Health inspection·March 11, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, observation, record review, and facility policy review, the facility failed to maintain infection control procedures to prevent the development of infections when staff failed to wash or sanitize their hands before a dressing change and after gloves changes during a dressing change. This affected one (Resident #32) of three Residents reviewed for wounds. The facility census was 50. Residents Affected - Few Findings include: Record review of Resident #32 revealed an admission date of 02/21/24 with pertinent diagnoses of: type two diabetes mellitus with other skin complications, paraplegia, muscular dystrophy, obstructive sleep apnea, need for assistance with personal care, non pressure chronic ulcer of left and right foot, atherosclerotic heart disease of native coronary artery, hypertension, spinal stenosis, disorder of kidney and ureter, hyperlipidemia, cardiac arrhythmia, hypothyroidism, anemia, peripheral vascular disease, chronic kidney disease, and chronic pain syndrome. Review of the 02/25/24 admission Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and uses a wheelchair to aid in mobility. The resident requires supervision or touching assistance for rolling left and right, and partial moderate assistance for sit to lying and lying to sitting on side of bed. The resident was coded as having diabetic foot ulcers Review of a Physician Order dated 03/06/24 revealed to cleanse right outer foot (pinky side) with Normal saline, pat dry, apply calcium alginate, cover with gauze island with border every day shift for wound care. Observation on 03/07/24 at 12:56 P.M. revealed Licensed Practical Nurse (LPN) #11 gathered the supplies for the wound change including calcium alginate, border gauze, wound cleanser, and four by four gauze. LPN #11 put on gloves, but did not wash her hands or use alcohol based hand rub for her hands. LPN #11 removed Resident #32 soiled dressing on the right outer foot, she then removed her soiled gloves, and put on new gloves but she did not wash or use alcohol based hand rub for her hands. LPN #11 used wound cleanser and gauze to clean the wound and she removed her gloves and put on clean gloves but did not wash hands or use hand sanitizer. LPN #11 placed calcium alginate and the wound dressing. Interview with LPN #11 on 03/07/24 at 1:08 P.M. verified she did not wash her hands or use alcohol based hand rub prior to starting Resident #32 dressing change or after removing gloves during the dressing change. Review of the undated facility Hand Hygiene policy revealed the use of gloves does not replace hand (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366170 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Sanctuary at Tuttle Crossing 4880 Tuttle Road Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)