F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
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
observation, interview and record review, the facility failed to monitor medication storage refrigerators on a
daily bases and maintain the refrigerator temperature at the recommended temperature of 36 to 46 degree
Fahrenheit (F). The facility also failed to monitor and expose of 13 expired Insyte Autoguards (used to start
intravenous lines) that were located in the Intravenous (IV) cart. This had the potential to affect 13 residents
(Resident #1, #2, #5, #20, #25, #32, #42, #45, #47, #50, #207, #258, and #261) of 13 residents reviewed
for medication storage, with the potential to affect all 53 residents in the facility.
Findings include:
1. Observation on [DATE] at 8:30 A.M. of the medication storage room with the Director of Nursing (DON)
revealed one medication storage refrigerator was located in the medication storage room. The forms titled,
Temperature log for [DATE], [DATE], [DATE] and [DATE] were located on the door of the refrigerator.
Interview with the DON at this time verified the temperature log had documentation of the internal
temperature of the refrigerator. The DON revealed the nurses should monitor the internal temperature of the
refrigerator daily to assure the medications are stored within the recommended range.
Record Review of the Temperature Log for [DATE] revealed the temperature was monitored for only two
dates.
Record review of the Temperature Log for [DATE], revealed the temperature was monitored for 17 dates.
The temperature ranged 35 to 40 degrees F. Record review revealed on [DATE], [DATE], and [DATE] the
refrigerator temperature was 35 degrees F.
Record review of the Temperature Log for [DATE], revealed the temperature was monitored for 11 dates.
The temperature ranged 35 to 40 degrees F. On [DATE] and [DATE], the temperature was 35 degrees F.
Record review of the Temperature Log from [DATE] through [DATE] revealed nine temperatures were
documented for the internal temperature of the refrigerator which ranged 35 to 40 degrees F. The last
temperature documented was [DATE]. On [DATE], the temperature was documented to be 35 degrees F.
Observation on [DATE] at 8:15 A.M. with the DON revealed the medication storage refrigerator was 30 to
31 degrees F. Medications stored in the medication storage refrigerator included:
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
365428
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
365428
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/29/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sanctuary Wadsworth
365 Johnson Rd
Wadsworth, OH 44281
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
1. One locked narcotic box.
Level of Harm - Minimal harm
or potential for actual harm
2. 46 insulin vials of insulin (NovoLog, Lantus, Novolin 70/30, Novolin R, and Lispro) belonging to 10
Residents (Resident #1, #2, #5, #20, #32, #42, #47, #50, #207, and #261).
Residents Affected - Many
3. One vial of Tuberculin solution titled house stock.
4. One Avanox pen (used in treatment of multiple sclerosis) for Resident #45.
5. Gabapentin solution for Resident #258.
6. Granix injection (a leukocyte growth factor for the reduction in the duration of severe neutropenia), eight
boxes, for Resident #25.
Observation on [DATE] at 9:05 A.M. with the DON confirmed the internal temperature of the medication
storage refrigerator was 30 to 31 degrees F. DON confirmed the lack of temperature monitoring through
April, May, June, and [DATE].
Record review of the medication inserts, located under storage for NovoLog, Lantus, Novolin 70/30, Novolin
R, Lispro, Tuberculin solution, Avanox pen, Gabapentin solution, and Granix injection revealed medications
were to be stored between 36 and 46 degrees F, do not freeze.
Interview on [DATE] at 10:35 A.M. with the facility Pharmacy Director #401 revealed he had spoke with the
DON in the past and told her the medication refrigerator temperatures must be monitored daily.
Interview on [DATE] at 2:15 P.M. with the facility Pharmacy Consultant revealed if the stated medications,
NovoLog, Lantus, Novolin 70/30, Novolin R, Lispro, Tuberculin solution, Avanox pen, Gabapentin solution,
and Granix injections, are stored below the recommended storage temperature, the potency of the
medication may deteriorate or be less effective.
Interview on [DATE] at 3:30 P.M. with DON confirmed she received a Pharmacy Recommendation form the
Facility Pharmacy on [DATE] stating refrigerator temperatures were to be monitored daily.
Record review titled, Medication Storage dated 2007 revealed medications requiring refrigeration or
temperatures between 36 F and 46 F are kept in a refrigerator with a thermometer to allow temperature
monitoring.
2. Observation on [DATE] at 8:50 A.M. with DON revealed the Intravenous (IV) cart was located in the
medication storage room. DON revealed there was only one IV cart for the facility, and all IV supplies were
stored in the IV cart. Observation revealed, in the top drawer of the IV cart was 34 Insyte Autoguard BC 22
gauge. Observation revealed, and DON confirmed 13 of the 34 Insyte Autoguard BC 22 gauge expired on
[DATE].
Interview ON [DATE] at 9:00 A.M. with DON revealed the pharmacy consultant audits the IV cart monthly
and the expired items should have been removed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365428
If continuation sheet
Page 2 of 2
