Inspection·April 6, 2023

F 0550 blood or see people getting stuck with needles, especially while she is eating her breakfast. Level of Harm - Minimal harm or potential for actual harm Interview on 04/04/23 at 2:32 P.M. with the Director of Nursing (DON) confirmed nurses should obtain permission from all residents at the table before checking blood sugars during mealtime. Residents Affected - Few Review of the facility policy titled Dignity dated 01/26/21 revealed the facility would ensure that each resident was cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. This deficiency represents non-compliance investigated under Complaint Number OH00141229. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 2 of 18 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 04/06/2023 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 0562 Provide immediate access to any resident. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and resident representative and staff interview, the facility failed to ensure immediate access to residents. This affected one (#33) of three residents reviewed for resident rights. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #33 revealed an admission date of 05/06/22 with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, epilepsy, major depressive disorder, and osteomyelitis. Review of the Minimum Data Set (MDS) for Resident #33 dated 02/08/23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's.) Interview on 04/04/23 at 1:12 P.M. with Resident #33's representative confirmed the facility did not always respond to phone calls including requests to access the resident/facility after hours in a timely manner. Observation on 04/05/23 at 5:46 A.M. revealed the front entrance to the facility was locked and there was a typed sign posted on the door which indicated the door was locked from 8:00 P.M. to 8:00 A.M. and to gain entrance to the facility the visitor had to call and request entrance. There were two local phone numbers posted. One was the main number for the facility, and the other number was for a call phone. Surveyor called the facility's main number at 5:48 A.M. and the phone rang multiple times but there was no answer. Surveyor called the cell phone number at 5:52 A.M. and the phone rang multiple times and then a voicemail greeting indicated the number had a voice mail box which had not been set up yet. Surveyor called the facility's main number at 5:52 A.M. and the phone rang multiple times with no answer. Surveyor called the cell phone number again at 5:54 A.M. with no response. Surveyor called the Administrator's cell phone (which was not posted) at 5:55 A.M., and the Administrator answered. Surveyor requested access to the facility, and the Administrator said she would reach out to staff in the building and have someone unlock the door so surveyor could access the facility. Observation revealed State Tested Nursing Assistance (STNA) #495 unlocked the front door and permitted Surveyor to enter the facility at 6:03 A.M. Interview on 04/05/23 at 6:03 A.M. with STNA #495 confirmed the cell phone number posted on the front door was for the supervisor's cell phone and there was no nursing supervisor on duty at the moment. Interview on 04/05/23 at 1:30 P.M. with the Administrator confirmed representatives of the State and resident representatives should be permitted immediate access to the residents. Administrator apologized for the delay the Surveyor experienced in gaining entry to the facility. Administrator confirmed they kept the building locked from 8:00 P.M. to 8:00 A.M. for security reasons and provided the main number so visitors could call to request access and the supervisor's cell phone number was also provided as a backup option. This deficiency represents non-compliance investigated under Complaint Number OH00140514. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 3 of 18 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 04/06/2023 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 record review, observation, resident representative and staff interview, and review of the facility policy, the facility failed to ensure resident representatives were notified promptly of changes in resident's condition. This affected one (#33) of three residents reviewed for resident rights. The facility census was 105. Findings include: Review of the medical record for Resident #33 revealed an admission date of 05/06/22 with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, epilepsy, major depressive disorder, and osteomyelitis. Review of the Minimum Data Set (MDS) for Resident #33 dated 02/08/23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of the April 2023 monthly physician orders for Resident #33 revealed an order dated 02/07/23 for resident to receive Isosource via feeding tube from 6:00 P.M. to 6:00 A.M. daily, an order dated 02/07/23 for resident to receive a bolus tube feeding of one 250 milliliter (ml) container of Isosource at 1:00 P.M. daily, and an order dated 12/26/22 for resident to receive gabapentin three times daily at 6:00 A.M., 1:00 P.M. and 6:00 P.M. Review of the April 2023 Medication Administration Record (MAR) for Resident #33 revealed the Isosource nocturnal tube feeding for 04/02/23 to 04/03/23 , the 1:00 P.M. bolus feeding of Isosource for 04/03/23, and the 1:00 P.M. dose of gabapentin were signed off as ordered. Review of the nurse progress note for Resident #33 dated 04/03/23 timed at 5:44 P.M. per Licensed Practical Nurse (LPN) #590 revealed resident's gastrostomy (g-tube) needed to be replaced and staff were not able to give med's or bolus tube feeding without it coming out the other side. Review of the nurse progress note for Resident #33 dated 04/04/23 timed at 6:32 A.M. revealed resident returned to facility from an emergency room visit for malfunctioning of g-tube. The resident's feeding tube was changed at the hospital and resident's tube was intact and functional. Review of hospital notes for Resident #33 dated 04/04/23 timed at 6:28 P.M. revealed resident arrived at the hospital via squad and presented with problems with his feeding tube. Resident #33 reported his feeding tube had been leaking since last night and the end cap of the tube was missing. Resident #33 was unsure what happened to the tube. Hospital replaced resident's g-tube and confirmed placement via x-ray, and the resident was returned to the facility on [DATE] at 5:23 A.M. Interview on 04/04/23 at 1:11 P.M. with Resident #33 and resident's representative confirmed he wanted his representative to be notified promptly of all changes in his care. Interview on 04/04/23 at 1:12 P.M. with Resident #33's representative confirmed the resident's gastrostomy tube had malfunctioned on 04/03/23 in the early morning hours and she was not notified in a timely manner of the resident's change in condition. Resident #33's representative confirmed the facility should notify her of all changes in condition and she learned of problem with resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 4 of 18 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 04/06/2023 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 g-tube on 04/03/23 at approximately 6:00 P.M. when she came to visit the resident and the staff was getting ready to send him out to the hospital to have the tube replaced. Resident #33's representative confirmed the nurse told her resident had not received his afternoon tube feeding or his afternoon dose of gabapentin because the tube was non-functioning. Interview on 04/05/23 at 9:13 A.M. with LPN #590 confirmed when she arrived at the facility on 04/03/23 at approximately 7:00 A.M. the night shift agency nurse told her Resident #33's g-tube was not functioning properly and his tube had been leaking all night. When LPN #590 went in to assess the resident at approximately 7:15 A.M. the nocturnal tube feeding was disconnected and there was a piece broken off the g-tube. LPN #590 confirmed she asked the supervisor if they could send the resident out to the hospital to have his tube replaced but supervisor told her to wait because she was going to try to figure out a way to repair the tube with replacement parts. LPN #590 confirmed they were not able to repair the tube and she tried to give resident a bolus feeding at 1:00 P.M. but it didn't work-the tube feeding would not go into the tube. LPN #590 confirmed she did not give the 1:00 P.M. dose of gabapentin. LPN #590 confirmed Resident #33's representative arrived to visit on 04/03/23 at approximately 6:00 P.M. which was at the same time the supervisor informed her the attending physician had given an order for resident to go to the hospital to have his g-tube replaced. LPN #590 confirmed Resident #33's representative expressed concern that no one had informed her Resident #33's g-tube had been non-functional since the nightshift on 04/03/23. LPN #590 confirmed the facility did notify Resident #33's representative in a timely manner that his feeding tube was non-functional and resident was unable to receive tube feeding and medications. Review of the facility policy titled Change of Resident Condition, Physician and Family Notification dated 01/2021 revealed the resident's responsible party will be notified in a timely manner regarding any significant change in status which warrants an alteration in treatment and possible transfer to an acute care setting. This deficiency represents non-compliance investigated under Complaint Number OH00141716. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 5 of 18 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 04/06/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident representative and staff interview, and review of the facility policy, the facility failed to ensure proper care and functioning of gastrostomy tubes (g-tubes.) This affected one (#33) of three residents reviewed for tube feedings. The facility census was 105. Findings include: Review of the medical record for Resident #33 revealed an admission date of 05/06/22 with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, epilepsy, major depressive disorder, and osteomyelitis. Review of the Minimum Data Set (MDS) for Resident #33 dated 02/08/23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of the care plan for Resident #33 dated 10/12/22 revealed resident had a percutaneous endoscopic gastrostomy (PEG) tube for enteral feeding related to dysphagia. Resident #33 has had to go to the emergency room to have tube replaced. Resident #33 had a history of pulling and tugging on the tube. and jamming the tip of the tube. Interventions included: abdominal binder if needed and as tolerated by resident, monitor tube feeding tolerance and document any gastrointestinal issues, provide tube feeding per orders, administer medications as ordered, monitor/document for side effects and effectiveness, provide local care to the g-tube site and monitor for any signs of infection Review of the April 2023 monthly physician orders for Resident #33 revealed an order dated 02/07/23 for the resident to receive Isosource via feeding tube from 6:00 P.M. to 6:00 A.M. daily, an order dated 02/07/23 for resident to receive a bolus tube feeding of one 250 milliliter (ml) container of Isosource at 1:00 P.M. daily, and an order dated 12/26/22 for resident to receive gabapentin three times daily at 6:00 A.M., 1:00 P.M. and 6:00 P.M. Review of the April 2023 Medication Administration Record (MAR) for Resident #33 revealed the Isosource nocturnal tube feeding for 04/02/23 to 04/03/23 , the 1:00 P.M. bolus feeding of Isosource for 04/03/23, and the 1:00 P.M. dose of gabapentin were signed off as ordered. Review of the nurse progress note for Resident #33 dated 04/03/23 timed at 5:44 P.M. per Licensed Practical Nurse (LPN) #590 revealed the resident's gastrostomy (g-tube) needed to be replaced and staff were not able to give med's or bolus tube feeding without it coming out the other side. Review of the nurse progress note for Resident #33 dated 04/04/23 timed at 6:32 A.M. revealed resident returned to facility from an emergency room visit for malfunctioning of g-tube. The resident's feeding tube was changed at the hospital and resident's tube was intact and functional. Review of hospital notes for Resident #33 dated 04/04/23 timed at 6:28 P.M. revealed the resident arrived at the hospital via squad and presented with problems with his feeding tube. Resident #33 reported his feeding tube had been leaking since last night and the end cap of the tube was missing. Resident #33 was unsure what happened to the tube. Hospital replaced resident's g-tube and confirmed placement via x-ray, and the resident was returned to the facility on [DATE] at 5:23 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 6 of 18 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 04/06/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/04/23 at 1:11 P.M. of Resident #33 revealed #33 resident was resting in his room with his representative at the bedside and his feeding tube was in place and intact. The tube was not hooked up to a tube feeding at the time of the observation. Interview on 04/04/23 at 1:11 P.M. with Resident #33 and resident's representative confirmed he wanted his representative to be included in discussions regarding his care. Resident #33 confirmed he had his g-tube replaced at the hospital the night before and the new tube was functioning properly. Interview on 04/04/23 at 1:12 P.M. with Resident #33's representative confirmed the resident's gastrostomy tube had malfunctioned on 04/03/23 in the early morning hours and she learned of problem with resident's g-tube on 04/03/23 at approximately 6:00 P.M. when she came to visit the resident and the staff was getting ready to send him out to the hospital to have the tube replaced. Resident #33's representative confirmed the nurse told her the resident had not received his afternoon tube feeding or his afternoon dose of gabapentin because the tube was non-functioning. Resident #33 representative confirmed prior to going to the hospital on [DATE] the caps were broken off the tube and it was covered with a plastic glove to keep stomach contacts from leaking out. Interview on 04/05/23 at 9:13 A.M. with LPN #590 confirmed when she arrived at the facility on 04/03/23 at approximately 7:00 A.M. the night shift agency nurse told her Resident #33's g-tube was not functioning properly and his tube had been leaking all night. When LPN #590 went in to assess the resident at approximately 7:15 A.M. the nocturnal tube feeding was disconnected and there was a piece broken off the g-tube. LPN #590 confirmed she asked the supervisor if they could send the resident out to the hospital to have his tube replaced but supervisor told her to wait because she was going to try to figure out a way to repair the tube with replacement parts. LPN #590 confirmed they were not able to repair the tube and she tried to give the resident a bolus feeding at 1:00 P.M. but it didn't work-the tube feeding would not go into the tube. LPN #590 confirmed she did not give the 1:00 P.M. dose of gabapentin. LPN #590 confirmed she placed a plastic glove over Resident #33's g-tube to keep stomach contents from leaking out. LPN #590 confirmed at approximately 6:00 P.M. on 04/03/23 the supervisor informed her the attending physician had given an order for resident to go to the hospital to have his g-tube replaced. Resident #33 was transported to the hospital via 911. Review of the facility policy titled Enteral Feeding Dated 02/28/20 enteral feedings will be provided according to physician's orders to assist the resident in meeting daily nutritional intake requirements. This deficiency represents non-compliance investigated under Complaint Number OH00141716. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 7 of 18 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 04/06/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure resident's pain was appropriately managed. This affected one (#106) of three residents reviewed for pain management. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #106 revealed an admission date of 11/29/22 with a diagnosis of aftercare following joint replacement surgery, presence of right knee artificial joint, unilateral primary osteoarthritis (OA). Review of the Minimum Data Set (MDS) for Resident #106 dated 12/03/22 revealed the resident was cognitively intact and required extensive assistance with activities of daily living (ADL's). Review of the MDS revealed the resident was coded for almost constant pain which was rated as eight on a scale of one to 10 with 10 being the worst pain. Review of the hospital continuity of care form for Resident #106 dated 11/29/22 revealed resident received oxycodone for pain on 11/29/22 at 10:12 A.M. before leaving the hospital to travel by ambulance to the facility. Resident #106 had a right total knee replacement on 11/28/22. Review of the admission nursing assessment for Resident #106 dated 11/29/22 timed at 11:53 A.M. revealed the resident complained of right knee pain which she rated as eight on a scale of one to 10. Review of the November 2022 admission orders for Resident #106 dated 11/29/22 revealed an order for oxycodone five milligrams (mg) every four hours as needed for pain. Review of the orders revealed there were no other orders for pain medication or non-pharmacological measures to be given for pain. Review of the emergency box controlled substance sheet for Resident #106 dated 11/29/22 revealed a five mg dose of oxycodone was pulled from the emergency supply for Resident #106 at 3:25 P.M. Review of the care plan for Resident #106 dated 11/30/22 revealed the resident was at risk for pain due to joint replacement surgery and generalized discomfort. Resident #106 remains at risk for fluctuations and potential for adverse effects related to medication therapy. Interventions included the following: administer analgesia as ordered, evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, monitor/document for side effects/adverse effects of pain medication, observe for constipation, urinary retention, new onset or increased agitation, restlessness, confusion, hallucinations, sedation, respiratory distress, dysphoria, nausea, vomiting, pruritus, dizziness and falls. Report occurrences to the physician, ask physician to review medication if side effects/adverse effects persist, offer and implement non-drug interventions to help manage pain/discomfort including food/drink, rest, and repositioning; monitor for effectiveness. Review of the November 2022 Medication Administration Record (MAR) for Resident #106 revealed pain scaled completed for resident for dayshift on 11/29/22 was for resident pain of a level eight on a scale of one to 10. Pain level on evening shift for 11/29/22 was a level nine on a scale of one to 10. Resident received oxycodone on 11/29/22 at 3:25 P.M. and 9:51 P.M. Resident #106 had no other pain medications ordered and MAR did not include nonpharmacological interventions for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 8 of 18 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 04/06/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the November 2022 Treatment Administration Record (TAR) for Resident #106 revealed the TAR did not include nonpharmacological interventions for pain. Review of the nurse progress note for Resident #106 dated 11/29/22 timed at 12:49 P.M. revealed the nurse verified the admitting orders with the attending physician with no changes from the hospital continuity of care form. Orders were faxed to pharmacy at this time. There was no documentation in the nurses' notes of nonpharmacological interventions for pain. Interview on 04/05/23 at 8:00 A.M. with Registered Nurse (RN) #500 confirmed she was the admitting nurse when Resident #106 arrived to the facility from the hospital following a right total knee replacement on 11/29/22 at approximately 11:53 A.M. RN #500 confirmed she assessed resident's pain to her right knee immediately upon resident's arrival to the facility, and resident reported her pain was eight on a scale of one to 10. RN #500 confirmed the facility called the doctor to verify resident's admitting orders but did not report the high pain level to the doctor and/or request additional options for pain management. RN #500 confirmed there was a delay in being able to pull oxycodone from the emergency supply because they had to wait until the pharmacy gave the authorization to pull the medication. RN #500 confirmed Resident #106 received oxycodone at 3:25 P.M. but did not receive anything else for pain sooner, including non-pharmacological interventions, because nothing else was ordered. Interview on 04/05/23 at 1:18 P.M. with the Administrator confirmed the facility did not have a pain management policy, and the facility assessed residents for pain on a daily basis and managed pain based on input from the attending physician and based on physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00141072. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 9 of 18 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 04/06/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident representative and staff interview, and review of the facility policy, the facility failed to ensure residents received medications as ordered by the physician. This affected one (#33) of three residents reviewed for medications The facility census was 105. Findings include: Review of the medical record for Resident #33 revealed an admission date of 05/06/22 with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, epilepsy, major depressive disorder, and osteomyelitis. Review of the Minimum Data Set (MDS) for Resident #33 dated 02/08/23 revealed the resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of the care plan for Resident #33 dated 05/11/22 revealed the resident has chronic back pain with right side sciatica, and bilateral lower extremity contracture's. Interventions included the following: administer analgesia (medication) as per orders. Give one half hour before treatments or care, monitor and document the side effects of the medication. Review of the care plan for Resident #33 dated 10/12/22 revealed the resident had a percutaneous endoscopic gastrostomy (PEG) tube for enteral feeding related to dysphagia. Resident #33 has had to go to the emergency room to have tube replaced. Resident #33 had a history of pulling and tugging on the tube and jamming the tip of the tube. Interventions included the following: abdominal binder if needed and as tolerated by resident, monitor tube feeding tolerance and document any gastrointestinal issues, provide tube feeding per orders, administer medications as ordered, monitor/document for side effects and effectiveness, provide local care to the g-tube site and monitor for any signs of infection Review of the April 2023 monthly physician orders for Resident #33 revealed an order dated 12/26/22 for the resident to receive gabapentin three times daily at 6:00 A.M., 1:00 P.M. and 6:00 P.M. for low back pain. Review of the April 2023 Medication Administration Record (MAR) for Resident #33 revealed the 1:00 P.M. dose of gabapentin was signed off as administered. Review of the nurse progress note for Resident #33 dated 04/03/23 timed at 5:44 P.M. per Licensed Practical Nurse (LPN) #590 revealed resident's gastrostomy (g-tube) needed to be replaced and staff were not able to give med's or bolus tube feeding without it coming out the other side. Review of the nurse progress note for Resident #33 dated 04/04/23 timed at 6:32 A.M. revealed the resident returned to facility from an emergency room visit for malfunctioning of g-tube. The resident's feeding tube was changed at the hospital and resident's tube was intact and functional. Review of hospital notes for Resident #33 dated 04/04/23 timed at 6:28 P.M. revealed the resident arrived at the hospital via squad and presented with problems with his feeding tube. Resident #33 reported his feeding tube had been leaking since last night and the end cap of the tube was missing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 10 of 18 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 04/06/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #33 was unsure what happened to the tube. Hospital replaced resident's g-tube and confirmed placement via x-ray, and the resident was returned to the facility on [DATE] at 5:23 A.M. Observation on 04/04/23 at 1:11 P.M. of Resident #33 revealed resident was resting in his room with his representative at the bedside and his feeding tube was in place and intact. The tube was not hooked up to a tube feeding at the time of the observation. Interview on 04/04/23 at 1:11 P.M. with Resident #33 and resident's representative confirmed he wanted his representative to be included in discussions regarding his care. Resident #33 confirmed he had his g-tube replaced at the hospital the night before and the new tube was functioning properly and the nurse did not administer his 1:00 P.M. dose of gabapentin on 04/04/23 because his g-tube wasn't working. Interview on 04/04/23 at 1:12 P.M. with Resident #33's representative confirmed the resident's gastrostomy tube had malfunctioned on 04/03/23 in the early morning hours and she learned of problem with resident's g-tube on 04/03/23 at approximately 6:00 P.M. when she came to visit the resident and the staff was getting ready to send him out to the hospital to have the tube replaced. Resident #33's representative confirmed the nurse told her the resident had not received his afternoon dose of gabapentin because the tube was non-functioning. Resident #33's representative confirmed prior to going to the hospital on [DATE] the caps were broken off the tube and it was covered with a plastic glove to keep stomach contacts from leaking out. Interview on 04/05/23 at 9:13 A.M. with LPN #590 confirmed when she arrived at the facility on 04/03/23 at approximately 7:00 A.M. the night shift agency nurse told her Resident #33's g-tube was not functioning properly and his tube had been leaking all night. When LPN #590 went in to assess the resident at approximately 7:15 A.M. the nocturnal tube feeding was disconnected and there was a piece broken off the g-tube. LPN #590 confirmed she asked the supervisor if they could send the resident out to the hospital to have his tube replaced but supervisor told her to wait because she was going to try to figure out a way to repair the tube with replacement parts. LPN #590 confirmed they were not able to repair the tube and she tried to give resident a bolus feeding at 1:00 P.M. but it didn't work-the tube feeding would not go into the tube. LPN #590 confirmed she did not give the 1:00 P.M. dose of gabapentin. LPN #590 confirmed she placed a plastic glove over Resident #33's g-tube to keep stomach contents from leaking out. LPN #590 confirmed at approximately 6:00 P.M. on 04/03/23 the supervisor informed her the attending physician had given an order for resident to go to the hospital to have his g-tube replaced. Resident #33 was transported to the hospital via 911. Review of the facility policy titled Medication Administration dated 02/05/20 revealed licensed nurses would administer med's in a safe and effective manner and as ordered. This deficiency represents non-compliance investigated under Complaint Numbers OH00141716, OH00141229 and OH00141072. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 11 of 18 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 04/06/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the facility policy, and review of an online medication resource, the facility failed to ensure appropriate monitoring in conjunction with administration of the anticoagulant, Coumadin. This affected one (#36) of three residents reviewed for Coumadin administration. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 07/15/21 with diagnoses including cerebral infarction and vascular dementia. Review of the Minimum Data Set (MDS) for Resident #36 dated 02/19/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's). Review of the care plan for Resident #36 dated 03/06/23 revealed resident was on anticoagulant therapy related to history of cerebrovascular accident (CVA). Interventions included the following: antidote is Vitamin K, have on hand for emergencies, daily skin inspection, report abnormalities to the nurse, labs as ordered, report abnormal lab results to the physician, monitor/document/report to physician as needed signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the April 2023 monthly physician orders for Resident #36 revealed an order dated 11/29/22 for the resident to take Coumadin seven milligrams (mg) at bedtime daily due to presence of automatic implantable cardiac defibrillator and an order dated 11/13/22 for a Prothrombin Time/International Normalized Ratio (PT/INR) every two weeks on Mondays. Review of the PT/INR lab results for Resident #36 revealed lab dated 02/20/23 results were PT=23.8, INR=2.1. Lab results dated 03/30/23 were PT=25.4, INR=2.3. Lab results dated 04/03/23 were PT=35, INR=3.2. There were no PT/INR results for Monday, 03/06/23. Review of the nurse progress note for Resident #36 dated 04/05/23 timed at 3:15 P.M. per Licensed Practical Nurse (LPN) #800 revealed nurse faxed the high INR results for 04/03/23 to Nurse Practitioner (NP) #885 in the evening on 04/03/23. Review of the fax cover sheets for communication of high INR results for Resident #36 revealed lab results were faxed on 04/03/23 at 5:18 P.M., 6:04 P.M., and 8:00 P.M. Review of the April 2023 Medication Administration Record (MAR) for Resident #26 revealed resident received seven mg of Coumadin on 04/04/23 at bedtime and the most recent INR result at the time of administration was recorded in the MAR as 2.3. Review of nurse progress note for Resident #36 dated 04/05/23 timed at 2:16 P.M. per Corporate Nurse (CN) #880 revealed resident's attending physician was notified of the high INR results for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 12 of 18 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 04/06/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident dated 04/03/23 which had not been addressed. Physician gave an order for a stat PT/INR and to hold Coumadin until results are received. Physician also noted if nurses are unable to reach the nurse practitioner (NP) they should call the attending physician or the facility medical director. Review of nurse progress note for Resident #36 dated 04/05/23 timed at 6:25 P.M. revealed the nurse was contacted by lab that blood that was drawn today for PT/INR was hemolyzed. Nurse contacted NP #885 and she gave an order to redraw blood in the morning on 04/06/23. Review of the nurse progress note for Resident #36 dated 04/06/23 timed at 9:37 A.M. revealed lab had not come out yet to draw blood for PT/INR for resident. Interview on 04/05/23 at 12:35 P.M. with CN #880 confirmed Resident #36 should have had a PT/INR drawn on 03/06/23 per physician's routine order but this did not occur due to an oversight/error. CN #880 confirmed PT/INR drawn on 04/03/23 for Resident #36 was high with an INR at 3.2. CN #880 confirmed there was no documentation of physician notification of the abnormal lab results. CN #880 confirmed Resident #36's April 2023 MAR indicates Coumadin was administered at 9:00 P.M. on 04/04/23 and the INR recorded at the time of administration was 2.3 which was the INR result from 03/20/23, not 04/03/23. Interview on 04/05/23 at 1:16 P.M. with CN #880 confirmed she notified the attending physician of Resident #36's high INR result on 04/03/23. CN #880 confirmed she notified the physician that agency LPN #890 administered seven mg of Coumadin to resident at 9:00 P.M. on 04/03/23. Physician gave order for the resident to have a stat PT/INR drawn and to hold Coumadin until results were received. Physician said if NP did not respond, staff should call him or the facility Medical Director. CN #880 confirmed she spoke with the nurse supervisor on 04/03/23, LPN #800 who confirmed she had faxed the high PT/INR results to NP #885 three times on 04/03/23 but did not receive a response. Interview on 04/06/23 at 12:43 P.M. with LPN #800 confirmed she faxed the high PT/INR results to NP #885 three times on 04/03/23 between 5:00 P.M. and 8:00 P.M. but she did not get a response. LPN #800 confirmed she did not document the high INR in Resident #36's record until 04/05/23. LPN #800 confirmed she verbally told the agency nurse to wait to give the Coumadin until they heard back from the doctor, but she did not document any of this. Review of the facility policy titled Coumadin Administration dated 01/26/21 revealed Coumadin will be administered by licensed nurses and laboratory monitoring will be completed and dosage adjustments will be made according to physician's order. Review of online resource Medscape at https://reference.medscape.com/drug/coumadin-jantoven-warfarin-342182#5 revealed Coumadin had a black box warning, because the medication could cause major or fatal bleeding particularly with a higher dose resulting in a higher INR. Risk factors for bleeding include high intensity of anticoagulation (INR greater than four), age [AGE] years or older, highly variable INR's, history of gastrointestinal bleeding, hypertension, cerebrovascular disease, serious heart disease, anemia, malignancy, trauma, renal insufficiency, concomitant drugs, and long duration of Coumadin therapy. Regular monitoring of INR should be performed on all treated patients, and those at high risk of bleeding may benefit from more frequent INR monitoring. Careful dose adjustment to desired INR's should be made. Patients should be instructed about prevention measures to minimize the risk of bleeding and to immediately report any signs or symptoms of bleeding to their physician. This deficiency represents non-compliance investigated under Complaint Number OH00141072. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 13 of 18 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 04/06/2023 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 - Few 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 record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were not left unattended. This affected two (#36 and #38) of four residents observed for medication administration. The census was 105. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 02/9/23 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #38 dated 03/13/23 revealed resident was cognitively intact and required extensive assistance of one staff with activities of daily living (ADL's). Review of the April 2023 monthly physician orders for Resident #38 revealed an order dated 02/27/23 for resident to receive Miralax 17 grams mixed in water once daily. Observation of medication administration on 04/04/23 at 8:30 A.M. in the dining room revealed Licensed Practical Nurse (LPN) #875 administered resident's oral tablet medications in a plastic cup and gave resident a cup of water mixed with the dose of Miralax to wash down the tablets. Resident #38 swallowed the tablets and still had approximately half a cup of water and Miralax remaining. LPN #875 left the dining room leaving the medication unattended and went back to the medication cart which was in the hallway. LPN #875 did not stay to ensure the entire resident consumed the entire dose of Miralax. 2. Review of the medical record for Resident #36 revealed an admission date of 07/15/21 with diagnoses including cerebral infarction and vascular dementia. Review of the MDS for Resident #36 dated 02/19/23 revealed resident was cognitively intact and required limited assistance of one staff with ADL's. Review of the April 2023 monthly physician orders for Resident #38 revealed an order dated 12/26/22 for resident to receive Miralax 17 grams mixed in water once daily. Observation of medication administration on 04/04/23 at 8:34 A.M. inside Resident #36's room revealed LPN #875 administered resident's oral tablet medications in a plastic cup and gave resident a cup of water mixed with the dose of Miralax to wash down the tablets. Resident #36 swallowed the tablets and still had approximately half a cup of water and Miralax remaining. LPN #875 left the resident's room leaving the medication unattended and went back to the medication cart. LPN #875 did not stay to ensure the entire resident consumed the entire dose of Miralax. Interview on 04/04/23 at 8:40 A.M. of LPN #875 confirmed Residents #36 and #38 did not have orders to self-administer Miralax. LPN #875 confirmed she did not observe Residents #36 and #38 to ensure the entire dose of Miralax was consumed. Interview on 04/04/23 at 2:32 P.M. with the Director of Nursing (DON) confirmed nurses should not leave medications unattended and should stay with the resident to ensure the entire dose of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 14 of 18 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 04/06/2023 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 medication is consumed. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Medication Storage dated 02/25/20 revealed medications are stored safely, securely, and properly. Residents Affected - Few Review of the facility policy titled Medication Administration dated 02/05/20 revealed nurses should administer med's in a safe and effective manner, and the medication cart is locked at all times unless in use and under the direct observation of the medication nurse. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 15 of 18 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 04/06/2023 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and review of the facility policy, the facility failed to ensure lab tests were obtained as ordered. This affected one (#36) of three residents reviewed for laboratory testing. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 07/15/21 with diagnoses including cerebral infarction and vascular dementia. Review of the Minimum Data Set (MDS) for Resident #36 dated 02/19/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's). Review of the care plan for Resident #36 dated 03/06/23 revealed resident was on anticoagulant therapy related to history of cerebrovascular accident (CVA). Interventions included the following: antidote is Vitamin K, have on hand for emergencies, daily skin inspection, report abnormalities to the nurse, labs as ordered, report abnormal lab results to the physician, monitor/document/report to physician as needed signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the April 2023 monthly physician orders for Resident #36 revealed an order dated 11/29/22 for resident to take Coumadin seven milligrams (mg) at bedtime daily due to presence of automatic implantable cardiac defibrillator and an order dated 11/13/22 for a Prothrombin Time/International Normalized Ratio (PT/INR) every two weeks on Mondays. Review of the PT/INR lab results for Resident #36 revealed lab dated 02/20/23 results were PT=23.8, INR=2.1. Lab results dated 03/30/23 were PT=25.4, INR=2.3. Lab results dated 04/03/23 were PT=35, INR=3.2. There were no PT/INR results for Monday, 03/06/23. Interview on 04/05/23 at 12:35 P.M. with Corporate Nurse (CN) #880 confirmed Resident #36 should have had a PT/INR drawn on 03/06/23 per physician's routine order but this did not occur due to an oversight/error. Review of the facility policy titled Coumadin Administration dated 01/26/21 revealed Coumadin will be administered by licensed nurses and laboratory monitoring will be completed and dosage adjustments will be made according to physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00141072. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 16 of 18 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 04/06/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review, staff interview and review of the facility policy, the facility failed to ensure residents' medical record included significant clinical information regarding changes in condition. This affected one (#36) of three residents reviewed for medical records. The facility identified three residents with orders for Coumadin. The facility census was 105. Findings include: Review of the medical record for Resident #36 revealed an admission date of 07/15/21 with diagnoses including cerebral infarction and vascular dementia. Review of the Minimum Data Set (MDS) for Resident #36 dated 02/19/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's). Review of the care plan for Resident #36 dated 03/06/23 revealed resident was on anticoagulant therapy related to history of cerebrovascular accident (CVA). Interventions included the following: antidote is Vitamin K, have on hand for emergencies, daily skin inspection, report abnormalities to the nurse, labs as ordered, report abnormal lab results to the physician, monitor/document/report to physician as needed signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the April 2023 monthly physician orders for Resident #36 revealed an order dated 11/29/22 for resident to take Coumadin seven milligrams (mg) at bedtime daily due to presence of automatic implantable cardiac defibrillator and an order dated 11/13/22 for a Prothrombin Time/International Normalized Ratio (PT/INR) every two weeks on Mondays. Review of the PT/INR lab results for Resident #36 revealed lab dated 02/20/23 results were PT=23.8, INR=2.1. Lab results dated 03/30/23 were PT=25.4, INR=2.3. Lab results dated 04/03/23 were PT=35, INR=3.2. There were no PT/INR results for Monday, 03/06/23. Review of the April 2023 Medication Administration Record (MAR) for Resident #26 revealed resident received seven mg of Coumadin on 04/04/23 at bedtime and the most recent INR result at the time of administration was recorded in the MAR as 2.3. Review of nurse progress note for Resident #36 dated 04/05/23 timed at 2:16 P.M. per Corporate Nurse (CN) #880 revealed resident's attending physician was notified of the high INR results for resident dated 04/03/23 which had not been addressed. Physician gave an order for a stat PT/INR and to hold Coumadin until results are received. Physician also noted if nurses are unable to reach the nurse practitioner (NP) they should call the attending physician or the facility medical director. Interview on 04/05/23 at 12:35 P.M. with CN #880 confirmed PT/INR drawn on 04/03/23 for Resident #36 was high with an INR at 3.2. CN #880 confirmed there was no documentation of physician notification of the abnormal lab results. CN #880 confirmed Resident #36's April 2023 MAR indicates Coumadin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 17 of 18 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 04/06/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was administered at 9:00 P.M. on 04/04/23 and the INR recorded at the time of administration was 2.3 which was the INR result from 03/20/23, not 04/03/23. Interview on 04/05/23 at 1:16 P.M. with CN #880 confirmed she notified the attending physician of Resident #36's high INR result on 04/03/23. CN #880 confirmed she notified the physician that agency LPN #890 administered seven mg of Coumadin to resident at 9:00 P.M. on 04/03/23. Physician gave order for resident to have a stat PT/INR drawn and to hold Coumadin until results were received. Physician said if NP did not respond, staff should call him or the facility Medical Director. CN #880 confirmed she spoke with the nurse supervisor for 04/03/23, LPN #800 who confirmed she had faxed the high PT/INR results to NP #885 three times on 04/03/23 but did not receive a response. CN #880 confirmed Resident #36's medical record did not include documentation of NP notification of the abnormal lab results dated 04/03/23. Interview on 04/06/23 at 12:43 P.M. with LPN #800 confirmed she faxed the high PT/INR results to NP #885 three times on 04/03/23 between 5:00 P.M. and 8:00 P.M. but she did not get a response. LPN #800 confirmed she did not document the high INR in Resident #36's record until 04/05/23. LPN #800 confirmed she verbally told the agency nurse to wait to give the Coumadin until they heard back from the doctor, but she did not document any of this in the medical record on 04/03/23. Review of the facility policy titled Change of Resident Condition, Physician and Family Notification dated 01/2021 revealed the nurse would document in the resident's medical record information relative to the changes in the resident including assessment and notification of changes. This deficiency represents non-compliance investigated under Complaint Numbers OH00141072 and OH00140514. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366432 If continuation sheet Page 18 of 18