Inspection·February 7, 2019

F 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's surety bond, reviewed of resident accounts, and staff interview, the facility failed to ensure their surety bond assured the security of all residents funds being managed by the facility. This affected 79 (#3, #4, #6, #8, #9, #11, #12, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25, #26, #27, #28, #29, #30, #32, #33, #36, #37, #38, #39, #40, #41, #43, #44, #45, #46, #47, #52, #54, #55, #58, #59, #60, #61, #63, #65, #66, #67, #68, #70, #72, #73, #78, #79, #80, #81, #85, #86, #87, #88, #91, #93, #94, #95, #98, #99, #304, #305, #306, #307, #308, #309, #310, #311, #312, #313, #314, #315, #316 and #317) of 111 residents residing at the facility who were identified as having personal funds accounts being managed by the facility. Residents Affected - Some Findings include: Review of the facility's surety bond dated 10/24/18 revealed the facility had a surety bond to cover a limit of $10,000.00. The surety bond was good from 11/01/18 to 11/01/19. Review a list of personal fund accounts at the facility dated 02/06/19 revealed the facility managed 79 residents (#3, #4, #6, #8, #9, #11, #12, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25, #26, #27, #28, #29, #30, #32, #33, #36, #37, #38, #39, #40, #41, #43, #44, #45, #46, #47, #52, #54, #55, #58, #59, #60, #61, #63, #65, #66, #67, #68, #70, #72, #73, #78, #79, #80, #81, #85, #86, #87, #88, #91, #93, #94, #95, #98, #99, #304, #305, #306, #307, #308, #309, #310, #311, #312, #313, #314, #315, #316 and #317) personal funds. The balance of those accounts was $13,112.48. Interview with the Administrator on 02/07/19 at 11:30 A.M., confirmed the facility had a surety bond in effect from 11/01/18 through 11/01/19 to cover $10,000.00. After surveyor intervention the facility had the surety bond updated on 02/07/19 to cover $15,000.00, which was back dated to provide coverage from 11/01/18 to 11/01/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 2 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

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, observation, staff interview, review of facility policy, and review of information from the National Pressure Ulcer Advisory Panel (NPUSP), the facility failed to ensure an advanced provider was notified about an unstageable pressure ulcer. This affected one ( #71) of four residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 111. Findings include: Medical record review revealed Resident #71 was admitted to the facility on [DATE] with a reentry date of 02/03/19. Diagnoses included atrial fibrillation, heart disease, respiratory failure, diabetes with foot ulcer, chronic pain, visual loss, unstageable pressure ulcer of the back, left and right buttocks. Review of wound care specialist initial assessment dated [DATE] revealed Resident #71 had an unstageable pressure ulcer to the lower mid back which measured 1.2 centimeters (cm) by 0.7 cm by 0.1 cm. The tissue was necrotic with 26-50 percent (%) slough. Treatment order was to cleanse with normal saline, apply Santyl, and cover with dry dressing. Resident #71 also had an unstageable pressure ulcer to the right buttock, a diabetic ulcer to the right lateral heel, an arterial/venous ulcer to the right calf and left stump. Review of Resident #71's wound care specialist assessment dated [DATE] revealed the pressure ulcer on the lower mid back was resolved with fragile scar tissue present. The plan was to cover the fragile scar tissue with a foam border gauze twice weekly. Review of five day minimum data set (MDS) assessment dated [DATE] revealed Resident #71 had moderately impaired cognitive skills. Resident #71 was noted with one unstageable pressure ulcer present upon admission/entry or reentry and two venous/arterial ulcers. Review of nursing progress note dated 02/03/19 at 8:00 P.M., revealed Resident #71 was readmitted to the facility in stable condition from the hospital with diagnosis of head laceration status post fall. Head-to-toe assessment was completed. Resident #71 complained of chronic back pain of an eight on a scale from zero to ten, with ten being the most severe. Pain medication was administered and effective. Review of admit/readmit documentation dated 02/03/19 at 8:00 P.M., revealed Resident #71 had open areas to the lower back, right ankle, right heel, right and left buttocks. Review of the care plan revised 02/04/19 revealed Resident #71 had actual impairment to the skin related to wounds including a pressure ulcers to the lower mid back which resolved on 01/21/19, the right buttocks which resolved on 02/04/19, left buttocks which resolved on 01/07/19, diabetic ulcer to the right lateral heel, skin tear to top of head, vascular ulcers to the right lateral stump which resolved on 01/28/19 and right lateral lower leg. Interventions included to monitor and document location, size, and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration, to medical doctor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 3 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of physician orders dated 02/04/19 revealed treatment orders were obtained for the head laceration, right buttocks, right lateral lower leg and heel. No treatment order was obtained for the lower mid back. Review of wound care specialist assessment dated [DATE] revealed the diabetic ulcer to the right lateral heel had improved, the pressure ulcer to the right buttocks was resolved with fragile scar tissue, and the ulcer on the left stump remained resolved with fragile scar tissue. A arterial/venous ulcer remained on the right calf. There was no evidence the area to Resident #71's lower mid back was assessed. Observation and interview with Resident #71 on 02/04/19 at 4:17 P.M., revealed the resident kept repositioning in his/herself in bed. Resident #71 reported severe back pain related to a wound. Observation of the resident's back revealed an approximate two inch square dressing dated 02/04/19 to the resident's lower middle back. Review of Treatment Administration Record (TAR) for February revealed treatment to lower mid back was not initiated until 02/06/19. Observation on 02/06/19 at 7:35 A.M., of wound treatments to Resident #71 by Licensed Practical Nurse (LPN) #16 revealed an abrasion to the head, and vascular wounds to the right lower outer leg and right lateral heel. Upon request by the surveyor, the resident's back was assessed which revealed an undated four inch dressing in place to the lower middle back. Upon removal of the dressing, a small amount of tan drainage was observed on the dressing and a dime sized open area with a wound bed covered in slough was observed to the middle of the resident's back. LPN #16, whom completed wound treatments at the facility, denied any knowledge of where the dressing came from. LPN #16 reported rounds were made with the wound specialist on 02/04/19 at which time Resident #71 was assessed, however they didn't look at the resident's back. Observation on 02/06/19 at 10:14 A.M., of the assessment and treatment to the lower middle back of Resident #71 by LPN #16 revealed a 0.9 cm by 0.9 cm by 0.1 cm unstageable pressure ulcer with 75 % yellow slough. The wound was cleansed with normal saline and a foam border dressing was applied. Interview on 02/06/19 at 1:46 P.M., with LPN #16 reported the nurse assessed Resident #71 upon readmission to the facility on [DATE], following a hospitalization, and documented an open area to the resident's back, applied a border foam dressing, however failed to notify the physician to obtain orders to initiate a treatment. Review of facility undated Pressure Ulcers policy, revealed all skin abnormalities would be assessed by charge nurse and treatment would be put into place per standing orders if needed. Treatment would be initiated, and notification was to be made to the responsible party and medical doctor. Wound Care Treatments included for a potential pressure injury unstageable (depth unknown due to slough, eschar or wound appeared as purple/maroon or blood filled blister on a bony prominence) if intact epithelial tissue (skin) on bony prominence-skin prep or betadine twice daily and leave open to air. There were no standing orders listed for a open potential pressure injury unstageable. Review of information from NPUSP a pressure injury was localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury could present as intact skin or an open ulcer and may be painful. The injury occurs a as result of intense and/or prolonged pressure or pressure in combination with shear. An unstageable pressure injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 4 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0580 was obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar, dead tissue. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 5 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, observation, and staff interview, the facility failed to ensure a resident received treatments as ordered for congestive heart failure (CHF). This affected one resident (#202) of three reviewed for edema. The facility census was 111. Residents Affected - Few Findings include: Medical record review revealed Resident #202 was admitted to the facility on [DATE] with diagnoses including CHF, localized edema, altered mental status, high blood pressure, and adult failure to thrive. Review of the 14 day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills. Review of Resident #202's physician order dated 01/18/19 revealed Torsemide, a diuretic medication, 60 milligrams (mg) daily by mouth for high blood pressure. On 01/23/19, Torsemide was increased to 100 mg daily for CHF. On 01/25/19 daily weights were ordered and to administer Zaroxolyn, a diuretic medication, 5 mg every 24 hours as needed for weights above 230 pounds. Give Zaroxolyn 30 minutes after administration of Torsemide. Review of care plan initiated 02/01/19 revealed Resident #202 was on diuretic therapy related to bilateral lower extremity edema secondary to CHF and high blood pressure. Interventions included administer medication as ordered. Review of Resident #202's Medication Administration Record (MAR) for January 2019 and February 2019 revealed weights were obtained daily 01/25/19 through 02/04/19 and were between 236 pounds and 240 pounds. Zaroxolyn was only documented as being administered once on 01/28/19 for a weight of 240 pounds. All other spaces for administration of Zaroxolyn on the MAR's were blank. Observation on 02/04/19 at 2:31 P.M., revealed Resident #202 was in bed with compression wraps in place to both lower legs. Edema was observed to both ankles and feet. Resident #202 was confused and unable to answer simple questions. The family was present at the bedside and reported Resident #202 had recently declined due to an acute illness. Review of nursing progress note dated 02/05/19 at 11:45 P.M., revealed Resident #202 was transported to the hospital per physician order for obstructive jaundice and admitted with diagnosis of CHF. Interview on 02/07/19 at 7:54 A.M., with the Director of Nursing (DON) confirmed Resident #202 did not receive Zaroxolyn as ordered for CHF when weights were in excess of 230 pounds. The DON revealed the order had been entered into the electronic health record as, as needed, and therefore did not trigger the need for administration when weights were beyond the ordered parameter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 6 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

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** 2. Review of Resident #76's medical record revealed an admission date to the facility on [DATE] with diagnoses including gastroesophageal reflux disease (GERD), and deep vein thrombosis (blood clot). A 14-day MDS assessment dated [DATE] indicated the resident was cognitively intact. Residents Affected - Some Review of Resident #76's admission screening form dated 01/02/19 revealed the resident's skin was intact. Review of pressure sore risk tool dated 01/02/19 revealed the resident was at high risk for skin breakdown. Review of Resident #76's care plan dated 01/03/19 revealed Resident #76 was at risk for skin breakdown related to limited mobility, incontinence, blood clots in both legs, thin frail skin, impaired balance, and weakness. The goal was for the resident's skin to remain intact. Interventions included - assess skin (head to toe) every week, monitoring turning and repositioning, assist with skin care, minimize pressure, use pillow for positioning, monitor position when in bed, cue, prompt, assist to change position two to four times per shift, educate resident on need to change positions. Interview on 02/05/19 at 1:50 P.M., with Resident #76 reported no pain except to both heels. The resident was observed with edema to both feet and ankles, and the resident was wearing tubi-grips (compression stockings) and non-skid socks. Interview on 02/05/19 at 1:59 P.M., with Licensed Practical Nurse (LPN) #98 revealed he was unaware of Resident #76 wearing tubi-grips and unaware of her complaints of heel pain. Observation on 02/06/19 at 8:40 A.M., of skin treatment completed by LPN #16 revealed Resident #76's heels revealed on the left heel a 0.5 x 1.0 centimeter (cm) non-blanchable le area, and deep purple in color. LPN #16 stated it appeared to be a deep tissue injury. Interview on 02/06/19 at 10:15 A.M.,with the Director of Nursing (DON) revealed LPN #98 received a written discipline due to not assessing Resident #76's heels, not obtaining wound orders, and not completing the wound referral form for Resident #76 when he was made aware of the resident's heel pain on 02/05/19. The DON revealed LPN #98 should have assessed Resident #76's heels when he learned of her complaint of pain and then followed the facility policy. Review of facility undated Pressure Ulcers policy, revealed all skin abnormalities would be assessed by charge nurse and treatment would be put into place per standing orders if needed. Treatment would be initiated, and notification was to be made to the responsible party and medical doctor. Wound Care Treatments included for a potential pressure injury unstageable (depth unknown due to slough, eschar or wound appeared as purple/maroon or blood filled blister on a bony prominence) if intact epithelial tissue (skin) on bony prominence-skin prep or betadine twice daily and leave open to air. There were no standing orders listed for a open potential pressure injury unstageable. Review of information from NPUAP a pressure injury was localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury could present as intact skin or an open ulcer and may be painful. The injury occurs a as result of intense and/or prolonged pressure or pressure in combination with shear. An unstageable pressure injury was obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar, dead tissue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 7 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, review of facility policy, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure pressure ulcers were assessed and treatments were initiated timely. This affected two ( #71 and #76) of four residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 111. Residents Affected - Some Findings include: 1. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with a reentry date of 02/03/19. Diagnoses included atrial fibrillation, heart disease, respiratory failure, diabetes with foot ulcer, chronic pain, visual loss, unstageable pressure ulcer of the back, left and right buttocks. Review of wound care specialist initial assessment dated [DATE] revealed Resident #71 had an unstageable pressure ulcer to the lower mid back which measured 1.2 centimeters (cm) by 0.7 cm by 0.1 cm. The tissue was necrotic with 26-50 percent (%) slough. Treatment order was to cleanse with normal saline, apply Santyl, and cover with dry dressing. Resident #71 also had an unstageable pressure ulcer to the right buttock, a diabetic ulcer to the right lateral heel, an arterial/venous ulcer to the right calf and left stump. Review of Resident #71's wound care specialist assessment dated [DATE] revealed the pressure ulcer on the lower mid back was resolved with fragile scar tissue present. The plan was to cover the fragile scar tissue with a foam border gauze twice weekly. Review of five day minimum data set (MDS) assessment dated [DATE] revealed Resident #71 had moderately impaired cognitive skills. Resident #71 was noted with one unstageable pressure ulcer present upon admission/entry or reentry and two venous/arterial ulcers. Review of nursing progress note dated 02/03/19 at 8:00 P.M., revealed Resident #71 was readmitted to the facility in stable condition from the hospital with diagnosis of head laceration status post fall. Head-to-toe assessment was completed. Resident #71 complained of chronic back pain of an eight on a scale from zero to ten, with ten being the most severe. Pain medication was administered and effective. Review of admit/readmit documentation dated 02/03/19 at 8:00 P.M., revealed Resident #71 had open areas to the lower back, right ankle, right heel, right and left buttocks. Review of the care plan revised 02/04/19 revealed Resident #71 had actual impairment to the skin related to wounds including a pressure ulcers to the lower mid back which resolved on 01/21/19, the right buttocks which resolved on 02/04/19, left buttocks which resolved on 01/07/19, diabetic ulcer to the right lateral heel, skin tear to top of head, vascular ulcers to the right lateral stump which resolved on 01/28/19 and right lateral lower leg. Interventions included to monitor and document location, size, and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration, to medical doctor. Review of physician orders dated 02/04/19 revealed treatment orders were obtained for the head laceration, right buttocks, right lateral lower leg and heel. No treatment order was obtained for the lower mid back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 8 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of wound care specialist assessment dated [DATE] revealed the diabetic ulcer to the right lateral heel had improved, the pressure ulcer to the right buttocks was resolved with fragile scar tissue, and the ulcer on the left stump remained resolved with fragile scar tissue. A arterial/venous ulcer remained on the right calf. There was no evidence the area to Resident #71's lower mid back was assessed. Observation and interview with Resident #71 on 02/04/19 at 4:17 P.M., revealed the resident kept repositioning in his/herself in bed. Resident #71 reported severe back pain related to a wound. Observation of the resident's back revealed an approximate two inch square dressing dated 02/04/19 to the resident's lower middle back. Review of Treatment Administration Record (TAR) for February revealed treatment to lower mid back was not initiated until 02/06/19. Observation on 02/06/19 at 7:35 A.M., of wound treatments to Resident #71 by Licensed Practical Nurse (LPN) #16 revealed an abrasion to the head, and vascular wounds to the right lower outer leg and right lateral heel. Upon request by the surveyor, the resident's back was assessed which revealed an undated four inch dressing in place to the lower middle back. Upon removal of the dressing, a small amount of tan drainage was observed on the dressing and a dime sized open area with a wound bed covered in slough was observed to the middle of the resident's back. LPN #16, whom completed wound treatments at the facility, denied any knowledge of where the dressing came from. LPN #16 reported rounds were made with the wound specialist on 02/04/19 at which time Resident #71 was assessed, however they didn't look at the resident's back. Observation on 02/06/19 at 10:14 A.M., of the assessment and treatment to the lower middle back of Resident #71 by LPN #16 revealed a 0.9 cm by 0.9 cm by 0.1 cm unstageable pressure ulcer with 75 % yellow slough. The wound was cleansed with normal saline and a foam border dressing was applied. Interview on 02/06/19 at 1:46 P.M., with LPN #16 reported the nurse assessed Resident #71 upon readmission to the facility on [DATE], following a hospitalization, and documented an open area to the resident's back, applied a border foam dressing, however failed to notify the physician to obtain orders to initiate a treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 9 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, resident interview, and facility policy review, the facility failed to ensure fall interventions were in place and the environment was maintained in a safe manner by keeping medications secured. This affected one (#71) of two residents reviewed for accidents and had the potential to affect 20 (#14, #16, #17, #26, #27, #29, #31, #34, #35, #41, #45, #54, #55, #59, #70, #72, #78, #86, #87, #98) cognitively impaired and independently mobile residents identified by the facility on the secure memory unit. The facility census was 111. Findings include: 1. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with a reentry date of 02/03/19. Diagnosis included atrial fibrillation, heart disease, respiratory failure, diabetes with foot ulcer, trochanteric bursitis, chronic pain, visual loss, unstageable pressure ulcer of the back, left and right buttocks. Review of five day minimum data set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, limited assistance with eating, and a walker, wheelchair, or limb prosthesis were utilized for mobility. Review of care plan initiated 02/01/19 revealed Resident #71 had an actual fall on 01/30/19 without injury and another fall on 01/31/19 with an injury to the top of the head. Interventions included to assess toileting needs as needed, remove bedside commode, and provide resident with urinal. Review of nursing progress occurrence note dated 01/30/19 at 3:32 A.M., revealed Resident #71 had an unwitnessed fall. Resident #71 went to the bathroom per self, with the use of walker, without requesting assistance and fell. The resident was assessed and without injuries, however the resident's oxygen saturation level was 84 percent (%). Oxygen was administered and oxygen level improved to 98%. The resident was educated to request assistance with all transfers. On 01/31/19 at 12:45 A.M., Resident #71 was observed on the floor between the bed and night stand with a bleeding scalp. Resident #71 was transported to the hospital for evaluation. On 01/31/19 at 2:54 P.M., an occurrence note revealed after discussion with interdisciplinary team and therapy, a new intervention was implemented to remove the bedside commode and provide the resident with a urinal. Interview on 02/04/19 at 4:24 P.M., with Resident #71 reported he/she was hospitalized recently due to uncontrolled bleeding to the head following a fall. Observation at the time of the interview revealed a bedside commode by the wall next to the bed. Interview on 02/05/19 at 5:19 P.M., with Registered Nurse (RN) #28 reported after Resident #71 fell on [DATE], therapy was consulted and the new intervention was to remove the bedside commode and provide Resident #71 with a urinal to discourage self transfers. Observation of Resident #71's bedroom, immediately following the interview, revealed a bedside commode by the wall, beside the bed. RN #28 verified the bedside commode remained next to Resident #71's bed and reported therapy had previously been instructed to remove the bedside commode. 2. Observation on 02/05/19 at 6:05 P.M., on the secure memory care unit revealed an unlocked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 10 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication cart on the wall near the common area. Activities #137 was on the other side of the common area, towards the patio, playing cards with a group of five residents at a table and State Tested Nursing Assistants (STNAs) #51 and #64 were in and out of the common area transporting residents back from the dining room. No nurse was visible on the unit. Two independently mobile residents, without use of assistive devices, ambulated past the unlocked medication cart and Resident #70, independently propelled in a wheelchair, to the hall side of the medication cart, out of the view of staff, and placed an empty plastic cup on top of the medication cart. At approximately 6:08 P.M., Licensed Practical Nurse (LPN) #12 returned to the medication cart and acknowledge the medication cart was left unlocked without direct supervision. LPN #12 reported he/she was down the hall assisting a resident in a bedroom, and was out of sight of the unsecured medication cart. Review of Medication Storage facility policy, revised August 2014 revealed medications were to be stored safely, securely, and properly. The medication supply was only accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of memory care guidelines revealed the unit was a self-contained unit for all stages of dementia. Residents on the unit had met a variety of criteria including a diagnosis of dementia, an assessment indicating they might be at risk to elope, and/or a pattern of behaviors that might indicate the individual would benefit from a setting with more personalized, one-on-one care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 11 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on medical record review, observation, staff interview, drug manufacturer information, and pharmacy instructions, the facility failed to ensure expired medications were discarded, were labeled, and stored properly. This affected three (#38, #53, #56) of 29 residents on the 300 unit. The facility census was 111. Findings include: 1. Medical record review revealed Resident #38 had a physician order dated 02/25/17 for Latanoprost Solution 0.005 %, install one drop in both eye at bedtime for dry eyes. Observation on 02/07/19 at 10:50 A.M., of the 300 A medication cart with Licensed Practical Nurse (LPN) #96 revealed Latanoprost 0.005 percent (%) eye drops for Resident #38 was dated opened on 12/12/18. Interview with LPN #96 at the time of the observation verified the bottle was opened on 12/12/18 and reported Resident #38 received the medication routinely on a daily basis. Review of Latanoprost ophthalmic solution package insert revealed once a bottle was opened for use, it may be stored at room temperature for six weeks. 2. Review of Resident #53's Medication Administration Record (MAR) revealed Resident #53 received two units of Humalog insulin on 01/25/19 at 12:00 P.M. Further review of the 300 A medication cart on 02/07/19 at 10:50 A.M. with LPN #96 revealed a Humalog insulin 100 units/milliliter (ml) kwikpen for Resident #53 dated as opened on 12/23/18. Interview with LPN #96, at the time of the observation, verified the Humalog kwikpen was opened on 12/23/18. LPN #96 reported Resident #53 only received this insulin for sliding blood sugar coverage and was unsure how often Resident #53 required coverage. Review of Humalog insulin manufacturer instructions revealed to discard the in use Humalog pen after 28 days, even if it still had insulin left in it. 3. Continued review of the 300 A medication cart on 02/07/19 at 10:50 A.M., with LPN #96 revealed one unopened, undated Victoza 18 milligrams (mg) per three ml pen for Resident #56, stored in the cart. Interview with LPN #96, at the time of the observation, reported the pen must have been delivered during the night by pharmacy and had been placed in the medication cart instead of the refrigerator. Resident #56's medications were on the 300 B cart and LPN #96 reported there was an open Victoza pen being utilized for Resident #56 on that cart. Review of Victoza medication guides provided by pharmacy revealed store unopened Victoza in refrigerator. Once used or stored at room temperature, it must be discarded after 30 days as storage at room temperature shortens the expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 12 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview, and facility policy review, the facility failed to ensure bins of flour and sugar in the kitchen, food and drink items in the nourishment refrigerators were maintained in a manner to prevent and protect food against contamination and spoilage. This affected all but two (#49 and #303) residents residing in the facility identified by staff as being no food by mouth (NPO). The facility census was 111. Findings include: Observation and interview with Dietary Manager (DM) #32 of the kitchen on 02/04/19 at 8:59 A.M., revealed there to be a scoop in a bin of flour and a scoop in a bin of sugar. Interview with DM #32 at the time of the observation verified there were scoops in the flour and sugar bin. Observation and interview with DM #32 of the nourishment refrigerator on the 100 unit on 02/04/19 at 9:10 A.M., revealed one frozen water with a broken seal, which was not dated or labeled, three freezer burned hot dogs in a sandwich bag which were not dated or labeled, a frozen half consumed orange sports drink which was not dated or labeled, and three honey thickened cranberry juices which expired on 01/02/19. DM #32 confirmed the above observations. Observation and interview with DM #32 of the nourishment refrigerator on the 200 unit on 02/04/19 at 9:13 A.M., revealed one honey thickened cranberry juice with an expiration date of 01/02/19, two pieces of pumpkin pie which were individual wrapped with no date and an open water which was not labeled or dated. Interview with DM #32 at the time of the observation confirmed the above findings. Observation and interview with DM #32 of the nourishment refrigerator on the 400 unit on 02/04/19 at 9:15 A.M., revealed two honey thickened cranberry juice with an expiration date of 01/02/19, three frozen waters with broken seals which were not dated or labeled, and a salad which was covered with two plates and were not dated or labeled. Interview with DM #32 at the time of the observation verified the above findings. Review of the facility's undated handling and storage of refrigerator food products policy revealed all leftovers should be labeled, dated and used within seven days. Review of the facility's undated food storage refrigerators in nourishment rooms policy revealed all food that is stored in the refrigerators should be dated and labeled. The policy also revealed outdated or unlabeled items should be removed while stocking the refrigerators. Review of the undated facility's undated kitchen storage and cleaning policy revealed all scoops should be stored outside of storage bins. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 13 of 14 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on Legionella records, staff interviews, review of the facility's Legionella management plan, and facility policy review, the facility failed to implement their Legionella Management Plan. This had the potential to affect all 111 residents residing in the facility. Residents Affected - Many Findings include: Review of annual backflow test report dated 04/09/18 revealed water temperature logs with performance weekly on 01/08/18 through 03/19/18, 05/29/18 through 06/18/18, then 12/03/18 through 02/4/19. The report revealed housekeeping staff were to flush toilets and run water x two minutes in all empty rooms. Interview on 02/07/19 at 10:21 A.M., with Maintenance Staff (MS) #167 revealed he did not monitor the cold water temperatures annually, or flush the bottom drain valve quarterly per plan. He revealed he was unaware of the plan stating need to. The MS #167 reported he was unable to assess the chlorine as indicated in the plan since he did not have the equipment needed. He also acknowledged the water temperatures were not documented weekly from 03/19/18 through 05/29/18, nor from 06/18/18 through 12/03/18. Interview on 02/07/19 at 2:25 P.M., with Licensed Nursing Home Administrator (LNHA) verified she did not have any further documentation for the facility management plan. Review of Appendix B Legionella Management Plan revealed the following tasks- record tank and distal point temperatures quarterly, monitor cold water temperatures at entries annually/summer, record free chlorine residual monthly, flush and drain all outlets that are used less then weekly- weekly, inspect faucets and showerheads for presence of scales, slimes, and other deposits semi-annually, conduct backflow preventer inspection/testing annually, assure timely change-out of filtration elements on drinking fountains and ice machines per manufacturer. Review of the facility policy titled Infectious Disease-Legionnaires Disease, dated 10/08/17, revealed, after long-term control measures have been implemented, the facility must develop, and regularly reevaluate an environmental surveillance plan for Legionella (routine water monitoring) along with their plan for active care surveillance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 14 of 14