Health inspection·December 4, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of a facility emergency management plan, the facility failed to ensure there was an adequate amount of food available in the facility to account for scheduled meals and emergency situations. This had the potential to affect all 99 residents in the facility who the facility identified as receiving food from the kitchen. The census was 99. Findings include: Observation of the kitchen with [NAME] #59, on 12/03/24 at 8:31 A.M. through 8:44 A.M., revealed the facility's dry food storage consisted of dry pancake mix, dry cake mix, instant potatoes, noodles, onions, brown sugar, two canisters of oats, frosting, 11 cans of fruit, six cans of vegetables, and 25 pounds of rice. The refrigerated food storage consisted of one opened gallon of milk, two five-pound logs of cheese, one bag of broccoli, one bag of carrots, and an opened bottle of salad dressing. Observation of frozen food items in the kitchen consisted of two bags of peas and carrot mix and approximately 60 breakfast sausage links. Interview at time of the kitchen tour with [NAME] #59 confirmed the facility did not have an emergency supply of food at that time. [NAME] #59 further confirmed the facility served meals as scheduled and had enough food at each meal, but hardly had any leftovers if any resident wanted a second serving. Interview on 12/03/24 at 8:49 A.M. with [NAME] #173 revealed the facility was able to serve the meals as scheduled on a daily basis, but had no extra food or an emergency food supply for a long time. Interview on 12/03/24 at 10:17 A.M. with Dietician #96 revealed the Administrator was aware of the facility did not have an emergency supply of food. Interview on 12/03/24 at 12:01 P.M. with [NAME] #4 revealed he did not have any lunch meat to use to start preparing for the evening meal of submarine (sub) sandwiches. Observation on 12/03/24 at 1:10 P.M. revealed Dietician #96 purchased and brought supplies into the kitchen consisting of 36 small cans of tuna, five one-gallon containers of milk, two roasted turkey breasts, 36 cans of ravioli, and 36 cans of fruit. Interview on 12/03/24 at 1:10 P.M. with [NAME] #4 confirmed the facility sent a kitchen staff member to the store after the observation of the lack of food supply in the kitchen earlier that morning. Interview on 12/03/24 at 3:01 P.M. with the Administrator revealed the facility food vendor had not been supplying the facility with all food ordered on a weekly basis and the facility and was Page 1 of 2 366035 366035 12/04/2024 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 - Many working with them to get those items delivered. The Administrator confirmed she has been the administrator since 10/01/24 and she was not aware of the facility not having an emergency food supply until recently. Interview on 12/04/24 at 7:27 A.M. with Dietary Supervisor #90 confirmed he has worked for the facility for approximately 90 days and the facility has not had an emergency food supply since he was hired. Dietary Supervisor #90 reported the food he ordered weekly just barely gets the kitchen through the week. Review of the undated document for the facility comprehensive emergency management plan (CEMP) revealed the facility will ensure there was an emergency food and drink service, and will procure and maintain a seven-day supply of food and meal service products on hand at all times. This deficiency represents non-compliance investigated under Master Complaint Number OH00160283. 366035 Page 2 of 2