A list of the most recent deficiencies for Momentous Health at Vandalia. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-18 | 2023-07-28 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-24 | 2023-06-20 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-04-24 | 2023-06-20 | N |
| 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. | Health | 2023-04-24 | 2023-06-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-24 | 2023-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-24 | 2023-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-24 | 2023-06-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-24 | 2023-06-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-24 | 2023-06-20 | N |
| 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. | Health | 2023-04-24 | 2023-06-20 | N |
| 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. | Health | 2023-04-24 | 2023-06-20 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-24 | 2023-06-20 | N |
| 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. | Health | 2023-04-24 | 2023-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-24 | 2023-06-20 | N |
| 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. | Health | 2023-04-24 | 2023-06-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-04-24 | 2023-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-24 | 2023-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-24 | 2023-06-20 | N |
| 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. | Health | 2023-04-24 | 2023-06-20 | N |
| Keep all essential equipment working safely. | Health | 2023-04-24 | 2023-06-20 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-04-24 | 2023-06-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-24 | 2023-06-20 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-17 | 2023-06-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-17 | 2023-06-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-17 | 2023-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-17 | 2023-06-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-17 | 2023-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-17 | 2023-06-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-17 | 2023-06-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-17 | 2023-06-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-06 | 2023-03-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-06 | 2023-03-24 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-01 | 2023-03-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-01 | 2023-03-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-19 | 2022-12-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-19 | 2022-12-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-19 | 2022-12-27 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-12-19 | 2022-12-27 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-07 | 2019-12-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-07 | 2019-12-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-07 | 2019-12-13 | N |
| 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. | Health | 2019-11-07 | 2019-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-07 | 2019-12-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-07 | 2019-12-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-07 | 2019-12-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-11-04 | 2019-12-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-04 | 2019-12-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-04 | 2019-12-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-04 | 2019-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-04 | 2019-12-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-04 | 2019-12-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-04 | 2019-12-13 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-10-04 | 2018-10-31 | N |
| 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. | Health | 2018-10-04 | 2018-10-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-10-04 | 2018-10-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-04 | 2018-10-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-04 | 2018-10-31 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-10-04 | 2018-10-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Establish methods for sharing information. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-03 | 2018-10-31 | N |
