Health inspection·November 26, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure the appropriate size brief was provided to the residents who require and prefer a specific size brief. This affected two (#8 and #16) of two residents reviewed for briefs. The facility census was 60. Residents Affected - Few Findings include: 1. Medical record review for Resident #7 revealed an admission date of 03/20/17. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 was dependent on staff for toileting and was incontinent for bowel and bladder. Interview with Resident #7 on 11/21/24 at 3:21 P.M. revealed the nursing aides do not provide her with a brief that fits. She has asked many times for a three x-large (XML) brief and the facility doesn't have them. Observation of Resident #7 on 11/21/24 at 3:30 P.M. with Certified Nursing Aide (CNA) #169 revealed CNA #169 stated Resident #7 had on a two XL brief and the right side was fastened ok, but the left side you could see her skin exposed through the fasteners. Interview with CNA #169 on 11/21/24 at 3:35 P.M. verified Resident #7 had on a two XL brief, and Resident #7 required a three XL brief. CNA #169 stated the facility doesn't have any three XL briefs in the facility so she wasn't able to put one on the resident. During an observation of incontinence care for Resident #7 and staff interviews on 11/24/24 at 6:40 A.M. with CNA #186 and CNA #188 both said the brief that was on the resident was a two XL and the agency worked yesterday and didn't put on a three XL on the resident. CNA #186 stated she searched the closet and there wasn't any three XL briefs, so a two XL was placed on Resident #7. Again the right side of the brief fit the resident, but the left side of the brief, one could see her skin through the fasteners. Observation of the three supply rooms in the facility on 11/25/24 at 1:45 P.M. with the Dietary Manager (DM) #116 revealed there wasn't any three XL briefs found. DM #116 verified there were no three XL briefs found in the three supply rooms. 2. Medical record review for Resident #16 revealed an admission date of 02/01/22. Diagnoses Page 1 of 6 365789 365789 11/26/2024 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0558 included peripheral vascular disease, respiratory failure, and renal insufficiency. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact. She was frequently incontinent for bowel and bladder. Residents Affected - Few Interview with Resident #16 on 11/24/24 at 2:40 P.M. revealed she wore a size three x-large (XL) brief and she wasn't able to get them because the facility runs out of them, and it happens all the time. She said when a two XL brief was placed on her and it makes her raw. Observation of the three supply rooms in the facility on 11/25/24 at 1:45 P.M. with the Dietary Manager (DM) #116 revealed there wasn't any three XL briefs found. DM #116 verified there were no three XL briefs found in the three supply rooms. Review of the policy titled Resident Rights dated 2024 revealed the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. This deficiency represents non-compliance investigated under Complaint Number OH00158992. 365789 Page 2 of 6 365789 11/26/2024 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to ensure a change of condition was reported to the physician. This affected one (#64) of three residents reviewed for change of condition. The facility census was 60. Findings include: Medical record review for Resident #64 revealed an admission date of 08/06/24. Diagnoses included aftercare for a displaced supracondylar fracture with intercondylar extension of lower end of right femur, diabetes mellitus, arthritis, and cerebrovascular accident. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Review of the Physical Therapy (PT) notes dated 08/12/24, 08/16/24, 08/20/24, 08/21/24, and 08/22/24 revealed Resident #64 was bleeding from her surgical incision site to her right lower extremity. These notes were absent for notifying the physician of the bleeding. Review of the Occupational Therapy (OT) notes dated 08/12/24, 08/22/24, and 08/30/24 revealed Resident #64 was bleeding from her surgical incision site to her right lower extremity. These notes were absent for notifying the physician of the bleeding. Review of the progress notes from 08/12/24 through 08/30/24 revealed the notes were absent for notifying the physician about the bleeding from her surgical incision site to Resident #64's right lower extremity. Review of the Wound Nurse Practitioner (NP) #189 notes on 08/21/24 revealed there was no mention of Resident #64's incision site was bleeding. Interview with NP #189 on 11/26/24 at 9:55 A.M. verified the staff did not notify her there was bleeding from Resident #64's incision site. NP #189 stated she would have notified the surgeon if she knew about the bleeding. Review of the undated policy titled Notification of Changes revealed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. This deficiency represents non-compliance investigated under Complaint Number OH00159578. 365789 Page 3 of 6 365789 11/26/2024 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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 incontinence care was provided appropriately and thoroughly. This affected one (Resident #7) of three residents reviewed for incontinence. The facility census was 60. Findings include: Medical record review for Resident #7 revealed an admission date of 03/20/17. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 was dependent on staff for toileting and was incontinent for bowel and bladder. Interview with Resident #7 on 11/21/24 at 3:21 P.M. revealed the aides do not clean her very good when they provide her with incontinence care. Observation of incontinence care for Resident #7 on 11/24/24 at 6:40 A.M. with Certified Nursing Aide (CAN) #186 and CNA #188 revealed CNA #186 took a end of the bath towel and wet it and placed soap in the cloth and washed the front of the resident with it and turned the resident over on her side towards CNA #188 and washed the backside of the resident with the bath towel without tuning it over to wash her. While the CNAs were cleaning the resident, she had urinated down the front of her legs and down in between them too. CNA #188 said it was urine running down the resident's legs. STNA #188 took a clean cloth and washed down the front of the resident and didn't wipe her legs. Interview with CNA #186 on 11/24/24 at 6:50 A.M. verified she had to use the same towel, because she didn't have anything else to wipe the back side of Resident #7 with. Interview with CNA #188 on 11/24/24 at 6:55 A.M. verified she saw urine running down Resident #7's legs and verified she did not wash Resident #7's legs afterwards. Review of the undated policy titled Perineal Care revealed it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Females: a. Assist resident in bending her knees slightly and spreading her legs. b. Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain the wet cloth. c. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping 365789 Page 4 of 6 365789 11/26/2024 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0690 in direction from front to back (from pubic area toward anus). Level of Harm - Minimal harm or potential for actual harm d. Repeat on opposite side using separate section of washcloth or new disposable wipe. e. Clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable Residents Affected - Few wipe with each stroke. f. Pat dry with towel. This deficiency represents non-compliance investigated under Complaint Number OH00158992. 365789 Page 5 of 6 365789 11/26/2024 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure residents were administered the COVID-19 vaccine when requested. This affected one (#7) of three residents reviewed for vaccines. The facility census was 60. Findings included: Medical record review for Resident #7 revealed an admission date of 03/20/17. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Review of the vaccine consent form dated 11/05/24 revealed Resident #7 had read the above information concerning risks for vaccines and had an opportunity to ask questions. The form was checked mark the resident requested to have two COVID-19 vaccines administered. Review of the progress notes and the Medication Administration Record (MAR) from 11/05/24 through 11/25/24 revealed no evidence the COVID-19 vaccines were administered to Resident #7. Interview with Resident #7 on 11/21/24 at 3:21 P.M. stated she had been asking for the COVID-19 vaccines since September 2024 and has not received them yet. Interview with Assistant Director of Nursing (ADON) #141 on 11/25/24 at 2:00 P.M. confirmed Resident #7 did not receive her COVID-19 vaccines. Review of the policy titled COVID-19 Vaccination dated 2024 revealed it is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complication from COVID-19 (SAR'S-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. This deficiency represents non-compliance investigated under Complaint Number OH00158992. 365789 Page 6 of 6