Sanctuary Grande

Based on observations, interview and record review, the facility failed to ensure food was stored in a clean and sanitary manner. This had the potential to affect all 144 residents that received food from the kitchen. The facility census was 144.

Findings include:

Review of the diet orders provided by the facility revealed all 144 residents residing in the facility received food from the kitchen and none were identified as having orders for nothing by mouth (NPO).

Observation on 11/21/24 at 9:20 A.M. during a kitchen tour revealed the following:

1. In the servery area between the kitchen and dining room, there were three individual metal containers of cream uncovered, undated, and unlabeled. Condiments in the reach in fridge lacked open dates which included a bottle of ketchup, whipped topping, mustard, and mayonnaise.

2. The reach in freezer in the kitchen had ten plastic bags of food without labels. Four bags of food in the freezer were not sealed and the four unsealed bags had ice build up on the food.

3. The walk in fridge had a container of peeled garlic without an open date and the garlic was past it's manufacturer's expiration date of 11/03/24. There were open containers of vinegar, steak sauce, Worcestershire sauce, black olives, shredded cheese, and fruit juice, all without open dates. A plastic container of eggs did not have a label. An uncovered plastic container of bread was stored on the top shelf and was not 18 inches from the ceiling.

4. The dry food storage area had three dented cans and there was one can was without a label. There was also an open container of popcorn oil, an open container of vegetable oil, and an open bag of pretzels, all without an open date. A plastic box without a lid was observed with food spilled in it and other food items still stored in the box.

An interview on 11/21/24 at 9:20 A.M. with Dietary Manager #300 confirmed the above findings.

Based on medical record review, observation, resident interview, and staff interview the facility failed to ensure adequate staff were available to meet resident care needs per the resident assessment. This affected one (Resident #92) of three residents sampled for assistance with activities of daily living (ADLs.) The facility census was 135.

Findings include:

Review of the medical record for Resident #92 revealed resident had the following diagnoses: non-pressure chronic ulcer of right foot, depression, sarcopenia, ulcer of right and left buttocks, constipation, spinal stenosis, hypertension, neuromuscular dysfunction of bladder, peripheral neuropathy, cord compression, and primary osteoarthritis.

Review of the care assessment for Resident #92 dated 05/17/23 revealed resident was cognitively intact and required minimal supervision with ADLS.

Review of the toileting care plan for Resident #92 dated 05/17/23 revealed resident was dependent on staff for toileting and perineal care.

Interview on 10/26/23 at 10:49 A.M. with Resident #92 revealed the facility was extremely short of help. At the time of the interview, Resident #92 indicated she had pressed the pendant call button for assistance with toileting approximately ten minutes ago. Resident #92 revealed she had to wait a long time for help because she was a Hoyer-lift transfer which required the assistance of two staff.

Observation on 10/26/23 at 10:54 A.M. revealed Resident #92 pressing her pendant call button to request assistance with toileting. Further observation revealed Care Associate (CA) #502 entered the resident's room at 11:10 A.M. and exited the room at 11:16 A.M.

Interview on 10/26/23 at 11:16 A.M. with CA #502 confirmed Resident #92 had requested assistance with toileting. CA #502 confirmed she was not able to assist Resident #92 because the resident required a Hoyer-lift transfer which was required to be completed with two staff members. CA #502 further confirmed other CAs were assisting other residents and unable to help with Resident #92.

Interview on 10/26/23 at 11:53 A.M. with Licensed Practical Nurse (LPN) #504 confirmed there were no CAs available to assist CA #502 with a Hoyer lift transfer for Resident #92 because they were busy taking residents downstairs to the dining room.

Interview on 10/26/23 at 12:34 P.M. with Resident #92 confirmed staff had not yet assisted with toileting since her request which was made at approximately 11:10 A.M.

Interview on 10/26/23 at 1:32 P.M. with CA #502 confirmed Resident #92 had not been assisted with toileting since the resident's initial request which occurred at approximately 11:10 A.M. CA #502 further confirmed the staff were busy and had multiple residents who required the assistance of two staff because they were transferred via Hoyer lift.

Observation on 10/26/23 at 2:02 P.M. revealed two CAs were observed assisting Resident #92 with a Hoyer lift transfer and toileting needs.

Interview on 10/26/23 at 3:36 P.M. with the Executive Director (ED) confirmed there were four CAs scheduled on day shift for a census of 111 residents, seven of whom required a Hoyer lift for transfers.

This violation represents non-compliance investigated under Complaint Number OH00147289.

Based on record review and interview the facility failed to request criminal records check no later than five days after conditional hire. This had the potential to affect all 131 residents residing in the facility. Findings include: On 08/02/23 review of Bureau of Criminal Investigation (BCI) log revealed that two new employees hired since 01/01/23 did not have a criminal records check submitted not later than five business days after beginning conditional employment as follows. 1. Resident Care Assistant (RCA) #313 had a hire date of 07/18/23 with no record that fingerprinting was completed on the log. 2. State Tested Nursing Assistant (STNA) #314 had a hire date of 03/28/23 with a completed date of fingerprinting of 04/21/23. Interview on 08/01/23 at 1:43 P.M. with Human Resource Director #311 revealed the date recorded on the BCI log was the date the fingerprints were submitted to the bureau for the background check. Interview on 08/02/23 at 7:43 A.M. with Human Resource Director #311 revealed the BCI log was updated to reflect the dates from the fingerprinting company's invoice and verified that RCA #313 and STNA #314 did not get fingerprinted with submission within five days of conditional employment. Review of facility policy dated 01/2012 with a revision date of 04/2023 titled, Abuse, Neglect and MisappropriationBased on record review and interview the facility failed to request criminal records check no later than five days after conditional hire. This had the potential to affect all 131 residents residing in the facility.

Findings include:

On 08/02/23 review of Bureau of Criminal Investigation (BCI) log revealed that two new employees hired since 01/01/23 did not have a criminal records check submitted not later than five business days after beginning conditional employment as follows.

1. Resident Care Assistant (RCA) #313 had a hire date of 07/18/23 with no record that fingerprinting was completed on the log.

2. State Tested Nursing Assistant (STNA) #314 had a hire date of 03/28/23 with a completed date of fingerprinting of 04/21/23.

Interview on 08/01/23 at 1:43 P.M. with Human Resource Director #311 revealed the date recorded on the BCI log was the date the fingerprints were submitted to the bureau for the background check.

Interview on 08/02/23 at 7:43 A.M. with Human Resource Director #311 revealed the BCI log was updated to reflect the dates from the fingerprinting company's invoice and verified that RCA #313 and STNA #314 did not get fingerprinted with submission within five days of conditional employment.

Review of facility policy dated 01/2012 with a revision date of 04/2023 titled, Abuse, Neglect and Misappropriation

Based on observations, interview and record review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect 131 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. The facility census was 131.

Findings include:

Tour of the kitchen on 08/01/23 from 9:00 A.M. through 9:30 A.M. with the Dietary Supervisor revealed tater tots, waffle fries, chicken tenders and beef patties were not properly covered, labeled, or dated in the reach-in refrigerator located near the cooking area. In the prep area the small mixer and large tabletop mixer had dried food on the splash guards. In the flour and sugar storage bins the scoops were laying on top of the flour and sugar.

Phone interview on 08/02/23 at 11:03 A.M. with Dietary Manager #312 revealed food items should be labeled and dated, and scoops should be stored outside the flour and sugar storage bins.

Review of undated facility policy titled, Frozen Storage

Based on observation, interview and record review, the facility failed to a copy of the most recent licensure survey readily available to the residents. This had the potential to affect all 131 residents in the facility. The facility census was 131.

Findings include:

Observation on 08/01/23 at 10:40 A.M. revealed survey results were not available in the lobby. A sign was posted that survey results could be found in the Community Information Binder at the front desk.

Interview on 08/01/23 at 10:43 A.M. with Receptionist #315 revealed survey results were not available at the front desk and she believed the binder was in the Executive Director's office.

Interview on 08/01/23 at 10:45 A.M. with Life Enrichment Director #316 revealed survey results were in a binder in the activity room.

Observation on 08/01/23 at 10:46 A.M. with Executive Director and Life Enrichment Director #316 revealed the binder was upright on the counter in the activity room with no title on the binder.