Health inspection·April 25, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure medications were discarded after their expiration date. This affected one (#59) of three residents observed for medication administration and also affected four (#1, #38, #72, and #368) of 30 residents who received medication from the 200 hall medication cart. The facility census was 114. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of [DATE]. Diagnoses included type two diabetes mellitus (DM II), Alzheimer's disease, and atrial fibrillation. Review of the physician order dated [DATE] revealed Resident #59 was ordered Novolog Solution 100 unit/milliliter (ml), inject per sliding scale subcutaneously two times a day for diabetes. Observation on [DATE] at 2:48 P.M. of medication cart on 400 hall revealed Resident #59's Novolog vial was opened on [DATE], indicating the insulin was expired. Interview on [DATE] at 2:53 P.M. with Licensed Practical Nurse (LPN) #138 verified Resident #59's insulin was expired. 2. Review of the medical record for Resident #72 revealed an admission date of [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, traumatic subarachnoid hemorrhage without loss of consciousness. Review of the physician order dated [DATE] revealed Resident #72 was ordered Pro-stat one time a day for nutrition support, preventative measure 30 milliliters (ml) via PEG tube daily. Observation on [DATE] at 3:14 P.M. of medication cart on 200 hall revealed Resident #72 was given over-the-counter Pro-stat that had expired on [DATE]. Interview on [DATE] at 3:17 P.M. with LPN #128 verified Resident #72's Pro-stat was expired and needed to be discarded. 3. Review of the medical record for Resident #368 revealed an admission date of [DATE]. Diagnoses congestive heart failure (CHF), type two diabetes mellitus (DM II), and peripheral vascular disease (PVD). Page 1 of 7 366432 366432 04/25/2024 Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231

F 0761 Level of Harm - Minimal harm or potential for actual harm Review of the physician order dated [DATE] revealed Resident #368 was ordered Pro-stat 30 milliliters (ml) two times a day for low pre-albumin level. Observation on [DATE] at 3:21 P.M. of medication cart on 300 hall revealed Resident #368 was given over-the-counter Pro-stat that had expired on [DATE]. Residents Affected - Some Interview on [DATE] at 3:24 P.M. with Registered Nurse (RN) #74 verified Resident #368's Pro-stat was expired and needed to be discarded. 4. Review of the medical record for Resident #1 revealed an admission date of [DATE]. Diagnoses included congestive heart failure (CHF), atrial fibrillation, type two diabetes mellitus (DM II), and moderate-protein calorie malnutrition. Review of the physician order dated [DATE] revealed Resident #1 was ordered Pro-stat 30 milliliters (ml) twice a day for low pre-albumin level. Observation on [DATE] at 3:25 P.M. of medication cart on 300 hall revealed Resident #1 was given over-the-counter Pro-stat that had expired on [DATE]. Interview on [DATE] at 3:26 P.M. with RN #74 verified Resident #1's Pro-stat was expired and needed to be discarded. 5. Review of the medical record for Resident #38 revealed an admission date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), osteoporosis, emphysema, and anxiety disorder. Review of the physician order dated [DATE] revealed Resident #38 was ordered Fish Oil Capsule 1000 milligrams (mg), give one capsule by mouth one time a day for supplement. Observation on [DATE] at 3:27 P.M. of medication cart on 300 hall revealed Resident #38 was given over-the-counter Fish Oil 1,000 mg that had expired in [DATE]. Interview on [DATE] at 3:28 P.M. with RN #74 verified Resident #38's Fish Oil was expired and needed to be discarded. Review of the facility policy titled, Medication Storage, dated [DATE] revealed medications and biological's were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order existed. 366432 Page 2 of 7 366432 04/25/2024 Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #88 on 04/24/24 revealed she was admitted to the facility on [DATE] with a diagnosis of benign neoplasm of meninges, diabetes type II, major depressive disorder, hypertensive retinopathy, and repeated falls. Residents Affected - Few Review of the Resident #88's MDS assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders dated 10/18/23 revealed laboratory work (complete blood count, comprehensive metabolic panel, and hemoglobin A1C to be completed every four months on the 18th. Review of the laboratory work orders revealed the facility failed to complete the blood work in February 2024 as ordered. Interview with the Administrator on 04/24/24 at 11:58 A.M. revealed the facility is changing laboratory companies next month and the blood work was missed in February 2024 for Resident #88. Review of the facility policy titled, Laboratory Testing dated 01/09/21 revealed physician ordered laboratory testing will be completed timely and results will be communicated to the physician. Based on medical record review, staff interviews and policy review, the facility failed to ensure blood work was completed as ordered. This affected two (#23 and #88) out of five residents reviewed for laboratory services. Facility census was 114. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 02/02/21. Diagnoses included dementia, peripheral vascular disease (PVD), psychosis, atrial fibrillation, anxiety disorder, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the physician order dated 10/13/23 revealed Resident #23 was ordered to obtain complete blood count (CBC), complete metabolic panel (CMP), thyroid stimulating hormone (TSH), Fasting Lipid Panel (FLP), creatine kinase (CK), A1C, Vitamin D, Folate, and Vitamin B12 every four months. Review of the laboratory work order dated 10/17/23 revealed Resident #23 received the blood work ordered by the physician. Further review of Resident #23's laboratory work revealed the facility did not obtain the ordered laboratory work as ordered in February 2024. Interview on 04/24/24 at 12:43 P.M. with the Director of Nursing (DON) revealed Resident #23 had labs drawn on 10/17/23 and the order was for the resident to receive the blood work every four months. 366432 Page 3 of 7 366432 04/25/2024 Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231

F 0770 The DON confirmed the facility did not obtain Resident #23's labs in February 2024 as ordered. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366432 Page 4 of 7 366432 04/25/2024 Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews and policy review, the facility failed to store, prepare, distribute, and serve foods in a sanitary manner and in accordance with the facility policies. This had the potential to affect all 114 residents who received food from the kitchen. Facility census was 114. Findings include: 1. Observations of the facility kitchen on 04/22/24 8:20 A.M., revealed the following areas of concern: a. There was no temperature log of the dishwasher temperatures for the month of April 2024 through the past six months. b. The ice machine, which provided ice to the entire facility, had a pink wet substance on the inside of the ice storage bin which was touching the ice. c. In the walk-in refrigerator, there was no thermometer, and eight bags of undated and unlabeled food. There was a container of opened coleslaw with expiration date of 04/14/24. There were 22 wrapped plates of unlabeled and undated food. The refrigerator temperature log for April 2024 had no daily entry past 04/22/24. d. The walk-in freezer temperature log for April 2024 had no daily entry past 04/22/24. e. In the dry food storage area, there were six boxes of rice with expiration date of April 2022. There were two opened, undated, bottles of vinegar and cooking wine. There was an unlabeled bulk container of dry food. f. The food temperature log, used to ensure food temperatures were safe for meal service, was not completed for multiple dates and meals in April 2024. This included dates, but limited to, lunch and dinner meals of 04/04/24, 04/06/24, 04/08/24, 04,09/24, 04/14/24, 04/15/24, and 04/22/24. Interview on 04/22/24 at 8:30 A.M. with Dietary Manager, (DM) # 300 verified the observations of the kitchen on 04/22/24. DM #300 stated he was an interim DM as the previous DM had vacated the position two weeks ago. The facility confirmed all 114 residents receive their meals/food from the kitchen. 2. Observation on 04/24/24 at 9:30 A.M. revealed [NAME] #60, put pieces of chicken into the blender with gloved hands. [NAME] #60 pureed the chicken, and put the chicken into holding container, by touching the blender, the counter, and serving container with gloved hands. [NAME] #60 proceeded to put more chicken in the blender with the same gloved hands, touching the blender, counter and serving container. [NAME] #60 took the blender container to the dishwasher and reassembled the blender, by inserting the clean service blade of the blender, with the same gloved hands. Vegetables were added, by [NAME] #60 touching some of the vegetables, to the service blade of the blender with the same gloved hands. [NAME] #60 added bread to the vegetables with the same gloved hands and proceeded to puree the vegetables. The observations revealed [NAME] #60 did not change gloves or perform hand hygiene at any time of the food pureeing process. 366432 Page 5 of 7 366432 04/25/2024 Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231

F 0812 Level of Harm - Minimal harm or potential for actual harm Interview on 04/24/24 at 10:24 [NAME] #60 verified he had not changed his gloves and/or did not perform hand hygiene during the entire process of pureeing the chicken and vegetables. [NAME] #60 verified he should have changed gloves between touching the chicken, touching the bread, and in between reassembling the blender blade. Residents Affected - Many 3. Observations of the kitchen on 04/24/24 at 12:14 P.M. revealed the following areas of concern: a. There were orange, pink and black wet substances, consistent with the appearance of mold, on the walls behind and around the dishwasher and under drain table. b. The floor drains of the three-compartment sink, in the dish room, had orange and black set substances, consistent with the appearance of mold and food debris. c. The stove top had a black, wet buildup of debris under and around the eight stove burners. d. The walls near the pan storage racks had brown dried drips of debris consistent with food spatters. e. The sanitation bucket, used for sanitation of food prep surfaces, tested at 50 parts per million, (PPM) by DM #300. DM #300 stated the sanitation bucket had not been emptied and refilled with sanitizer since the early morning of 04/24/24. Interview on 04/24/24 at 12:14 P.M. DM #300 verified the dish room area, floor drain and walls need cleaned. DM #300 verified the sanitation bucket tested at 50 PPM, should have been changed after each meal and should have tested at 200 PPM. DM #300 verified there were no cleaning schedules for April 2024 and no previous cleaning schedules were provided. 4. Observations of on 04/24/24 at 12:47 P.M. through 1:15 P.M. revealed the following areas of concern: a. The Unit 100 resident designated refrigerator did not have temperature log for April 2024. There was a insulated lunch box unlabeled and undated stored in the refrigerator. b. The Unit 400 resident designated refrigerator had a plate of food, unlabeled and undated. Interview on 04/24/24 at 12:50 P.M., State Tested Nurse Aide, (STNA) #275 identified the lunch box in Unit 100 resident refrigerator and verified the employees are not permitted to store personal food items in the resident designated refrigerator. Interview on 04/24/24 at 1:15 P.M. Maintenance Director, (MD) #190 verified the employees are not to store personal food items in the resident designated refrigerators and all food items are to be labeled and dated. MD #190 verified all refrigerators should have a daily temperature log to ensure the refrigerator is holding stored foods at a safe temperature. MD #190 verified the ice machine is to be cleaned monthly, including removal any pink substance from inside the ice bin. MD #190 further verified the pink, orange and black substances on the walls around the dish machine and in the floor drain, were consistent with the appearance of mold. MD #190 stated the dish machine hood had not been removing the steam appropriately from the dish machine room. Review of undated facility policy titled, Facility Walk-in and Resident Refrigerator, revealed 366432 Page 6 of 7 366432 04/25/2024 Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231

F 0812 Level of Harm - Minimal harm or potential for actual harm temperatures will be logged daily in resident refrigerator, and no staff food will be co-mingled with resident foods. Review of facility policy titled, Storage and Dispensing of Ice, dated 2023, revealed the ice dispenser will be cleaned and sanitized inside of the machine at least monthly. Residents Affected - Many Review of facility policy titled, Employee Hygiene for Food Safety, dated 2023, revealed all employees will use utensils to handle food, and will use disposable single use gloves. Hands must be washed prior to using gloves and after removing gloves. Avoid touching items while preparing food. Review of facility policy titled, Food Storage, dated 2021, revealed leftovers will be labeled, dated and used within three days. The DM will review the temperature logs daily. Review of facility policy titled, Equipment Temperature Logs, dated 2021, revealed the dish machine temperatures are taken and recorded with each meal and monitored by the DM. Copies are maintained in the dietary department. Review of facility policy titled, Sanitation Standards: Equipment and Kitchen, dated 2021, revealed the dietary department will establish and maintain standards for sanitation with systematic cleaning and sanitizing procedures to ensure sanitation of equipment, storage areas and work areas are routinely cleaned. 366432 Page 7 of 7