Sanctuary At Ohio Valley

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #5) of three residents reviewed for PASRR documents. The census was 79. Findings Include: Resident #5 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, diabetes mellitus type II, muscle weakness, abnormal posture, constipation, atrial fibrillation, unspecified psychosis, hypertension, Chronic Obstructive Pulmonary disease, hyperlipidemia, anxiety, depression, renal dialysis, chronic kidney disease, arteriovenous fistula, end stage renal disease, and morbid obesity. Review of her Minimum Data Set (MDS) assessment, dated 01/28/25 revealed she had minimal cognitive impairment. Most recent PASSR was completed on 11/29/23 with a diagnosis of mood disorder. A new diagnosis of unspecified psychosis was added on 04/12/24 and a new PASSR was not completed…

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, interview, medical record review and facility policy review the facility failed to ensure Resident #59 had a physicians order for oxygen therapy. This affected one (Resident #59) of one residents reviewed for respiratory care. The facility census was 79. Findings include: Review of the medical record for Resident #59 revealed an admission date of 07/12/23 with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disorder, chronic pulmonary embolism, and hypertension. Review of the physician orders dated 03/25 revealed Resident #59 did not have an order for oxygen therapy. Resident #59 had an order for Bilevel positive airway pressure (BiPap), a mechanical breathing device, to be worn as tolerated except during meals. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #59 was cognitively intact and refused care four to six days of look back period. Resident #59 was depended on staff for completion of most activities of daily…

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 interview, medical record review, and facility policy review the facility failed to ensure Resident #80 had physician order for dialysis treatment and care. This affected one (Resident #80) of two residents reviewed for dialysis. The facility census was 79. Findings include: Review of the medical record for Resident #80 revealed an admission date of 02/10/25 with diagnoses including acute kidney failure with tubular necrosis, chronic kidney disease stage five, hypertension and congestive heart failure. Review of the physician orders dated 03/25 revealed Resident #80 did not have a physician order for dialysis treatment, the name of the facility or contact information and no orders for care and treatment of dialysis port. Review of the nursing progress notes from 02/10/25 through 03/05/25 revealed one note on 02/28/25 at 3:40 P.M. indicated the local dialysis center was notified of Resident #80 discharge date of 03/09/25 from the facility and residents request for chair time change. No other progress…

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 record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected two residents (#23 and #70) out of two residents identified by the facility as having PTSD/trauma. The facility census was 79. Findings include: 1. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE] and had diagnoses including cerebrovascular disease, acute and chronic respiratory failure, hyperlipidemia, insomnia, anxiety, depression, peripheral vascular disease, hypertension, atherosclerosis, Post-Traumatic Stress Disorder (on 5-9-18), transient ischemic attack, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 02/11/25, revealed this resident was assessed to have intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15.…

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 interview, medical record review and facility policy review the facility failed to ensure Resident #22 and Resident #72 had low blood sugar parameters and directions of action when obtaining accucheck blood sugars with sliding scale insulin. This affected two (Resident #22 and Resident #72) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 01/09/23 with diagnoses including cerebrovascular disease, diabetes mellitus type two, schizoaffective disorder, hypothyroidism and mood disorder. Review of the physician orders dated 03/25 revealed Resident #22 received Novolog (fast acting insulin) injection solution 100 units per milliliter (ml) per sliding scale. Inject insulin subcutaneously before meals and at bedtime. Inject as per sliding scale if blood sugar was 200-249 give two units, 250-299 give four units, 300-349 give six units, 350-400 give 8 units, 401-450 give 10 units and…

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, review of the Electronic Information Dissemination and Collection (EIDC) portal for Self-Reporting Incidents (SRI) and review of the facility policy, the facility failed to report an allegation of sexual abuse to the state agency and failed to implement the abuse policy. This affected one (Resident #64) of three reviewed for sexual abuse. The facility census was 82. Findings include: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus type two, psychotic disorder, dementia, and depression. Review of Resident #64's admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 had a Brief Interview for Mental Status (BIMS) score of one of 15, indicating severely impaired cognition. Resident #64 required staff assistance with activities of daily living. Review of Resident #64 nursing progress notes dated 11/29/24 through 12/18/24 revealed no documentation…

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 record review and interview the facility failed to complete the Pre-admission Screening and Resident Review (PASARR) Identification Screen correctly for two residents (Resident #20 and #58) out of six residents reviewed during the annual survey. The facility census was 64. Findings include. 1. Medical record review for Resident #58 revealed an admission date of 08/12/22. Diagnoses included but were not limited to chronic obstructive pulmonary disease, idiopathic aseptic necrosis of right femur, right femur fracture, ventricular tachycardia, major depressive disorder, generalized anxiety disorder, unspecified mood disorder, bipolar disorder, and history of alcohol dependence. Review of Resident #58's physician orders revealed an order for Clonazepam one milligram by mouth twice daily, start date of 08/13/22, Aripiprazole 10 milligrams by mouth once daily for depression, start date of 08/12/22, and Sertraline 50 milligrams by mouth once daily for depression, start date of 08/12/22. Review of Resident…

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 observations, interviews, and record reviews, the facility failed to administer oxygen as ordered by the physician and failed to obtain physician orders for the administration of oxygen. This affected two residents (#36 and #38) of the three residents reviewed for respiratory care. The facility census was 64. Findings include: 1. Record review for Resident #36 revealed this resident was admitted to the facility on [DATE] and had diagnoses including legal blindness, dementia, history of falling, hypertension, and dyspnea. This resident had no known allergies. Review of the annual Minimum Data Set (MDS) assessment, dated 07/14/22, revealed this resident had severely impaired cognition. This resident was assessed to require extensive assistance from one staff member for bed mobility, extensive assistance from two staff members for transfers, extensive assistance from one staff member for toileting, and extensive assistance from one staff member for eating. This resident was assessed to have used oxygen…

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 resident interview, staff interview and a test tray, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affect all residents except three residents (Resident #17, #48, and #78) who received no food from the kitchen. The facility census was 75. Findings include: Interview of Resident #45 on 01/13/20 at 2:44 P.M. revealed sometimes the hot foods were served cold. A test tray was requested on 01/15/20. The test tray was loaded on to the meal cart at 12:07 P.M. The meal cart arrived on the hallway at 12:08 P.M. The first tray was served at 12:10 P.M., and the last tray was served at 12:30 P.M. The temperature of the food on the test tray at 12:31 P.M. included: the hot ham and cheese sandwich was 110 degrees Fahrenheit (F) and cool to taste, the potato wedges were 108 degrees F and cool to taste, and the milk was 60 degrees F and warm to taste. The temperatures were verified with Licensed Practical Nurse (LPN) #20. The facility identified Residents #17, #48, and #78 did not receive food from the kitchen. Interview of Dietary…

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, staff interview and medical record review, the facility failed to ensure a resident with mental disorders received treatment for the disorder. This affected one (Resident #28) of two sampled residents reviewed for mood and behavior. The facility census was 75. Findings include: Review of Resident #28's medical record revealed he was admitted on [DATE] with diagnoses including dementia, mood disorder, bipolar disorder, anxiety and agitation. Review of Resident #28's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the following: Resident # 28's speech was unclear, he was rarely understood, he rarely understands, his short and long-term memory was impaired, he recalled staff names and faces and had severely impaired decision making. Resident #28 had minimal depression, had no indicators of psychosis, had other behaviors one to three days of the assessment reference period that did not significantly impact him or other residents, he 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 staff interview and medical record review, the facility failed to ensure residents who received psychotropic drugs had target behaviors identified and were monitored for those behaviors. This affected two (Residents #28 and #50) of five sampled residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #28's medical record revealed he was admitted on [DATE] with diagnoses including dementia, mood disorder, bipolar disorder, anxiety and agitation. Review of Resident #28's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the following: Resident # 28's speech was unclear, he was rarely understood, he rarely understands, his short and long-term memory was impaired, he recalled staff names and faces, and had severely impaired decision making. Resident #28 had minimal depression, had no indicators of psychosis, had other behaviors one to three days of the assessment reference period that did not significantly impact him or other residents, he did not reject care…

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.