Health inspection·December 23, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, review of Wound Physician notes, and policy review, the facility failed to ensure pressure ulcer treatment orders were initiated and ordered timely and accurately. This affected three residents (#20, #40, and #50) of three residents reviewed for pressure ulcer care. The facility census was 59. Findings include:1.Review of the medical record for Resident #20 revealed an admission date of 11/06/25 and a transfer to the hospital date of 12/03/25. Diagnoses included but were not limited to wedge compression fracture of thoracic 11 and thoracic 12 vertebra, heart failure, type two diabetes mellitus with diabetic neuropathy, muscle weakness, repeated falls, and cognitive communication deficit. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 indicating the resident was cognitively intact. The resident was assessed to require substantial/maximal assistance with shower/bathing, bed mobility, lying to sitting on the side of the bed, sit to stand, transfers, and required total staff dependence for toilet hygiene as well as sitting to lying. The resident was also assessed to have a stage 3 pressure ulcer on admission. Review of the plan of care dated 11/06/25 for Resident #20 revealed the resident was at risk for/had an actual alteration in skin integrity related to being admitted with impaired skin integrity of a sacral pressure area with an intervention including but not limited to providing treatments as ordered. Review of the Skin Risk assessment dated [DATE] for Resident #20 revealed the resident was at high risk for skin breakdown. Review of the pressure ulcer assessment dated [DATE] for Resident #20 revealed a sacrum stage two pressure ulcer measuring 2 cm (centimeters) by 2 cm by no depth. Review of the physician order dated 11/07/25 for Resident #20 revealed an order for barrier cream to the sacrum, coccyx and peri area twice a day and after each incontinence episode every shift. The order was discontinued on 11/21/25. Review of the Wound Physician #1500 note dated 11/11/25 for Resident #20 revealed a sacrum stage three pressure ulcer measured 2.3 cm by 1.2 cm by 0.2 cm with a treatment order for Hydrocolloid paste (triad) twice a day and as needed. Review of the Wound Physician #1500 note dated 11/18/25 for Resident #20 revealed a sacrum stage three pressure ulcer measured 2.6 cm by 2 cm by 0.2 cm with a treatment order to continue the Hydrocolloid paste (triad) twice a day and as needed. Review of Resident #20's physician order dated 11/21/25 revealed the facility initiated the order (10 days late) for the Hydrocolloid paste to sacrum, coccyx and peri area twice a day and after each incontinence. Interview on 12/16/25 at 2:45 P.M. with the Director of Nursing (DON) revealed the facility had a barrier cream and a Hydrocolloid paste (triad) in house and if they were not ordered correctly, the staff did not know which one to use. The DON verified Resident #20 received the barrier cream treatment from 11/11/25 through 11/21/25 for the sacrum stage three pressure ulcer instead of Hydrocolloid paste (triad) treatment. 2.Review of the medical record for Resident #40 revealed an admission date of 09/21/25 and a transfer to hospital date of 10/12/25. Diagnoses included but were not limited to cervical disc disorder at cervical 5 to cervical 6 with radiculopathy, Residents Affected - Few Page 1 of 2 366170 366170 12/23/2025 The Sanctuary at Tuttle Crossing 4880 Tuttle Road Dublin, OH 43017

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pressure ulcer of sacral region stage four, type two diabetes mellitus without complications. Review of Resident #40's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. The resident was assessed to require partial/moderate assistance with bed mobility, substantial/maximal assistance with transfers and total dependence on toilet hygiene and shower/bathing. The resident was also assessed to have a stage four pressure ulcer on admission. Review of the plan of care dated 09/22/25 for Resident #40 revealed the resident was at risk for/had an actual alteration in skin integrity related to being admitted with a pressure ulcer to the sacrum with an intervention including, but not limited to, providing treatments per physician's orders. Review of the Skin Risk assessment dated [DATE] for Resident #40 revealed the resident was at high risk for skin breakdown. Review of the pressure ulcer admission assessment dated [DATE] for Resident #40 revealed a sacrum unstageable pressure ulcer measured 4 centimeters (cm) by 6 cm by undetermined depth. Review of the physician order dated 09/22/25 for Resident #40 revealed an order to clean the sacral wound with wound wash, pat dry, cover with foam border dressing and change every three days and as needed. The order was discontinued on 09/25/25. Review of the Wound Physician #1500 note dated 09/23/25 revealed Resident #40 had a sacrum stage four pressure ulcer measured 5.5 cm by 7 cm by 1 cm with a treatment order for Mesalt with a gauze dressing daily and as needed. Review of the physician order dated 09/23/25 for Resident #40 revealed an order for Mesalt with a gauze dressing daily and as needed. Interview on 12/23/25 at 9:44 A.M. with the Director of Nursing (DON) verified Resident #40 had two active orders for the sacrum stage IV pressure ulcer from 09/23/25 through 09/25/25. 3.Review of the medical record for Resident #50 revealed an admission date of 05/18/22. Diagnoses included, but were not limited to, systolic heart failure, chronic kidney disease stage three, peripheral vascular disease and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of the Skin Risk assessment dated [DATE] for Resident #50 revealed the resident was at high risk for skin breakdown. Review of Resident #50's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. The resident was assessed to require total dependence for toilet hygiene, shower/bathing, bed mobility, and transfers. This resident was assessed to be at risk for developing pressure ulcers and to have two stage three pressure ulcers currently. Review of the plan of care, revised 12/02/25, for Resident #50 revealed actual skin alterations related to the sacrum and right ischium pressure ulcers with interventions including, but not limited to, wound treatments per orders. Review of the Wound Physician #1500 note dated 12/02/25 for Resident #50 revealed a sacrum stage three pressure ulcer measured 4.5 centimeters (cm) by 0.6 cm by 0.2 cm and a right ischium stage three pressure ulcer measured 1 cm by 1.7 cm by 0.2 cm with treatments for both to be Hydrocolloid paste (triad) twice a day and as needed. Review of the physician orders dated 12/04/25 for Resident #50 revealed for the sacrum and right ischium stage three pressure ulcers to use Hydrocolloid paste (triad) twice a day and as needed. Interview on 12/23/25 at 9:43 AM with the Director of Nursing (DON) verified Resident #50 did not have a treatment order for the sacrum and right ischium stage three pressure ulcers from 12/02/25 through 12/04/25. Review of the undated facility policy titled Pressure Injury Prevention and Management revealed evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. This deficiency represents non-compliance investigated under Complaint Number 2685037 and Complaint Number 2669759. 366170 Page 2 of 2