Sanctuary Pointe Nursing & Rehabilitation Center

Based on observations, staff interviews and policy review, the facility failed to store, prepare, distribute, and serve foods in a sanitary manner and in accordance with the facility policies. This had the potential to affect all 114 residents who received food from the kitchen. Facility census was 114. Findings include: 1. Observations of the facility kitchen on 04/22/24 8:20 A.M., revealed the following areas of concern: a. There was no temperature log of the dishwasher temperatures for the month of April 2024 through the past six months. b. The ice machine, which provided ice to the entire facility, had a pink wet substance on the inside of the ice storage bin which was touching the ice. c. In the walk-in refrigerator, there was no thermometer, and eight bags of undated and unlabeled food. There was a container of opened coleslaw with expiration date of 04/14/24. There were 22 wrapped plates of unlabeled and undated food. The refrigerator temperature log for April 2024 had no daily entry past 04/22/24. d. The walk-in freezer temperature log for April 2024 had no daily entry past…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure medications were discarded after their expiration date. This affected one (#59) of three residents observed for medication administration and also affected four (#1, #38, #72, and #368) of 30 residents who received medication from the 200 hall medication cart. The facility census was 114. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of [DATE]. Diagnoses included type two diabetes mellitus (DM II), Alzheimer's disease, and atrial fibrillation. Review of the physician order dated [DATE] revealed Resident #59 was ordered Novolog Solution 100 unit/milliliter (ml), inject per sliding scale subcutaneously two times a day for diabetes. Observation on [DATE] at 2:48 P.M. of medication cart on 400 hall revealed Resident #59's Novolog vial was opened on [DATE], indicating the insulin was expired. Interview on [DATE] at 2:53 P.M. with Licensed Practical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and policy review, the facility failed to ensure blood work was completed as ordered. This affected two (#23 and #88) out of five residents reviewed for laboratory services. Facility census was 114. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 02/02/21. Diagnoses included dementia, peripheral vascular disease (PVD), psychosis, atrial fibrillation, anxiety disorder, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the physician order dated 10/13/23 revealed Resident #23 was ordered to obtain complete blood count (CBC), complete metabolic panel (CMP), thyroid stimulating hormone (TSH), Fasting Lipid Panel (FLP),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and physician interviews, and review of facility policy, the facility failed to notify a physician of a resident's change in condition. This affected one (#110) of three residents reviewed for death. The census was 108. Findings include: Review of Resident #110's closed medical record revealed an admission date of [DATE]. Diagnoses included diverticulosis, hypertension, atrial fibrillation, carotid stenosis, congestive heart failure, and chronic obstructive pulmonary disease. Resident #110 passed away in the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had severe cognitive impairment and was receiving Hospice services. Review of progress notes dated [DATE] at 10:41 A.M. revealed Resident #110's oxygen (O2) level was at 79 percent (%) on four liters upon waking. A breathing treatment was administered. Supervisor and Hospice were notified of the low O2 level. Review of progress notes dated [DATE] at 4:33 P.M.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and physician interviews and policy review, the facility failed to coordinate hospice care to ensure hospice recommendations were timely implemented. This affected one (#110) of three residents reviewed for death. The census was 108. Findings include: Review of Resident #110's closed medical record revealed an admission date of [DATE]. Diagnoses included diverticulosis, hypertension, atrial fibrillation, carotid stenosis, congestive heart failure, and chronic obstructive pulmonary disease. Resident #110 passed away in the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had severe cognitive impairment and was receiving Hospice services. Review of progress notes dated [DATE] at 10:41 A.M. revealed Resident #110's oxygen (O2) level was ar 79 percent (%) on four liters upon waking. A breathing treatment was administered. Supervisor and Hospice were notified of the low O2 level. Review of progress notes dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen was administered as ordered. This affected three Residents (#11, #12, and #13) out of four residents reviewed for working oxygen concentrators. The census was 108. Findings include: 1. Review of Resident #11's medical record revealed Resident #11 was admitted on [DATE] with diagnoses including congested heart failure, acute kidney failure, and chronic respiratory failure. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #11 had moderate cognitive deficits and required extensive assistance with activities of daily living (adl). Review of Resident #11's care plan, dated 07/13/23, revealed Resident #11 had oxygen therapy related to congestive heart failure and respiratory failure with interventions to monitor for respiratory distress and to give medicine as ordered by the physician. Review of Resident #11's physician order, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, interviews with a local health department Epidemiologist and facility staff, review of the Ohio Department of Health Infection Disease Control Manual and review of the Ohio Administrative Code (OAC), the facility failed to report an outbreak of suspected scabies to local and state health departments. This affected five (#6, #25, #40, #54, and #306) of five residents reviewed and had the potential to affect all 103 residents residing in the facility. The facility in-house census was 103. Findings include: 1. Review of the medical record for the Resident #25, revealed an admission date of 09/24/19. Diagnoses include anemia, cellulitis, chronic kidney disease, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, hypertension, metabolic encephalopathy, neuromuscular dysfunction of bladder, dementia without behavioral disturbances and osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 12/31/19, revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to discard discontinued controlled narcotics and discard an opened influenza (flu) vaccine after it expired. This affected one out of four medication storage areas observed during the survey and had the potential to affect four (#1, #17, #22 and #104) residents on 100 hallway who could potentially receive the expired flu vaccine. Facility census was 103. Findings include: Observation of 100 hall medication storage room refrigerator on [DATE] at 9:12 A.M. with RN #50 revealed one multi vial flu vaccine dated [DATE]. Interview with RN #50 on [DATE] at 9:13 A.M. verified the multi vial flu vaccine was opened and dated [DATE] being stored inside the refrigerator. RN #50 stated the multi vial flu vaccine should have discarded 28 days after it was opened. RN #50 confirmed this had the potential to affect four (#1, #17, #22 and #104) residents on 100 hallway who could potentially receive the expired flu vaccine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to notify the physician when a resident had to wait for transportation to the hospital emergency room. This affected one (#6) out of 31 residents sampled during the annual survey. Facility census was 103. Findings include: Review of the medical record for Resident #6 revealed an admission date of 05/16/18. Diagnoses include cerebral infarction, hypertension, acute respiratory infection, dementia, severe protein calorie malnutrition, dysphagia oropharyngeal phase, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6's cognition was severely impaired. Review of Resident #6's nursing notes dated 01/07/20 revealed a note which revealed the facility nurse practitioner had seen and examined Resident #6, ordered an antibiotic for the resident, intravenous fluids, orders for labs to be drawn on the morning of 01/08/20 and an order for oxygen via nasal cannula due to the diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to code a resident's minimum data set (MDS) assessment accurately to reflect the resident's prognosis. This affected one (#62) of one resident's reviewed for hospice services. The total facility census was 103. Findings include: Review of Resident #62's medical record revealed resident was admitted on [DATE]. Diagnoses include metabolic encephalopathy, mixed incontinence, tremor, osteoarthritis, zoster without complications, weakness, type two diabetes mellitus, hypertension, and dementia. Review of the resident physician orders revealed the resident was admitted to hospice services on 07/20/19. Review of Resident #62's quarterly minimum data set (MDS) dated [DATE] revealed the resident was coded under section J1400 as no, and section O0100-Special Treatment, Procedures and Programs; K-Hospice- as yes for receiving hospice services. Further review of question J1400 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to follow physician's orders regarding monitoring resident's weights and/or implementing as needed medications as physician ordered related to a residents weight. This affected two (#54 and #55) out of 31 residents reviewed during the annual survey. Facility census was 103. Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of 10/11/19. Diagnoses include displaced fracture of sixth cervical vertebra, congestive heart failure, atrial fibrillation, peripheral vascular disease and venous insufficiency. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54's cognitive was moderately impaired. Review of Resident #54's current physician orders revealed an order for daily weights before breakfast and to notify the physician if a three pound weight gain in one day or five or more pounds in a week related to congestive heart failure. Review of Resident #54's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff and resident interviews, the facility failed to provide timely care and services regarding audiology recommendations. This affected one (#75) of one residents reviewed for communication-sensory services. Facility census was 103. Findings include: Review of Resident #75 medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include sprain of ligament of left ankle, vascular dementia with behavioral disturbances, arthritis, hypertension, hyperlipidemia, weakness, dry eye syndrome, and age related osteoporosis with out pathological fracture. Resident #75 medical record contained a signed consent for treatment for the audiologist dated 01/31/20 Review of admission minimum data set (MDS) dated [DATE] revealed the resident is cognitively intact with a brief interview of mental status score of 14 out of 15, the resident had no hallucinations, delusions, or behaviors. The resident required extensive assist for toileting, dressing, transfers, bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observations, staff interview, and policy review, the facility failed to ensure residents head of bed (HOB) was at or greater than 30 degrees during a bolus gastrostomy tube (G-Tube) feeding administration and facility failed to ensure resident had a gauze covering her stoma for a G-Tube. This affected one (#4) of the 15 residents reviewed during the survey. Facility census was 103. Findings include: Review of the medical record for the Resident #4, revealed an admission date of 11/17/27. Diagnoses included cerebral vascular accident (CVA), dysphagia, hypertension, conjunctivitis, osteoarthritis, congestive heart failure (CHF), diabetes mellitus (DM), and G-tube. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 02/26/29, revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Resident was a two-person physical assist, dependent for eating, and dependent or required extensive assistance for activities of daily living (ADL's). Review of plan of care for Resident #4 dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to timely remove and dispose of discontinued controlled narcotics being stored in the medication carts. This affected two (#60 and #355) residents out of four medication storage areas observed during the survey. Facility census was 103. Findings include: 1. Observation of the 300-B hall medication storage cart with Licensed Practical Nurse (LPN) #230 on 03/11/20 at 8:56 A.M. revealed two discontinued Fentanyl (Scheduled II controlled narcotic pain patches) 50 micrograms (mcg)/hour (hr) for Resident #60 in the locked narcotic bin. Interview with LPN #230 on 03/11/20 at 8:57 A.M. verified the two discontinued controlled Fentanyl patches for Resident #60 were discontinued on 01/15/20. LPN #230 stated Registered Nurse (RN) #250 and the Director of Nursing (DON) were supposed to remove the discontinued controlled medications on a weekly basis. 2. Observation of 100-B hall medication storage cart with LPN #100 on 03/11/20 at 9:15 A.M. revealed two discontinued Oxycodone (Scheduled II controlled pain medication) five milligram…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.