because she was dressed for bed and the aides were too busy to get her up again. LPN #66 told the resident you already missed the smoke break and there will not be another one till later. The surveyor followed the nurse out of the room and asked her why the resident could not get up because it was the resident's choice to do so. LPN #66 stated she would see if the aides were busy and could get her up again. Interview on 04/18/23 at 4:10 P.M., with the Resident #47 revealed STNA #113 came into her room and 366035 Page 8 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0600 Level of Harm - Minimal harm or potential for actual harm stated she knew everything the resident said to the surveyor, and she was not going to get her up again and left the room and went home. Resident #47 stated STNA #113 and LPN #66 are rough with her when they provide care to her. Resident #47 stated they both make her feel afraid and it hurts her feelings when they will not get her out of bed. Resident #47 denied she told anyone about the aide and the nurse because she did not know who to tell. Residents Affected - Few Interview on 04/18/23 at 4:34 P.M., with LPN #66 revealed she was not aware of any staff that treat residents differently. LPN #66 stated Resident #47 treat staff differently and she felt that the state surveying agency was coming down hard on her STNA's #113 and wanted to know if the state surveying agency looked at resident diagnoses and care plans as Resident #47 was on the buddy system. LPN #66 stated Resident #47 was not usually like this, and Resident #47 usually sleeps in and gets up after lunch for her the 1:00 P.M. smoke break. LPN #66 stated she had never witnessed STNA #113 treat Resident #47 differently. LPN #66 stated that she and STNA #113 both demanded respect from Resident #47 and that she has told Resident #47 that she needs to think about how she treated people. LPN #66 reported Resident #47 threatens staff all the time, but they never refuse her care and always re-approach her. LPN #66 stated she won't put up Resident #47 talking mean and doesn't expect her girls (STNA #113) to deal with it. The allegations were reported to the Administrator by the surveyor on 04/18/23 at 5:00 P.M. The Administrator suspended the LPN #66 and STNA #113, to start investigation. Review of policy titled Abuse Prevention dated 08/20/21 revealed this facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devices to demean or humiliate a resident. In the case of staff-to-resident Abuse, the facility will follow This facility's procedure for disciplining or dismissing an employee, depending upon the circumstances and results of the investigation. This facility will report the results of the investigation to the appropriate licensing agencies and registries (e.g., Board of Nursing, nurse aide registry, etc.) in accordance with the law. 366035 Page 9 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, facility investigation review, and policy review, the facility failed to report resident to resident altercation. This affected four residents (#80, #5, #4 and #77) of five reviewed for potential abuse. The census was 103. Findings include: 1. Medical record review for Resident #80 revealed an admission date of 10/04/22, with diagnoses including schizoaffective disorder, dementia with behaviors, depression, anxiety disorder, weight loss, psychosis bipolar disorder, visual hallucinations, and auditory hallucinations. Review of the Minimum Data Set assessment dated [DATE] for Resident #80 revealed a brief interview mental status was completed by staff with severe cognitive impairment. Resident #80 revealed physical and verbal behavioral symptoms director towards others, behaviors such as hitting, scratching self, pacing rummaging, occurs 4-6 days during the assessment period. Resident #80 requires limited assistance for bed mobility, transfers, and extensive assistance for eating and toileting by one staff member. Review of the progress note dated 02/15/23 at 12:55 P.M., for Resident #80 revealed a report from outgoing nurse about possible /unwitnessed altercation between this Resident #80 and Resident #5 as evidenced by visible scratches on Resident #80's chest, face and hands. Noted reopened area on Resident #5's face respectively. Both residents rested in their respective beds throughout the shift. No further incident observed or reported his shift. Will continue to monitor and maintain safety. Interview on 04/20/23 at 1:15 P.M., with the Administrator verified a self-reported incidents (SRI) was not completed for the potential resident to resident altercation, stating it was just missed and should have been reported. 2. Record review of Resident # 77 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #77 included: anxiety disorder, depression, agoraphobia with panic disorder, and peripheral neuropathy. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of nursing notes dated 04/12/23 at 2:19 P.M., revealed Resident #77 was physically assaulted by Resident #4. Resident #77 was pushed to the floor and threatened. Resident #77 sustained a skin tear to the left elbow requiring a treatment. Resident #77 complained of body pain and headache and a pain medication was provided. Interview on 04/18/23 at 10:20 A.M., with Resident #77 revealed a couple weeks ago, her previous roommate (Resident #4) had pushed her to the floor in her room and she had bruises on her arms. Interview on 04/19/23 at 4:00 P.M., and review of the investigation report, the Administrator revealed on 04/12/23, Resident #77 was pushed to the floor her room by her roommate (Resident #4). Resident #77 had a skin tear and bruising on the left arm. The Administrator revealed the incident was not reported to the State Agency, (SA). The Administrator verified the incident should have been reported to the SA. 366035 Page 10 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0609 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Abuse Prevention dated 08/20/21, revealed the Administrator or his/her designee will notify the department of health of all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and Injuries of Unknown Sources as soon as possible, but in no event later than twenty-four (24) hours from the time the incident/ allegation was made to the staff member. Residents Affected - Few 366035 Page 11 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and policy review, the facility failed to ensure residents had a care plan for hearing loss and antipsychotic medications. This affected two (#82 and #92) of 25 residents reviewed for care plans. The facility census was 103. Findings include: 1. Review of Resident #92's medical record revealed an admission date of 01/25/23, with diagnoses including metabolic encephalopathy, sepsis, osteomyelitis, anemia, hematuria, hyperlipidemia, major depressive disorder, and other symbolic dysfunctions. Review of Resident #92's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #92 required extensive assistance with bed mobility, dressing, and toileting. Resident #92 also required total assistance with personal hygiene and supervision with eating. Resident #93 had adequate hearing with the use of a device. Review of Resident #92's care plans dated 04/18/23 revealed Resident #92 did not have a care plan related to hearing loss or the use of hearing aids. Interview on 04/19/23 at 8:56 A.M., with Resident #92 revealed the resident could not hear the surveyor and he had difficulty hearing. Resident #92 stated he had hearing aids but rarely wore them. Interview on 04/19/23 at 8:56 A.M.,with Registered Nurse (RN) #80 verified Resident #92 did not have a care plan for hearing aids. 2. Review of Resident #82's medical record revealed an admission date of 01/08/21, with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disorder and anxiety, dysphagia, pain in right knee, other low back pain, altered mental status, abnormal posture, congestive heart failure, other reduced mobility, acute respiratory failure with hypoxia, depression, abnormal electrocardiogram, pressure ulcer of left heel stage three, syncope and collapse, hyperkalemia, and acute kidney failure. Review of Resident #82's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and Resident #82 required extensive assistance with bed mobility, dressing, personal hygiene, eating and toileting. Resident #82 required supervision with eating. Review of Resident #82's physician order dated 01/19/23 revealed Resident #82 was ordered Seroquel 25 milligrams (mgs) by mouth at bedtime for behaviors. Review of Resident #82's care plans dated 04/19/23 revealed Resident #82 did not have a care plan for the use of antipsychotic medication or Resident #82's Seroquel. Interview on 04/20/23 at 12:28 P.M., with the Director of Nursing (DON) verified Resident #82 did not have a care plan for the use of antipsychotic medication or Resident #82's Seroquel. 366035 Page 12 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the policy titles Resident Care Plans dated 05/01/22 revealed the resident will have a comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Residents Affected - Few 366035 Page 13 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident #47 revealed an admission date of 06/14/22. Medical diagnoses included puerperal psychosis, cancer, heart failure, peripheral vascular disease, diabetes, bilateral below the knee amputation (BKA), schizophrenia, and obstructive uropathy. Residents Affected - Some Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Her functional status was extensive assistance for bed mobility, personal hygiene, and toilet use. She was a total dependence for transfers, and supervision for eating. She has an indwelling Foley catheter. Review of care plan dated 10/05/22 for Resident #47 revealed she needed assistance with ADL's related to bilateral below the knee amputations (BKA). Interventions included she needed assistance with personal hygiene. Review of bathing records for Resident #47 from 01/18/23 through 04/18/23, revealed out of 25 opportunities the resident only received two baths. Interview and observation on 04/17/23 at 7:55 P.M., with Resident #47 revealed she was not receiving bathing, nails were long with yellow substance under them, and she had long hairs on her chin. Resident #47 said she does not refuse the bathing, but the staff refuse. She stated they have not cleaned her nails or shaved her chin. Observation of a bed bath on 04/18/23 at 9:51 A.M., for Resident #47 revealed State Tested Nursing Aide (STNA) #113 did not offer to clean the resident's long nails which had a yellow substance under them and did not shave the chin hairs for the resident. STNA #113 was observe not to wash the resident's back during the bathing. Interview on 04/18/23 at 10:20 A.M., with STNA #113 confirmed she did not ask the resident to shave her chin or soak her nails. STNA #113 stated this was a part of bathing process and confirmed she did not wash the resident's back. Interview on 04/19/23 at 9:29 A.M., with the Director of Nursing verified she did not have any other documentation to state the resident was provided additional bathing. 4. Medical record review for Resident #91 revealed an admission date of 01/19/22. Medical diagnoses included epilepsy, thyroid disorder, arthritis, and traumatic brain injury. Review of annual MDS dated [DATE] revealed Resident #91 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfer, and toilet use. She was supervision for eating. Review of care plan dated 02/02/23 revealed Resident #91 required supervision and assistance with activities of daily living (ADL's). Review of showers records from 01/19/23 through 04/19/23 revealed out of 23 opportunities Resident #91 received two bathing episodes with one refusal. 366035 Page 14 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 04/18/23 at 10:50 A.M., with Resident #91 revealed she was not getting her showers twice a week. Interview on 04/19/23 at 9:29 A.M., with the Director of Nursing verified she did not have any other documentation to state the resident was provided additional bathing/ showers. Residents Affected - Some Review of the policy titled Resident ADL Care dated 05/01/22 revealed the facility believes in fully supporting and encouraging the autonomy and independence of all residents in activities of daily living (ADL) possible given the limitations of their debility and disease. Residents will be expected to maintain reasonable standards of hygiene and grooming during their stay at the facility. When autonomy and independence are no longer possible or feasible, the facility resident care staff will provide the necessary support in all ADL functioning. All residents will be expected to bathe, assisted as necessary, twice per week unless otherwise specified by the physician or the resident requests more frequent bathing. Resident nails are expected to be trimmed and kept neat to prevent skin tears, scratches, or injuries to both resident and/or staff providing care. Nail care will be provided as needed to the resident. Male and female residents will be expected (per the resident's preference) to be clean shaven or have clean and neatly trimmed beards and mustaches. Assistance with shaving, when necessary, will be provided as needed. Based on observation, record review, resident interviews, staff interview and policy review, the facility failed to ensure residents received showers per their preference. This affected four (#05, #40, #47 and #91) of five residents reviewed for activities of daily living. The census was 103. Findings include: 1. Review of Resident #05's medical record revealed an admission date of 12/15/22, with diagnoses including arthrogryposis multiplex congenita, low back pain, quadriplegia, and other reduced mobility. Review of Resident #05's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #05 required extensive assistance with bed mobility, dressing, personal hygiene, and toileting. Resident #05 required total dependence with eating and two-person physical assistance with part of the bathing activity. Review of Resident #05's activities of daily living (ADL) care plan dated 12/15/22 revealed Resident #05 needed assistance with ADLs. Interventions included Resident #05 required total care with showering at least twice weekly and whenever she prefers. Resident #05 did not have a care plan for refusals of showers. Review of Resident #05's progress notes from 02/14/23 to 04/18/23 revealed Resident #05 did not refuse any showers and Resident #05 was provided a shower on 04/08/23. Interview on 04/17/23 at 7:35 P.M., with Resident #05 revealed the resident did not receive regular showers and had not had a shower in over a week. Observation on 04/17/23 at 7:35 P.M., of Resident #05 revealed her hair to appear unwashed and had a shiny texture. Review of Resident #05's shower sheets from 02/14/23 to 04/18/23 revealed Resident #05 received a 366035 Page 15 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0677 shower on 02/14/23, 02/28/23, 03/24/23, 04/05/23 and 04/07/23. Level of Harm - Minimal harm or potential for actual harm Interview on 04/18/23 at 5:32 P.M., with Registered Nurse (RN) #80 verified Resident #05 did not receive a shower from 02/14/23 to 02/28/23, from 02/28/23 to 03/24/23, from 03/24/23 to 04/05/23 and from 04/07/23 to 04/18/23. Residents Affected - Some 2. Review of Resident #40's medical record revealed an admission date of 07/06/22, with diagnoses including acute kidney failure, nasal congestion, uninhibited neuropathic bladder, pain in left foot, gangrene, weakness, hyperlipidemia, chronic kidney disease stage three, peripheral vascular disease, chronic gout, low back pain and polyneuropathy. Review of Resident #40's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #40 required extensive assistance with bed mobility, dressing, personal hygiene, and toileting. Resident #40 required supervision with eating and one-person physical assistance with part of the bathing activity. Review of Resident #40's activities of daily living (ADL) care plan dated 08/31/22 revealed Resident #40 needed assistance with ADLs. Interventions included Resident #40 required assistance by staff with bathing and showering at least weekly or whenever he prefers. Resident #40 did not have a care plan for refusals of showers. Review of Resident #40's progress notes from 02/11/23 to 04/18/23 revealed Resident #40 did not refuse any showers. Interview on 04/18/23 at 8:43 A.M., with Resident #40 revealed the resident did not receive regular showers. Review of Resident #40's shower sheets from 02/11/23 to 04/18/23 revealed Resident #40 received a shower on 02/11/23, 03/08/23, 03/23/23, and 04/06/23. Interview on 04/18/23 at 5:32 P.M., with Registered Nurse (RN) #80 verified Resident #40 did not receive a shower from 02/11/23 to 03/08/23, 03/08/23 to 03/23/23 and from 03/23/23 to 04/06/23. 366035 Page 16 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, the facility failed to ensure a resident experiencing pain was provided timely pain management. This affected one (#47) of one reviewed for pain management. The census was 103. Residents Affected - Few Findings included: Medical record review for Resident #47 revealed an admission date of 06/14/22. Medical diagnoses included puerperal psychosis, cancer, heart failure, peripheral vascular disease, diabetes, bilateral below the knee amputation (BKA), schizophrenia, and obstructive uropathy. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Her functional status was extensive assistance for bed mobility, personal hygiene, and toilet use. She was a total dependence for transfers, and supervision for eating. She has an indwelling Foley catheter. Review of care plan dated 06/22/22 revealed Resident #47 had the potential for pain discomfort. Interventions were to anticipate my need for pain relief and respond as soon as possible. Observe and report complaints of pain. Review of care plan dated 10/05/22 revealed Resident #47 needed assistance with activities of daily living due to weakness and bilateral below the knee amputation. Intervention was to observe for pain/discomfort during care and report. Review of physician orders dated 07/27/22 revealed Oxycodone HCL to give 10 milligrams (mg) one tablet every eight hours for pain. Further review of orders revealed there was not any additional medications for breakthrough pain. Review of a pain assessment tool dated 02/09/23 revealed Resident #47 had pain that hurt a little bit and medication, rest/relaxation and repositioning helped make the pain better. The level of pain at its least was a 2/10. Movement made her pain worse, and her worst level of pain was 7/10, with 10 being the worst pain on the scale. Review of the Medication Administration Record (MAR) dated 04/18/23 at 6:31 A.M. revealed Resident #47 received Oxycodone and again at 1:44 P.M. Observation during a bed bath on 04/18/23 at 9:51 A.M., revealed every time the State Tested Nursing Aide (STNA) #113 turned the resident from side to side the resident moaned in pain. STNA #113 asked the resident how long the pain had been going on, Resident #47 stated about three days and was in her right hip area. STNA #113 stated Resident #47 complained about her hip on 04/17/23. Review of progress notes for 04/18/23 revealed they were silent for the nurse being notified of pain for Resident #47. Interview on 04/18/23 at 1:59 P.M., with Licensed Practical Nurse (LPN) #66 revealed STNA #113 did not report the pain for Resident #47. LPN #66stated Resident #47 came out of her room at 1:45 P.M. and asked for something for pain. LPN #66 stated she was medicated the resident with Oxycodone. Interview on 04/18/23 at 2:08 P.M., with STNA #113 revealed she told LPN #66 about Resident #47's 366035 Page 17 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0697 pain, but she was not sure if she heard her. STNA #113 stated she did not get up to make sure LPN #66 heard her report the pain. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366035 Page 18 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for the Resident #89 revealed an admission date of 11/17/22, with diagnoses including polyneuropathy, encephalopathy, obesity, type two diabetes, vascular dementia, delusional disorders, asthma, obstructive sleep apnea, metabolic encephalopathy, cerebral palsy, blindness, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/17/23, for Resident #89 revealed the resident had intact cognition. Resident #89 was coded as having delusions, behaviors, and rejection of care. Resident #89 required supervision with bed mobility, transfers, eating and toileting. Resident #89 was assessed as receiving psychotropic medications during the assessment period. Review of the plan of care dated 12/13/22 revealed Resident #89 was receiving psychotropic medications related to behavior management, vascular dementia with behavioral disturbances and delusional disorder. Interventions include administering psychotropic medications, observing adverse reactions, and discussing with resident behaviors and alternate therapies. Review of the physician orders for Resident #89 revealed an order for trazodone tablet 100 milligrams (mg), give 2 tablets by mouth at bedtime for depression dated 03/17/23 and Haloperidol Decanoate 50 mg per milliliter (ml) Solution, inject 1 ml intramuscularly one time a day every 15 days for schizophrenia dated 12/27/23. Review of the progress notes for Resident #89 revealed monthly medication reviews completed by the pharmacy dated 02/16/23 and 03/20/23. Interview on 04/20/23 at 7:41 A.M., with the Director of Nursing (DON) verified only two monthly reviews were able to be located for Resident #89. DON verified the reviews should have been completed monthly by the pharmacist and the facility was missing three reviews for Resident #89. Review of the facility policy titled Drug Regimen Review dated 05/01/22 revealed routine reviews will be done monthly. The purpose of this review is to help the facility maintain each resident highest practicable level of functioning by helping them utilize medication appropriately and prevent adverse consequences. Copies of drug regiment review reports including physician responses will be maintained as part of the permanent medical record. Based on record review, staff interviews and policy review, the facility failed to ensure pharmacy recommendations were reviewed by the physician timely and monthly medication reviews were completed by the pharmacy. This affected two (#83 and #89) of five residents reviewed for unnecessary medications. The facility census was 103. Findings include: 1. Review of Resident #83's medical record revealed an admission date of 04/19/21, with diagnoses including schizophrenia, other pneumonia, muscle weakness, dysphagia, type two diabetes, major depressive disorder, necrotizing fasciitis, unspecified atrial fibrillation, osteomyelitis, schizoaffective disorder, and delusional disorder. Review of Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the 366035 Page 19 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0756 Level of Harm - Minimal harm or potential for actual harm resident to be cognitively intact and Resident #83 required supervision with bed mobility, dressing, personal hygiene, eating and toileting. Review of Resident #83's physician order dated 04/23/22 revealed Resident #83 was ordered Sertraline (Zoloft) 25 mgs give one tablet one time a day related to major depressive disorder. Residents Affected - Few Review of Resident #83's pharmacy recommendation dated 09/23/22 revealed Resident #83 had been taking Sertraline (Zoloft) 25 mg every day since April 2022. If this therapy is required to prevent further episodes, please document that in the progress notes. Further review of the pharmacy recommendation revealed the physician did not respond or sign the recommendation. Review of Resident #83's physician order dated 04/03/22 and discontinued 12/29/22 revealed Resident #83 was ordered aripiprazole 5 mg give one tablet by mouth one time a day related to schizophrenia. Review of Resident #83's physician order dated 12/29/22 and discontinued 03/30/23 revealed Resident #83 was ordered aripiprazole 2 mg give one tablet by mouth one time a day for behaviors. Review of Resident #83's physician order dated 03/30/23 revealed Resident #83 was ordered aripiprazole 5 mg give one tablet by mouth one time a day for behaviors. Review of Resident #83's pharmacy recommendation dated 11/22/22 revealed Resident #83 had been taking aripiprazole five milligrams (mg) every day since May 2022 without a gradual dose reduction. The pharmacy recommendation asked if a dose reduction could be attempted. Further review of the pharmacy recommendation revealed the physician did not respond or sign the recommendation. Review of Resident #83's pharmacy recommendation dated 02/16/23 revealed Resident #83 had been taking Sertraline (Zoloft) 25 mg every day since for approximately six months without an attempted gradual dose reduction or documented contraindication of a gradual dose reduction. Further review of the pharmacy recommendation revealed the physician did not respond or sign the recommendation. Interview on 04/19/23 at 12:16 P.M., with Assistant Director of Nursing (ADON) #13 verified the physician did not respond to Resident #83's 09/23/22, 11/22/22 and 02/16/23 pharmacy recommendations. Interview on 04/20/23 at 8:03 A.M., with the Director of Nursing (DON) verified Resident #83 did not have a response to Resident #83's pharmacy recommendation on 09/23/22 or 02/16/23 and Resident #83 had not had any gradual dose reductions of her Sertraline (Zoloft) 25 mgs give one time a day related to major depressive disorder ordered on 04/23/22. 366035 Page 20 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure a resident received a gradual dose reduction or contraindication for a gradual dose reduction of an antidepressant. The facility also failed to ensure a resident that received an antipsychotic medication had an appropriate diagnosis and indications for use. This affected two (#82 and #83) residents of five residents reviewed for unnecessary medications. The facility census was 103. Findings include: 1. Review of Resident #83's chart revealed an admission date of 04/19/21, with diagnoses including schizophrenia, other pneumonia, muscle weakness, dysphagia, type two diabetes, major depressive disorder, necrotizing fasciitis, unspecified atrial fibrillation, osteomyelitis, schizoaffective disorder, and delusional disorder. Review of Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #83 required supervision with bed mobility, dressing, personal hygiene, eating and toileting. Review of Resident #83's physician order dated 04/23/22 revealed Resident #83 was ordered Sertraline (Zoloft) 25 milligrams (mgs) give one tablet one time a day related to major depressive disorder. Review of Resident #83's chart from 04/23/22 to 04/19/23 revealed Resident #83 had no gradual dose reduction or contraindication for a gradual dose reduction of her Sertraline (Zoloft) 25 mgs one time a day related to major depressive disorder that was ordered on 04/23/22. Review of Resident #83's pharmacy recommendation dated 09/23/22 revealed Resident #83 had been taking Sertraline (Zoloft) 25 mg every day since April 2022. If this therapy is required to prevent further episodes, please document that in the progress notes. Further review of the pharmacy recommendation revealed the physician did not respond or sign the recommendation. Review of Resident #83's pharmacy recommendation dated 02/16/23 revealed Resident #83 had been taking Sertraline (Zoloft) 25 mg every day since for approximately six months without an attempted gradual dose reduction or documented contraindication of a gradual dose reduction. Further review of the pharmacy recommendation revealed the physician did not respond or sign the recommendation. Interview on 04/20/23 at 8:03 A.M., with the Director of Nursing (DON) verified Resident #83 did not have a response to Resident #83's pharmacy recommendation on 09/23/22 or 02/16/23 and Resident #83 had not had any gradual dose reductions of her Sertraline (Zoloft) 25 mgs give one time a day related to major depressive disorder ordered on 04/23/22. 2. Review of Resident #82's chart revealed an admission date of 01/08/21, with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disorder and anxiety, dysphagia, pain in right knee, other low back pain, altered mental status, abnormal posture, congestive heart failure, other reduced mobility, acute 366035 Page 21 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few respiratory failure with hypoxia, depression, abnormal electrocardiogram, pressure ulcer of left heel stage three, syncope and collapse, hyperkalemia, and acute kidney failure. Review of Resident #82's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and Resident #82 required extensive assistance with bed mobility, dressing, personal hygiene, eating and toileting. Resident #82 required supervision with eating. Review of Resident #82's physician order dated 01/19/23 revealed Resident #82 was ordered Seroquel 25 milligrams (mgs) by mouth at bedtime for behaviors. Review of Resident #82's care plan dated 04/19/23 revealed Resident #82 did not have a care plan for antipsychotic medication or Resident #82's Seroquel. Interview on 04/20/23 at 12:28 P.M., with the Director of Nursing (DON) verified Resident #82's Seroquel 25 milligrams (mgs) by mouth at bedtime for behaviors did not have an appropriate diagnosis and Resident #82 did not have any psychiatric diagnoses. The DON also verified Resident #82 was not receiving psychiatric services due to him being on hospice. Review of the policy Antipsychotic Medication Use dated 05/01/22 revealed antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and review. 366035 Page 22 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure medications were not stored at the bedside. This affected one (#21) of five reviewed for medications. The facility also failed to ensure insulin and inhaler was discarded when expired. This potentially could affect 15 residents identified as receiving insulin and/or inhaler. The census was 103. Findings included: Medical record review for Resident #21 revealed an admission date of [DATE]. Medical diagnoses included diabetes, heart failure, and Schizophrenia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 revealed the resident was cognitively intact. Review of the medical record from [DATE] through [DATE] revealed Resident #21 was not a self-medicate. Observation on [DATE] at 8:24 P.M., revealed Resident #21 had a bottle of refresh tears, Lotemacx eye drops, Advair inhaler, and an Atrovent inhaler lying on the bed in a baggie. Interview with Licensed Practical Nurse (LPN) #67 on [DATE] at 8:30 P.M., revealed she watched the resident take all her medications, but left the medications in the room, because she got called out to another room even though the nurse prior to the observation was standing at her cart getting medications ready for another resident. 2. Observation of the medication cart on the [NAME] Short Hall on [DATE] at 2:32 P.M., revealed a vial of Novolog, Lantus, and Lispro were used and not dated the day of opening. Further review of the med cart revealed there was a bottle of liquid Omeprazole that had expired on [DATE]. There was a Serevent Diskus refilled on [DATE] and one filled on [DATE] and on the packaging it said these were to expire in six weeks and these were being used. Interview on [DATE] at 2:39 P.M., with LPN #69 confirmed the above-mentioned medications were not labeled and were out of date. 3. Observation of the East Hall medication cart on [DATE] at 2:43 P.M., revealed there were three vials of Novolog insulin and one vial of Lantus insulin that were opened and used that were not dated for opening or expiration. Further review revealed there was a Lantus insulin pen opened and used that was not dated for opening and expiration. There was a Lantus insulin pen that was dated [DATE]. Interview on [DATE] at 2:43 P.M., with LPN #63 confirmed the above-mentioned insulin's had been opened and not dated for opening and for expiration. She confirmed the Lantus insulin pen was out of date and should be thrown away. 366035 Page 23 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0791 Provide or obtain dental services for each resident. 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 interviews and policy review, the facility failed to provide dental services. This affected one (#33) of one resident reviewed for dental services. The facility census was 103. Residents Affected - Few Findings include: Medical record review for Resident #33 revealed an admission on [DATE], with diagnoses including schizophrenia, Addisonian crisis, toxic encephalopathy, kidney failure, major depressive disorder, acute respiratory failure, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 revealed an impaired cognition. Resident #33 requires extensive assistance for bed mobility, transfers, toileting, and supervised eating. Resident #33 was assessed and coded for no dental problems. Review of the plan of care for Resident #33 revealed a nutritional risk related to diagnoses of schizophrenia with potential for altered oral intakes related to behavior, history of refusing meals. Interventions include assessing signs and symptoms of aspirations, assistance with meals as needed and dental consultation as needed and oral care as needed. Review of the dental visits for Resident #33 revealed resident last visit for dental services was on 10/29/20. Resident #33 was treated for symptomatic pain and sensitivity with surgical extraction recommended for three teeth. Amoxil 500 milligram (mg) three times a day for seven days as well as Motrin 800 mg as ordered. Two radiology pictures were taken. Observation on 04/17/23 at 7:58 A.M., revealed Resident #33 had heavy plague build up on lower teeth. Interview on 04/17/23 at 7:58 A.M., with Resident #33 stated she did not have any mouth pain at this time. Observation on 04/18/21 at 9:03 A.M., revealed Resident #33 had heavy plague build up on lower teeth. Interview on 04/18/23 at 4:57 P.M. with State Tested Nursing Assistant (STNA) #119 verified Resident #33 had plaque buildup on her teeth. Interview on 04/20/23 at 8:46 A.M., with Social Services Designee (SSD) #534 stated the dentist will be here on 05/08/23 and Resident #33 is on the list. SSD #534 stated she does not know why the resident has not been seen by the dentist. Additionally stated if Resident #33 refuses the facility will receive a refusal letter and it would have been documented on the summary report from the dental services. Review of the policy titled Dental Services dated 05/01/22 revealed routine and 24-hour emergency dental services are provided to our residents through contract agreements with a dentist that comes to the facility monthly. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan. 366035 Page 24 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, meal spreadsheet review, observation, staff interviews and policy review, the facility failed to provide food portions as planned by a Registered Dietitian. This affected 16 (#3, #54, #53, #20, #47, #12, #73, #38, #83, #22, #41, #11, #95, #26, #69, and #52) of 16 residents who received a consistent carbohydrate diet and all 101 residents who received food from the kitchen did not receive a bread portion at the lunch meal on 04/19/23. Residents #29 and #59 do not receive food from the kitchen. The census was 103. Findings include: 1. Record review revealed Residents #3, #54, #53, #20, #47, #12, #73, #38, #83, #22, #41, #11, #95, #26, #69, and #52 were on consistent carbohydrate diets. Review of the 04/19/23 lunch meal spreadsheet revealed residents with physician orders for a consistent carbohydrate diet were listed to receive a number 10 size portion of rice. Observation on 04/19/23 at 11:13 A.M., revealed [NAME] #2 had mixed the rice portion with the meat portion. There was no separate rice portion for the consistent carbohydrate diet. Interview on 04/19/23 at 11:14 A.M., with [NAME] #2 verified she had mixed the rice portion with the meat portion, and there was no separate rice portion for the consistent carbohydrate diet. [NAME] #2 verified she had not followed the recipe and spreadsheet as written by the Registered Dietitian. Interview on 04/19/23 at 11:15 A.M., with the Dietary Manger #28 verified the rice and meat should not have been mixed and rice. Residents with physician order for consistent carbohydrate diet should have been portioned at a number 10 serving for the rice. 2. Review of the 04/19/23 lunch meal spreadsheet revealed all residents on diets of regular, consistent carbohydrate, renal, and mechanical soft and puree consistencies, were to receive a bread portion. Observation on 04/19/23 at 11:13 A.M., revealed there was no bread portion served on any lunch meal tray. Interview on 04/19/23 at 11:14 A.M., [NAME] #2 verified she had not served any bread to any resident at the lunch meal. [NAME] # 2 stated she did not see the bread portions as written on the meal spreadsheet. Interview on 04/19/23 at 11:15 A.M., the Dietary Manger #28 verified no bread portion was served on any diet at the lunch meal as planned by the Registered Dietitian on the meal spreadsheet. Review of the undated policy, Food Preparation, revealed portions are to be served as listed on the menu. All menu items will have standardized recipes for menus prepared by the Registered Dietitian. 366035 Page 25 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation, staff interviews and policy review, the facility failed to label stored foods, discard expired foods, and maintain food equipment in a sanitary manner. This had the potential to affect 101 residents who received food from the kitchen. Residents #29 and #59 do not receive food from the kitchen. The facility census was 103. Findings include: Observation on 04/17/23 at 6:15 P.M. of the kitchen, revealed the following sanitation violations: 1. In the hand washing area, there were no paper towels. 2. In the walk-in refrigerator, there was a large container, identified as pudding, with no label or date. A large container, identified as cooked vegetable, with no label or date. A container, identified as cheese, with no label or date. A container of identified chicken soup dated 04/13/23. 3. In the walk-in freezer, there was no thermometer. 4. In the food preparation area, the was an undated bottle of opened lemon juice. There were two opened undated bread bags. There were two bulk food containers of white substances with no label. 5. In the reach in refrigerator, there were 16 undated serving cups of fruit. 6. The floors, throughout the kitchen, were blacked with built of debris in corners and behind equipment. Observation on 04/19/23 at 10:19 A.M., revealed the following sanitation violations: 1. [NAME] # 2 prepared puree food in a blender eight inches from an open screened window with a breeze. The screen had a curtain hanging over the screen. The curtain had grey dust over the curtain surface and blowing onto the puree food equipment. 2. The entire kitchen ceiling had stains of darkened splatters and spots of shiny grease areas. A wall mounted fan was blowing into the clean dish storage area. The fan blades had a rim of dark, blackened debris and blackened debris noted on the walls and ceiling near the fan. 3. A 4 foot by 4-foot wall mounted air controlling equipment was over food service plates to be used for the lunch meal. The plates were 4 inches in front of the air equipment. There was a heavy thick covering of dark black dust material covering the outside of the equipment. There was air movement in the kitchen blowing over the black debris onto the plates. 4. Four ceiling ventilation coverings had edges with a dark rim of dust-like material over the food service area. Observation on 04/19/23 at 11:22 A.M., revealed the following violations in the resident food 366035 Page 26 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0812 storage refrigerator on [NAME] Unit: Level of Harm - Minimal harm or potential for actual harm 1. There was no temperature log to monitor the refrigerator temperature for the month of April. Residents Affected - Some 2. There was a bag of assorted containers of food unlabeled and undated. A container of opened macaroni unlabeled and undated. A container of chicken liver dated 02/24/23. A large clear food container of unlabeled and undated food. Interview on 04/17/23 at 6:17 P.M., [NAME] #3 verified the hand washing sink should have had paper towels. [NAME] #3 verified the foods in the walk-in refrigerator, food preparation areas and reach in refrigerator should have been labeled and dated. [NAME] #3 verified the walk freezer should have a thermometer inside the freezer to monitor temperatures. Interview on 04/19/23 at 10:20 A.M., Dietary Manger (DM) #28 verified the floors throughout the kitchen were blackened and needed cleaning. DM #28 verified the curtain above the food preparation area needed cleaned, the ceiling was stained and spotted with flood and a built up of grease. DM #28 verified the ceiling ventilation, and dish room fan had a buildup of dust and debris in food service areas. DM #28 stated the 4-foot by 4-foot air wall mounted air controller was not in use but had a thick buildup of debris close to plates used for meal service and air movement over the plates. DM #28 stated he did not know when the equipment had last been cleaned. Interview on 04/19/23 at 11:30 A.M., State Tested Nurse Aide (STNA) #99 verified the resident refrigerator on [NAME] unit was to only contain resident food items. STNA #99 verified there were open containers of foods which were not labeled or dated. STNA #99 verified the container of labeled chicken liver, dated 02/24/23, was expired and should have been discarded on 02/27/23. STNA #99 verified the refrigerator temperatures should be monitored daily and there was no April monitoring log. STNA #99 stated she had no knowledge of who was responsible for cleaning and maintaining the sanitation of the resident unit refrigerator. Interview on 04/20/23 at 11:30 A.M., Maintenance Director #81 verified the air controller equipment and ceiling ventilation vents were to be cleaned by the maintenance department. There was no documentation of when the air handlers had last been cleaned. Review of the undated policy titled, Sanitation, revealed ceilings and floor are cleaned routinely and ventilation ducts are to be cleaned at least monthly. All kitchen equipment is to be maintained in a sanitary manner. All leftover foods are labeled and dated. 366035 Page 27 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, hospice staff interview and policy review, the facility failed to ensure the hospice provider and the facility collaborated to develop a plan of care. This affected one (#79) of one resident reviewed for hospice services. The census was 103. Findings include: Medical record review for Resident #79 revealed an admission date on 11/01/22, with diagnoses including metabolic encephalopathy (brain damage), pulmonary embolism (blood clot), deep vein embolism, hypoxemia (low oxygen), kidney failure and kidney disease, history of covid-19, vascular dementia with behavioral disturbances, major depressive disorder, diabetes mellitus type two, adult failure to thrive, Alzheimer's disease and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #79 revealed severe cognitive impairment. Resident #79 requires total assistance from two staff members for bed mobility, transfers, and toileting. Resident #79 requires total assistance with eating. Resident #79 received hospice care during the assessment period. Review of the plan of care for Resident #79 revealed a terminal condition with a life limiting prognosis of 6 months or less if the disease were to follow a natural course. Interventions include contacting the hospice for changes in resident condition and hospice services as ordered. Review of physician orders dated 11/16/22, for Resident #79 revealed orders for admit to Hospice #500 with terminal diagnosis: Alzheimer disease with life expectancy of 6 months or less if disease runs normal course. Review of the binder for Hospice Provider #500 at the nurses' station revealed two pieces of paper, both contained information of a Resident #79 visit dated 11/23/22. Review of the facility Nursing Facility Services Agreement with Hospice #500 dated 04/21/22, stated under the plan of care states hospice and the facility will jointly develop and agree upon a coordinated plan of care which is consistent with the hospice philosophy. The plan of care will identify which provider is responsible for performing the respective functions. Interview on 04/20/23 at 10:06 A.M., with Licensed Practical Nurse (LPN) #531 verified the binder held two sheets containing data for resident visit dated 11/23/22. LPN #531 was unable to locate any additional hospice information for Resident #79. LPN #531 is unable to locate a schedule for hospice staff visits or what care they will provide. Interview on 04/20/23 at 11:51 P.M., with admitting Hospice Registered Nurse (RN) #501 stated she did not meet with the facility to collaborate in the development of the plan of care. Recertification and plan of care are faxed to the facility. RN #501 stated the hospice staff do not have the ability to print documents at the time of the visits. RN #501 stated she does not have Resident #79 on her case load at this time. Interview on 04/20/23 at 12:19 P.M., with State Tested Nursing Assistant (STNA) #126 stated there 366035 Page 28 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is not a schedule for the hospice aide posted. STNA #126 stated we provide care as usual and when the hospice staff comes in, they take over the care. Interview on 04/20/23 at 12:25 P.M., with Director of Nursing (DON) verified the facility plan of care had two interventions. Further verified the facility plan of care did not contain information on which services the hospice would provide for the resident and when the services would occur. Review of the policy titled Hospice Care dated 05/01/23, revealed it is the responsibility of the hospice to manage the resident's care as it related to the terminal illness including determining the appropriate hospice plan of care. 366035 Page 29 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

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 record review, staff interviewand policy review, the facility failed to conduct Quality Assurance and Performance Improvement meetings at least quarterly. This had the potential to affect all 103 residents in the facility. The census was 103. Residents Affected - Many Findings include: Review of meetings for Quality Assurance and Performance Improvement, (QAPI), for the years 2023, and 2022, revealed no documentation of at least quarterly meetings. Interview on 04/20/23 at 2:00 P.M., with the Administrator verified there was no documentation of regular QAPI meetings for years 2023 and 2022. The Administrator stated she was newly hired and the documentation of previous QAPI meetings was missing. Review of the policy titled, QAPI Committee, dated 05/01/22, revealed the QAPI committee will meet at least quarterly to develop plans of action to correct issues. 366035 Page 30 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record reviews, employee file review, staff interviews and policy reviews, the facility failed to implement and monitor the water system to prevent Legionella disease, and to ensure employees were screened or tested for tuberculosis. This had the potential to affect all 103 residents in the facility. The facility census was 103. Residents Affected - Many Findings include: 1. Review of facility Legionella disease control program revealed no water temperature monitoring log for the months of September 2022, October 2022, November 2022, December 2022, January 2023, February 2023, March 2023, and April 2023. Interview on 04/20/23 at 12:00 P.M., Maintenance Director (MD) #81 verified the water temperature monitoring was a process identified in the facility Legionella Water Management plan for the prevention of Legionella disease. MD #81 verified the last water temperature monitoring occurred on 08/17/22. MD #81 verified he had been in the maintenance department since December 2022. Review of the policy titled, Legionella Water Management, dated 05/01/22, revealed the plan was to reduce the risk of Legionella in the healthcare facility water systems and to prevent cased and outbreaks of Legionnaire Disease. The plan identified control measures to monitor water heater temperatures. 2. Review of employee files revealed three recently hired employees revealed no evidence of Mantoux tuberculosis testing. Registered Nurse, (RN) #132 hired on 12/09/20, and had no record of tuberculosis first step testing prior to hire or second step testing after hire. Licensed Practical Nurse (LPN) #66 hired 01/01/22, had no record of tuberculosis first step testing prior to hire or second step testing after hire. Housekeeper #39 hired on 02/03/23 had no record of tuberculosis first step testing prior to hire or second step testing after hire. Interview on 04/20/23 at 10:30 A.M., the Human Resource Manager (HM) #520 verified there was no Mantoux tuberculosis testing record for RN#132, LPN #66 or Housekeeper #39. HM #520 stated she was newly hired, and no tuberculosis testing documentation could be located for the employees. Review of policy titled, Employee TB Testing, dated 05/01/22 revealed all employees shall be screened for tuberculosis using a two-step skin test prior to beginning employment. 366035 Page 31 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record reviews, staff interviews and policy reviews, the facility failed to ensure residents were offered and received pneumococcal and influenza vaccines. This affected two (#89 and #55) of five residents reviewed for vaccinations. The facility census was 103. Residents Affected - Few Findings include: 1. Review of Resident #89's medical record revealed an admission date of 11/17/22, with diagnoses including polyneuropathy, encephalopathy, type two diabetes mellitus with diabetic polyneuropathy, vascular dementia, asthma, metabolic encephalopathy and generalized abdominal pain. Review of Resident #89's medical record from 11/17/22 to 04/20/23, revealed no documentation that Resident #89 received a consent for the pneumococcal vaccine, refused the pneumococcal vaccine or received the pneumococcal vaccine. Interview on 04/19/23 at 5:45 P.M., with the Director of Nursing (DON) verified Resident #89 did not have any documentation indicating Resident #89 had received a consent for the pneumococcal vaccine, refused the pneumococcal vaccine or received the pneumococcal vaccine. 2. Review of Resident #55's medical record revealed an admission date of 03/20/20, with diagnoses including bipolar disorder, alcohol dependence with withdrawal delirium, pain in left hip, hypertension, major depressive disorder, and schizophrenia. Review of Resident #55's medical record from 09/01/22 to 04/18/23 revealed no documentation that Resident #55 received or refused the influenza vaccine. Review of Resident #55's Medication Administration Record from 09/01/22 to 04/18/23 revealed no documentation that Resident #55 received or refused the influenza vaccine. Review of Resident #55's physician from 09/01/22 to 04/18/22 revealed no documentation that Resident #55 was ordered an influenza vaccine from 09/01/22 to 04/18/23. Review of Resident #55's undated influenza consent provided by the facility on 04/18/23 revealed Resident #55's guardian consented by phone for Resident #55 to receive the annual influenza immunization. Review of Resident #55's influenza consent dated 11/22/22 provided by the facility on 04/19/23 revealed Resident #55's guardian consented by phone for Resident #55 to receive the annual influenza immunization on 11/22/22. Further review of the consent revealed the guardian also refused the vaccine. Interview on 04/19/23 at 3:00 P.M., with Assistant Director of Nursing (ADON) #13 verified the Resident #55 had two influenza consents of file and he was not aware of which consent was accurate due to Resident #55 having a separate consent for his influenza vaccine in 2021. ADON #13 verified Resident #55 did not receive the influenza vaccine from 09/01/22 to 04/18/23 and that there was no documentation that the resident refused the vaccine in the chart or the date the vaccine was refused. Review of the policy titled Influenza Vaccine dated 05/01/22 revealed all residents and employees 366035 Page 32 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who have no medical contraindications to the vaccine will be offered the influenza vaccine annually. A resident's refusal of the vaccine shall be documented on the flu consent form. Review of the policy titled Pneumococcal Vaccine dated 05/01/22 revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated will be offered the vaccine series within 30 days of admission unless medically contraindicated or the resident has already been vaccinated. 366035 Page 33 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on record review, staff interview and policy review, the facility failed to ensure a resident was offered a COVID-19 vaccine. This affected one (#89) of five residents reviewed for vaccinations. The facility census was 103. Findings include: Review of Resident #89's medical record revealed an admission date of 11/17/22, with diagnoses including polyneuropathy, encephalopathy, type two diabetes mellitus with diabetic polyneuropathy, vascular dementia, asthma, metabolic encephalopathy and generalized abdominal pain. Review of Resident #89's medical record from 11/17/22 to 04/20/23 revealed no documentation that Resident #89 received a consent for the coronavirus (COVID-19) vaccine, refused the COVID-19 vaccine or received the COVID-19 vaccine. Interview on 04/19/23 at 5:45 P.M., with the Director of Nursing (DON) verified Resident #89 did not have any documentation indicating Resident #89 had received a consent for the COVID-19 vaccine, refused the COVID-19 vaccine or received the COVID-19 vaccine. Review of the policy titled COVID-19 Precautions and Prevention, dated 10/05/22 revealed residents will be asked if they received or needed a COVID-19 vaccine or booster shot within 72 hours of admission. 366035 Page 34 of 35 366035 04/24/2023 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interviews, the facility failed to maintain essential equipment in operating condition. This had the potential to affect 101 residents who received food from the kitchen. Residents #29 and #59 do not receive food from the kitchen. The facility census was 103. Residents Affected - Some Findings include: Observation on 04/19/23 at 10:19 A.M, revealed in the kitchen the following food equipment in disrepair and or not operational: 1. The food plate warmer was not operation and not heating meal service plates. 2. The left door of the reach in refrigerator was no able to open. It was taped closed on the exterior surface. There was noted food debris on the shelves of the refrigerator and around the exterior surface of the taped areas. 3. The garbage disposal near the three-compartment sink was not operational. There was noted food debris around the trash cans. Interview on 04/19/23 at 9:20 A.M., with [NAME] #2 verified the plate warmer had not been operational for several weeks. The meal plates were not heated, causing loss of meal food temperatures. [NAME] #2 stated the door of the reach in refrigerator affected the cleaning of the refrigerator interior and exterior. [NAME] #2 stated the three-compartment sink garbage disposal had not been operational for several months. Interview on 04/19/23 at 10:20 A.M., with Dietary Manger (DM) # 28 verified the plate warmer had not been operational for several weeks and noted the food would be served at a higher temperature if it were functional. DM #28 verified the reach in refrigerator exterior door was taped and was a non-cleanable surface. DM #28 verified the garbage disposal had not been operational for several months resulting in insufficient pan cleaning process. Interview on 04/20/23 at 11:30 A.M., with Maintenance Director #81 verified the plate warmer, refrigerator door and garbage disposal were nonfunctional and needed repaired and or replaced. 366035 Page 35 of 35

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Citations

21 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0569GeneralS&S Epotential for harm
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0849GeneralS&S Dpotential for harm
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
0868GeneralS&S Fpotential for harm
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0557GeneralS&S Dpotential for harm
F557 - Respect and Dignity
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
0887GeneralS&S Dpotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
0600GeneralS&S Dpotential for harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0791GeneralS&S Dpotential for harm
F791 - Dental Services
Provide or obtain dental services for each resident.
0883GeneralS&S Dpotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0908GeneralS&S Epotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.

FAQ · About this visit

Common questions about this visit

What happened during the April 24, 2023 survey of MOMENTOUS HEALTH AT VANDALIA?

This was a inspection survey of MOMENTOUS HEALTH AT VANDALIA on April 24, 2023. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MOMENTOUS HEALTH AT VANDALIA on April 24, 2023?

Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·April 24, 2023