Health inspection·November 16, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incidents (SRI's), staff interviews and policy review, the facility failed to timely report an allegation involving misappropriation of resident's medications to the Ohio Department of Health as required. This affected one (#18) out of three residents reviewed for misappropriation. Facility census was 53. Findings include: Review of medical record for Resident #18 revealed admission date of 09/13/23. Diagnoses include wedge compression fracture, hypertension and depression. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had impaired cognition. He required partial assistance for eating and substantial assistance for bed mobility, transfers and toileting. Review of Resident #18's physician orders revealed an order for Oxycodone (narcotic for pain) five milligram (mg) capsule every six hours as needed for pain with a start date of 09/13/23. Further review of the controlled substance record sign out sheet from 09/27/23 through 10/16/23 revealed Licensed Practical Nurse (LPN) #16 signed for Resident #18's Oxycodone a total of 34 times and wasted the medication with another nurse 11 times. Review of facility SRI's revealed there was no SRI regarding an allegation involving potential misappropriation of medications involving Resident #18 or LPN #16. Interviews on 11/16/23 with the Director of Nursing (DON) revealed it had been brought to her attention by Registered Nurse (RN) #12 and LPN #18 that they felt LPN #16 was wasting a lot of narcotic medications specifically for Resident #18 and there was the possibility of misappropriation of narcotics. The DON stated she reviewed the narcotic sheets on LPN #16's assignment for items of suspicion and noted there were several incidents of medications being wasted by LPN #16, but the second nurse present during the medication wasting varied. The DON shared she contacted the Corporate DON and the facility pharmacy to review the narcotic log documentation. The DON stated LPN #16 was interviewed and denied misappropriation of medication. LPN #16 was given a urine drug screen at the facility on 10/18/23 which was negative. The DON verified a SRI for potential misappropriation of medication was not done. Review of a facility's undated Abuse Policy revealed misappropriation of resident property, means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's Page 1 of 5 365789 365789 11/16/2023 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0609 Level of Harm - Minimal harm or potential for actual harm belongings or money without the resident's consent. The facility process for reporting/response to allegations of abuse includes, but not limited to: immediately reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframe's. Residents Affected - Few This deficiency is based on incidental findings discovered during the course of this complaint investigation. 365789 Page 2 of 5 365789 11/16/2023 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and resident and staff interviews, the facility failed to ensure residents received timely incontinence care. This affected one (#22) of three residents reviewed for incontinence care. Facility census was 53. Residents Affected - Few Findings include: Review of medical record for Resident #22 revealed admission date of 05/21/23. Diagnoses include prostate cancer, dementia, peripheral vascular disease, depression, anxiety, contact and expected exposure to other hazardous substances (agent orange), non-pressure chronic ulcer of right lower leg and left lower leg. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had a Brief Interview Mental Status (BIMS) score of 11 out of 15 indicating impaired cognition. He required set up for eating, maximum assistance for toileting, lying to sitting and dependent for transfers. Review of Resident #22's care plan for alteration in elimination was last revised on 07/26/23 with an intervention to provide incontinence care as needed. Observation of incontinence care on 11/13/23 at 11:30 A.M. by State Tested Nursing Assistant (STNA) #11 for Resident #22 revealed the resident was incontinent of both urine and stool. Resident #22 was cleansed with wet soapy towel, and patted dry. Bilateral buttocks and peri were noted to be bright red with an approximate 2.0 centimeter (cm) by (x) 0.65 (cm) apparent open area to the right thigh fold. This was verified with STNA #11. Barrier cream was applied and a new incontinence product was secured. Interview on 11/13/23 with Resident #22 following incontinence care revealed he had not been checked and changed since 6:15 A.M. that morning and this was verified with STNA #22 who shared she usually did rounds prior to breakfast but was unable to that morning. This deficiency represents non-compliance investigated under Complaint Number OH00147600. 365789 Page 3 of 5 365789 11/16/2023 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0687 Provide appropriate foot care. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, resident, and Certified Nurse Practitioner (CNP) #19 interviews and policy review, the facility failed to appropriately assessment and implement a physician ordered treatment for a residents newly identified skin breakdown on the residents toes on the left foot. This resulted in Actual Harm when Resident #22's newly identified open areas on the resident's left toes were not assessed, and a physician ordered treatment was not implemented subsequently resulting in worsening of the area and hospitalization. This affected one (#22) of three residents reviewed for skin breakdown. Facility census was 53. Residents Affected - Few Findings include: Review of medical record for Resident #22 revealed an admission date of 05/21/23 and was recently readmitted on [DATE]. Diagnoses include prostate cancer, dementia, peripheral vascular disease, depression, anxiety, contact and expected exposure to other hazardous substances (agent orange), lower extremity venous insufficiency with recurrent ulceration, and non-pressure chronic ulcer of right lower leg and left lower leg. Review of Resident #22's care plan dated 06/08/23 revealed the resident at risk for alterations in skin integrity related to requiring assistance with personal care, peripheral vascular disease, dementia, Alzheimer's disease, incontinence, morbid obesity, osteoarthritis and prostate cancer. The care plan instructed staff to provide skin care as needed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had a Brief Interview Mental Status (BIMS) score of 11 out of 15 indicating impaired cognition. Resident #22 required set up for eating, maximum assistance for toileting, lying to sitting and dependent for transfers. Review of Resident #22's progress notes revealed a late entry for 10/04/23 which was created on 10/10/23 at 7:53 A.M. by the Director of Nursing (DON) documented Resident #22's toes on his left foot were open and bleeding. The physician was notified and a treatment order to cleanse with normal saline, pat dry, apply collagen sheet and cover with bordered super absorbent dressing was obtained. The note did not identify which toes were affected on Resident #22's left foot and no further assessment/measurements were documented. Review of Resident #22's physician orders to cleanse the second and third toes on left foot with normal saline, pat dry and apply collagen sheet, and cover with super absorbent dressing was ordered on 10/05/23 and was created and discontinued on 10/10/23. Further review of the October 2023 Treatment Administration Record (TAR) revealed there was no order to cleanse the second and third toes on left foot with normal saline, pat dry and apply collagen sheet, and cover with super absorbent dressing. Review of the Wound Clinic Notes dated 10/09/23 revealed Resident #22 presented to his appointment for chronic bilateral foot wounds, the clinic documented there were new wounds to the second and third toes with exposed bone. Review of the hospital notes for Resident #22 revealed he was referred from the wound clinic with new left foot wounds to the second and third digit with exposed bone and a concern for osteomyelitis. 365789 Page 4 of 5 365789 11/16/2023 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0687 Level of Harm - Actual harm Residents Affected - Few Review of Resident #22's hospital note dated 10/11/23 revealed an Magnetic Resonance Imaging (MRI) was completed and the the findings were suggestive of osteomyelitis involving the second proximal and middle phalanges as well as the third middle and distal phalanges. No definite abscess. Review of Resident #22's a surgical note dated 10/12/23 documented surgical amputation of the left foot second and third digit. Resident #22 was readmitted to the facility following the hospitalization on 10/20/23. Interview on 11/14/22 at 10:53 A.M. with Resident #22 revealed he had seen an outside physician for the care of his foot wounds due to poor circulation of the lower extremities. Resident #22 was unable to recall how long he had the wounds to his lower extremities and left foot, but did share he had two toes on the left foot removed the month prior. Observation on 11/14/23 at 4:05 P.M. of Resident #22's dressing change by Registered Nurse (RN) #12 revealed the dressing dated 11/14/23 was removed from Resident #22's left foot. Further observations revealed Resident #22 had amputations on the left second and third digits and there were no signs of infection noted. Interview on 11/15/23 at 2:53 P.M. with the DON revealed Resident #22 had been admitted to the facility with chronic bilateral ulcers for which he received treatment from a wound clinic. The DON verified Resident #22 had new wounds observed on 10/04/23 and the physician was notified of the new areas; however, the treatment order was not implemented. The DON confirmed there were no measurements or further assessment documented of Resident #22's left toes on 10/04/23 through 10/09/23. The DON confirmed Resident #22 went to the wound clinic on 10/09/23 and was subsequently hospitalized due to worsening of the left toe areas. Interview on 11/15/23 at 3:42 P.M. with CNP #19 revealed she did assess Resident #22 at the facility on 10/05/23 and denied anyone from the facility informing her on the day of visit a concern with the resident toes to the left foot. CNP #19 further stated Resident #22 was seen by an outside physician for wound care related to ongoing issues with wounds to the lower extremities, and she generally only checked to ensure the dressing appeared dry and intact. Review of an undated facility policy revealed the effectiveness of treatments will be monitored through ongoing assessment of the wound. This deficiency represents non-compliance investigated under Complaint Number OH00147600. 365789 Page 5 of 5