Health inspection·October 8, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on medical record review, observations and resident and staff interviews and policy review, the facility failed to ensure an adequate supply of paper towels and toilet paper for a resident's bathroom. This affected one (#84) out of three residents reviewed for the physical environment. The facility census was 103. Findings include: Medical record review for Resident #84 revealed an admission on [DATE] with diagnoses including but not limited to synovitis, hypertension, diabetes mellitus, depression and schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #84 dated 07/24/24 revealed an intact cognition. Resident #84 required supervision for eating, bed mobility and transfers. Resident #84 required moderate assistance with toileting. Interview on 10/08/24 at 8:10 A.M. with Housekeeper #21 stated the facility was out of toilet paper and paper towels today. Additionally, Housekeeper #21 stated that it happens often and they are just not ordering enough until the next order comes in. Interview on 10/08/24 at 8:12 A.M. with Housekeeper # 56 stated the facility was out of toilet paper and paper towels today and they didn't have enough to stock Resident #84's bathroom room. Interview on 10/08/24 at 8:16 A.M. with Resident #84 stated they have run out of paper towels and toilet paper before. Interview on 10/08/24 at 11:15 with Housekeeping and Laundry Director #503 verified that the facility did not have toilet paper or paper towel. Request for a policy related to stock supplies was requested and advised the facility did not have a policy by management. This deficiency represents non-compliance investigated under Complaint Number OH00158425 and OH00158273. Page 1 of 5 366035 366035 10/08/2024 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, staff and resident interviews, observations and policy review the facility failed to ensure prescription medications were appropriately stored in a secured manner. This had the potential to affect 17 residents (#69, #70, #73, #75, #78, #79, #80, #83, #85, #86, #88, #89, #91, #94, #95, #97 and #101) residing on the [NAME] Hall and eight resident (#6, #7, #11, #17, #21, #22, #23 and #29) residing on the East Hall who were cognitively impaired and independently mobile who could potentially access unsupervised and unsecured medications. Additionally, the facility failed to ensure refrigerated medications were appropriately stored. This had the potential to affect 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #68) residing in the Northeast unit. The facility census was 103. Findings include: 1. Medical record review for Resident #82 revealed an admission on [DATE] with diagnoses including but not limited to respiratory failure with hypoxia, chronic obstructive pulmonary disease, type two diabetes, hypothyroidism, schizoaffective affective disorder, anxiety, open angle glaucoma severe and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #82 dated 07/30/24 revealed an intact cognition. Resident required set up for meals and supervision for toileting, bed mobility and transfers. Review of the plan of care for Resident #83 revealed cognitive function altered related to diagnoses of depression, psychosis, schizoaffective disorder, cognitively compromised, unable to make safe decisions, mental function varies over the course of the day. Resident #83 has a history of auditory and visual hallucinations, short term/long term memory impairment, impulse control impairment, resident can become verbally and physically aggressive with staff and other residents, has a rigid medication regimen. Interventions include allow resident time to remember and respond, assist with decision making problems and provide cues or reminders. Review of the active physician orders for Resident #82 revealed an order dated 10/02/24 stating resident able to self-administer drops and inhaler, an order dated 03/28/24 for Brimonidine Tartrate Opthalmic solution 0.2 percent instill one drop in both eyes three times a day for glaucoma, an order dated 03/22/24 for carboxymethycellulose sodium ophthalmic solution one percent instill one drop in left eye four times a day for dry eye, an order dated 03/23/24 for Dulera inhalation aerosol 200-5 microgram(mcg) one puff two times a day for shortness of breath, rinse mouth with water and spit after each use, an order dated fluticasone propionate nasal suspension 50 mcg instill one spray in both nostrils one time a day for rhinosinusitis, an order dated 03/22/24 for Luteomas ophthalmic gel instill one drop in left eye one time a day for dry eyes, an order dated 03/21/24 for tiotropium Bromide Monohydrate inhaler aerosol solution 1.25 mcg inhale orally one time a day for shortness of breath. Review of the self-administration assessment dated [DATE] at 7:23 A.M. revealed Resident #82 was able to self-administer medications. 366035 Page 2 of 5 366035 10/08/2024 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 Observation on 10/02/24 at 10:05 A.M. of the top of the medication cart on the [NAME] Hall revealed multiple clear medication bags with a pharmacy label for Resident #82 which were unsupervised and unsecured. The bags contained Luteomas eye gel, Tiotropium Bromide Monohydrate inhaler, fluticasone nasal spray, and bromide monohydrate inhaler aerosol solution. Interview on 10/02/24 at 10:10 A.M. with Licensed Practical Nurse (LPN) #18 verified she had left the medication in Resident #82's room for her to administer. LPN #18 stated she must have brought them out to the cart after she was finished. LPN #18 stated she thought she had an order for her to self-administer. Interview on 10/02/24 at 11:15 A.M. with Unit Manager LPN #121 verified the order to administer eye drops and inhalers was added after the observation of medication unsecured and unsupervised on the medication cart. Interview on 10/02/24 at 11:19 A.M. with the Nurse Practitioner (NP) #501 verified the facility notified him with a request to allow Resident #82 to self-administer medications, was unable to recall the exact but stated it was after 10:30 A.M. Review of the physician's order dated 10/02/24 at 11:23 A.M. revealed the resident was able to self-administer gtt (drops) and inhalers. The order was signed by LPN #18 and ordered by NP #502. Interview on 10/02/24 at 11:37 A.M. with Resident #82 stated the nurses leave her medication in her room and she takes it by herself and has been for a long time. 2. Observation of the facility treatment cart in the [NAME] Hall was unlocked and unsupervised. Observation of the top drawer revealed multiple tubes of barrier creams and a bottle of betadine with a warning label indicating to seek medical assistance if ingested. Interview on 10/02/24 at 10:07 A.M. with LPN #121 verified the treatment cart was unlocked and should not have been. 3. Observation on 10/08/24 at 8:40 A.M. of treatment cart on East Hall unlocked and supervised. Observation of treatment cart contents in the top drawer revealed hydrocortisone cream, nystatin powder and betamethasone dipropionate cream. Hydrocortisone cream was labeled with warning label to seek medical treatment if cream was ingested. Interview on 10/08/24 at 8:42 A.M. with LPN #26 verified the treatment cart was unlocked and unsupervised and should not have been. The facility confirmed there are 17 residents (#69, #70, #73, #75, #78, #79, #80, #83, #85, #86, #88, #89, #91, #94, #95, #97 and #101) residing on the [NAME] Hall and eight resident (#6, #7, #11, #17, #21, #22, #23 and #29) residing on the East Hall who were cognitively impaired and independently mobile and that could potentially access unsupervised and unsecured medications. 4. Observation on 10/08/24 at 8:59 A.M. of the nurses' station refrigerator on the Northeast unit revealed no log for monitoring the temperatures on a daily basis. Additionally, observation of the inside of the refrigerator revealed a thermometer with a reading of forty-eight degrees and a large buildup of ice around the small freezer. Medication stored in the refrigerator at the time of the 366035 Page 3 of 5 366035 10/08/2024 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 observation included one Retacrit injection, tuberculin purified multidose vial, one Basaglar kwikpen insulin, two Mounjaro pen 2.5 milligrams/0.5 milliliters, and a bottle of Ativan liquid all with labels indicating it should be stored between thirty-six- and forty-six-degrees F. Interview on 10/08/24 at 9:03 A.M. with LPN #44 verified the observation and stated the refrigerator temperatures supposed to be monitored daily on night shift and the medication will have to be replaced. Interview on 10/08/24 at 4:50 P.M. with the Administrator verified the pharmacy would be notified and the medications replaced due to the elevated temperatures. The Administrator further verified each refrigerator should have a log on the front for staff to monitor the temperature daily. Observation on 10/08/24 at 8:59 A.M. of the nurses' station refrigerator revealed no log for monitoring the temperatures on a daily basis. Additionally observation of the inside of the refrigerator revealed a thermometer with a reading of forty eight degrees and a large build up of ice around the small freezer. Medication stored in the refrigerator at the time of the observation included Retacrit. The facility confirmed there are 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #68) residing in the Northeast unit who potentially be affected by the identified concern with the medication refrigerator. Review of the facility policy titled Medication Storage, dated 05/01/22 stated the facility shall store all drugs and biologicals in a safe, secure and orderly manner. This deficiency represents non-compliance investigated under Complaint Number OH00158425. 366035 Page 4 of 5 366035 10/08/2024 Momentous Health at Vandalia 208 North Cassel Road Vandalia, OH 45377

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations and staff interviews, the facility failed to maintain the building in a safe homelike manner. This had the potential to affect the 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #56, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67 and #68) residing in the Northeast Unit of the facility. The facility census was 103. Findings include: Observation on 10/07/24 at 1:55 P.M. of the facility roof revealed areas over the Northeast unit, facing the south had an area of splintered/missing wood with rain gutters not attached to the roof exposing the soffit and sagging. Further observation of the roof in the same area revealed multiple rows of shingles sagging between the roof rafters. Observation on 10/07/24 at 1:59 P.M. of the facility roof revealed two areas over the Northeast Unit, facing north had areas of splintered/missing wood with rain gutters not attached and sagging exposing the soffit and roofing shingles sagging between the rafters. Additionally, there was a large blue tarp present over the shingles in the same area. Observation on 10/08/24 at 9:05 A.M. of the dining area in the Northeast Unit revealed two outlets that did not have covers on them. Additional observation revealed a ceiling light that did not have a cover on it, exposing the electrical outlet boxes on all three items. Observation on 10/08/24 at 9:07 A.M. of the corridor located just outside of the nursing station revealed an entire section of the wall from the ceiling to the floor was covered with heavy black plastic and stapled in place. Additionally, observations noted a section on plaster cut from the wall approximately two inches vertically and twelve inches horizontally exposing the inside of the space between the walls. Additionally, directly below the cut plaster was an electrical outlet with undetermined type of beige tape covering the entire perimeter of the outlet cover. Interview on 10/08/24 at 9:11 A.M. with the Maintenance Director verified the observations and stated prior to his employment in July 2024 the facility had had a water heater leak and the water damaged the areas in the dining area, the hot water storage area, the corridor outside of the storage area and the resident room next to the storage area. Additionally, stated the facility has called multiple repair companies and have not had any return calls to address the repairs so he has been fixing them himself as time will allow. The facility confirmed there were 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #56, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68) residing in the Northeast Unit of the facility that could potentially be affected by the identified concerns/observations. This deficiency represents non-compliance investigated under Complaint Number OH00158425 and OH00158273. 366035 Page 5 of 5