Health inspection·May 22, 2024

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. Based on observations and resident and staff interviews, the facility failed to ensure shower rooms were clean and ceilings were maintained. This had the potential to affect 60 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102 and #103) residents who receive showers in the [NAME] and Northeast shower rooms. The facility census was 101. Findings include: Interview with Resident #96 on 05/20/25 at 8:30 A.M. revealed the [NAME] shower room smelled like mold. Observation of facility on 05/20/24 at 8:35 A.M. revealed there was a black substance on the floor of the [NAME] shower room where the floor of the shower met the wall of the shower. There was also a black substance on the floor and caulk where the floor of the shower met the wall of the shower and a large round black spot on the ceiling of the shower in the Northeast shower room. Interview with Licensed Practical Nurse (LPN) Unit Manager #800 on 05/20/24 at 8:35 A.M. verified there was black substance on the floor of the [NAME] shower room where the floor of the shower met the wall of the shower. LPN Unit Manager #800 also verified there was also a black substance on the floor and caulk where the floor of the shower met the wall of the shower and a large round black spot on the ceiling of the shower in the Northeast shower room. Interview with Registered Nurse (RN) #148 on 05/20/25 at 9:14 A.M. revealed the State Tested Nurse Aides (STNA's) had informed her that there was mold in the shower room on the Northeast unit, but she did not go in the shower room. Interview with LPN #124 on 05/20/24 at 9:19 A.M. revealed there was mildew in the shower room on the Northeast unit. Interview with STNA #114 on 05/20/24 at 9:20 A.M. revealed there was mold in the shower room on the Northeast unit. Interview with Housekeeper #88 on 05/20/24 at 9:22 A.M. revealed there was mold in the shower room on the Northeast unit. The facility confirmed 60 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, Page 1 of 6 366035 366035 05/22/2024 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0584 Level of Harm - Minimal harm or potential for actual harm #94, #95, #96, #97, #98, #99, #100, #101, #102 and #103) residents who receive showers in the [NAME] and Northeast shower rooms. This deficiency represents non-compliance investigated under Complaint Number OH00153585. Residents Affected - Some 366035 Page 2 of 6 366035 05/22/2024 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, and policy reviews, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was cognitively impaired with a history of wandering did not elope from the facility. This affected one (#53) out of three residents reviewed for elopements. The facility census was 101. Findings include: Review of Resident #53's chart revealed Resident #53 admitted to the facility on [DATE] with diagnoses including cardiac arrest cause unspecified, major depressive disorder, chronic obstructive pulmonary disease, anxiety disorder, hypertension, encephalopathy, and malignant neoplasm of prostate. Review of Resident #53's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #53 required set up assistance with eating, and oral hygiene. Resident #53 required moderate assistance with toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, tub transfers and walking ten feet. Resident #53 was reported to have wandered four to six days. Review of Resident #53's elopement care plan dated [DATE] revealed Resident #53 exhibited exit seeking behavior and had periods of high confusion with exit seeking behavior. Interventions included consult with psychiatric services if needed, encourage activities of choice, keep resident's picture in the elopement book so all are aware, observe resident for his whereabouts frequently, personalize resident's room to be homelike, and resident to reside on a secured unit. Review of Resident #53's consent form for a locked unit dated [DATE] revealed a telephone consent was completed. Review of Resident #53's elopement assessment dated [DATE] revealed resident had exit seeking behaviors in the past month, had wandered within the facility without leaving the grounds, had a diagnosis of dementia or cognitive impairment, had a history of wandering and was at right risk to wander. Review of Resident #53's guardianship order dated [DATE] revealed Resident #53 had a guardian of the person. Review of Resident #53's physician order dated [DATE] revealed Resident #53 may reside on a secured unit. Review of Resident #53's progress note dated [DATE] at 12:44 P.M. revealed Social Services Director (SSD) #152 spoke with Resident #53's guardian and resident would be moved off the secured unit. Review of Resident #53's progress note dated [DATE] at 2:01 P.M. revealed resident was transferred to a room on the west unit. 366035 Page 3 of 6 366035 05/22/2024 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #53's elopement assessment dated [DATE] revealed resident could move without assistance in a wheelchair, could communicate, had no history of wandering, had a medical diagnosis of dementia or cognitive impairment, had no reported episodes of exiting seeking behavior in the past six months and was at low risk to wander. Review of Resident #53's progress note dated [DATE] at 1:00 P.M. revealed SSD #152 spoke with Resident #53's stepsister. Resident #53 has been dialing his stepmother's phone number and asking for his mother to come and get him. His mother was deceased and had been for several years. SSD #152 advised Resident #53's stepsister that the resident was no physical threat, and the facility would attempt to redirect his behavior. Resident #53's stepsister stated that she would reach out to the phone company and see if it was possible to block the facility phone number on the stepmother's phone. Review of Resident #53's progress note dated [DATE] at 9:40 P.M. revealed Licensed Practical Nurse (LPN) #87 was notified by the police that Resident #53 was with the police and Resident #53 had been knocking on the neighbor's door. Resident #53 had recently been seen propelling himself in the hallway to talk to other residents. Resident #53 was returned to the facility at that time by police and a full skin assessment was completed. No new areas were noted, vitals were taken, and no pain was noted. Resident #53 was pleasant and laughing. One on one was provided. Review of Resident #53's progress note dated [DATE] at 4:28 A.M. revealed Resident #53 was currently in bed resting comfortably with his eyes closed. No complaints of pain were noted. Assistance was provided by staff with needs and care. Supervision and safety checks were completed throughout the shift. Resident #53 was continued antibiotics related to prevention. Vital signs obtained and documented. No adverse reactions observed. Call light within reach. Review of Resident #53's physician order dated [DATE] and discontinued [DATE] revealed Resident #53 was on doxycycline 100 milligrams (mg) give one table two times a day for preventative for seven days. Review of Resident #53's elopement assessment dated [DATE] revealed resident could move without assistance in a wheelchair, could communicate, had a history of wandering, had no diagnosis of dementia or cognitive impairment, had a history of wandering, had exited the home unassisted, had exit seeking behavior in the past month and was at high risk for wandering. Review of LPN #87's witness statement dated [DATE] revealed she observed Resident #53 in the hallway ambulating freely at 8:50 P.M. Review of Resident #53's physician order dated [DATE] revealed Resident #53 may reside on a locked unit. Review of the police report dated [DATE] revealed the police received a call at 9:21 P.M. that a male in a wheelchair was in a driveway. Police entry at 9:39 P.M. stated police located Resident #53 at N [NAME] and Hailfix Drive (approximately 0.3 miles from the facility). Resident #53 stated he wandered away from the facility and police drove him back to the facility. Observation of Resident #53 on [DATE] at 9:17 A.M. revealed Resident #53 was lying in bed. Resident #53 was clean and dressed appropriately. Interview with Resident #53 on [DATE] at 9:17 A.M. revealed the resident stated he had not gone 366035 Page 4 of 6 366035 05/22/2024 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0689 outside the facility by himself. Level of Harm - Minimal harm or potential for actual harm Interview with SSD #152 on [DATE] at 11:32 A.M. revealed Resident #53 resided on the secured unit prior to him being moved to a regular unit on [DATE] due to him not having any exit seeking behaviors. SSD #152 stated that Resident #53's stepsister called and stated that Resident #53 was calling his deceased stepmother's phone after he was moved off the secured unit, but SSD #152 reported the behavior was not abnormal for Resident #53 and he never attempted to leave the facility or the secured unit prior to the incident on [DATE]. SSD #152 stated Resident #53 was moved back on the secured unit on [DATE]. Residents Affected - Few Interview with the Administrator and Director of Nursing (DON) on [DATE] at 11:40 A.M. revealed Resident #53 eloped from the facility on [DATE]. The DON stated Resident #53 was last seen in his wheelchair in the hallway on [DATE] at 8:50 P.M. and the facility received a call from the police at 9:30 P.M. stating Resident #53 was with them after he was observed knocking on doors around the corner from the facility. The DON stated the police brought Resident #53 back to the facility. The resident was assessed upon return with no injuries and the guardian, DON and Administrator were made aware. Resident #17 was placed on one on one, and a head count of the facility was completed. Resident #17 was placed back on the secured unit on [DATE] and the codes to the facility doors were changed on [DATE]. Review of the facility's elopement policy dated [DATE] revealed the facility shall investigate and report all cases of missing residents. As a result of the incident, the facility took the following actions to correct the deficient practice by [DATE]: • On [DATE] at approximately 9:30 P.M., Resident #53 was placed on one on one upon return to the facility. • On [DATE] at 10:10 P.M., the facility completed an audit to ensure all residents were accounted for in the facility. • On [DATE], Resident #53 was moved to the secured unit. • On [DATE], an elopement drill was completed. • On [DATE] and [DATE], the Administrator or designee completed all staff education regarding the facility elopement policy. 366035 Page 5 of 6 366035 05/22/2024 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0689 This deficiency represents non-compliance investigated under Complaint Number OH00153343. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366035 Page 6 of 6