Health inspection·December 27, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #4's care plan, dated 10/27/22, revealed there was a plan in place for advanced care planning needs for resident code status of full code. The interventions included code status and orders reviewed as needed, review advanced care planning wishes upon admission, quarterly and as needed, review and coordinate advanced care planning choices with Resident #4 and/or responsible party. Review of Resident #4's medical record on 12/18/22 revealed Resident #4's code status in the paper chart was Do Not Resuscitate Comfort Care (DNRCC). Resident #4's electronic medical record indicated Resident #4's code status was full code. Interview with the Unit Manager #47 on 12/29/22 at 9:04 A.M. confirmed Resident #4's code status in the paper chart and electronic medical record did not match on 12/18/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 2 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure residents and/or resident representatives were provided Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) when required. This affected two (#33 and #46) out of three residents reviewed for beneficiary notices. The facility census was 58. Residents Affected - Few Findings include: 1. Review of Resident #33's medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including but not limited to type two diabetes mellitus without complications, unspecified dementia unspecified severity without behavioral disturbance, contracture of muscle of the left lower leg, and contracture of muscle right lower leg. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment, dated 11/09/22, revealed Resident #33 was severely cognitively impaired. Review of Resident #33's payer source documentation revealed Resident #33 was on Medicare Part A with a last covered day of 11/09/22. Resident #33's payer source was changed to private pay on 11/10/22. Review of Resident #33's Notice of Medicare Non Coverage (NOMNC), dated 11/09/22, revealed Resident #33's last covered day of skilled services was on 11/09/22. Resident #33's responsible party was made aware of the NOMNC by phone on 11/07/22 at 1:00 P.M. but the NOMNC was not signed. Review of Resident #33's chart revealed Resident #33 did not have a SNFABN to inform the resident of the potential liability for a non-covered stay for Resident #33's payer change on 11/10/22. Interview with Licensed Practical Nurse (LPN) #82 on 12/19/22 at 4:41 P.M. verified Resident #33 and/or Resident #33's responsibly party were not provided a SNF ABN as a result of Resident #33 changing payer sources from Medicare Part A to private pay on 11/10/22, having skilled days remaining, and remaining in the facility. 2. Review of the Resident #46's medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including but not limited to fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing, Parkinson's disease, and unspecified fracture of head of right femur subsequent encounter for closed fracture with routine healing. Review of Resident #46's quarterly MDS assessment, dated 11/11/22, revealed Resident #46 was moderately cognitively impaired. Review of Resident #46's payer source documentation revealed Resident #46 was on Medicare Part A with a last covered day of 10/04/22. Resident #46's payer source was changed to private pay on 10/05/22. Review of Resident #46's NOMNC, dated 10/04/22, revealed Resident #46's last covered day of skilled services was on 10/04/22. Resident #46's responsible party signed the NOMNC on 09/30/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 3 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #46's medical record revealed Resident #46 did not have a SNFABN to inform the resident of the potential liability for a non-covered stay for Resident #46's payer change on 10/05/22. Interview with LPN #82 on 12/19/22 at 4:41 P.M. verified Resident #46 and/or Resident #46's responsibly party were not provided a SNF ABN as a result of Resident #46 changing payer sources from Medicare Part A to private pay on 10/05/22, having skilled days remaining, and remaining in the facility. Review of the facility's undated Advanced Beneficiary Notices policy revealed the facility shall use a SNF ABN form for part A items and services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 4 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on review of personnel files, staff interview, and policy review, the facility failed to implement their abuse policy. This had the potential to affect all 58 residents in the facility. The facility census was 58. Residents Affected - Many Findings include: Review of State Tested Nurse Aide (STNA) #67's personnel file revealed STNA #67 was hired at the facility on 11/28/22. Further review of STNA #67's personnel file revealed STNA #67 did not have any reference checks completed upon hire. Review of Registered Nurse (RN) #25's personnel file revealed RN #25 was hired at the facility on 10/11/22. Further review of RN #25's personnel file revealed RN #25 did not have any reference checks completed upon hire. Review of the Administrator's personnel file revealed the Administrator was hired at the facility on 08/22/22. Further review of the Administrator's personnel file revealed the Administrator did not have any reference checks completed upon hire. Interview on 12/21/22 at 10:50 A.M. with Human Resources #32 verified STNA #67, RN #25, and the Administrator did not have reference checks completed upon hire as required by the facility's abuse policy. Review of the facility's undated Abuse policy revealed screening of potential employees will consist of reference checks from previous and current employers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 5 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and policy review, the facility failed to provide residents and/or resident representatives with bed hold notices upon transfer to the hospital. This affected two (#15 and #43) out of six residents reviewed for hospitalizations. The facility census was 58. Findings include: 1. Review of Resident #15's medical record revealed Resident #15 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, hypertension, displaced fracture of shaft of right clavicle, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #15's significant change Minimum Data Set (MDS) assessment, dated 10/05/22, revealed Resident #15 was cognitively intact. Review of Resident #15's progress note, dated 09/26/22, revealed Resident #15 was sitting in the front lobby at 10:15 A.M. and was unable to hold her head up and was slow to arouse. Resident #15's blood pressure was 82 over 37. The nurse practitioner was notified, and an order was obtained to send Resident #15 to the emergency room. Resident #15's daughter was notified. Review of Resident #15's progress note, dated 10/04/22, revealed Resident #15 arrived back at the facility from the hospital. Review of Resident #15's progress note, dated 10/07/22, revealed Resident #15 was noted with increased lethargy, increased weakness and was unable to stay awake. A new order was obtained to send Resident #15 to the hospital. Resident #15's daughter was notified. Review of Resident #15's progress note, dated 10/12/22, revealed Resident #15 was readmitted to the facility. Review of Resident #15's progress note, dated 11/07/22, revealed Resident #15 was sent to the hospital. Resident #15 had a previous fall on 11/06/22 and x-rays showed an acute mildly displaced right distal clavicular fracture. Resident #15 also had a big bruise to the right side of her forehead up to the top of her head. Resident #15 was complaining of right hip pain. Resident #15's daughter was notified, and Resident #15's daughter stated to send Resident #15 to the hospital for treatment. Review of Resident #15's progress note, dated 11/11/22, revealed Resident #15 was readmitted to the facility. Review of Resident #15's medical record revealed no evidence a bed hold notice was provided to Resident #15 when Resident #15 was discharged to the hospital on [DATE], 10/07/22, and 11/07/22. Interview on 12/21/22 at 8:39 A.M. with Corporate Registered Nurse (CRN) #81 verified Resident #15 did not receive a bed hold notice for her admissions to the hospital on [DATE], 10/07/22, and 11/07/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 6 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the Resident #43's medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including heart failure, diverticulosis of large intestine without perforation or abscess without bleeding, type two diabetes mellitus with diabetic polyneuropathy, other specified abdominal hernia with obstruction, peptic ulcer, and hypertension. Review of Resident #43's quarterly MDS assessment, dated 10/11/22, revealed Resident #43 was cognitively intact. Review of Resident #43's progress note, dated 10/16/22, revealed Resident #43 was sent to the hospital at 12:10 P.M. due to profuse emesis events consisting of dark vomit. Review of Resident #43's progress note, dated 10/25/22, revealed Resident #43 was transported back to the facility by ambulance. Review of Resident #43's progress note, dated 11/01/22, revealed Resident #43 was admitted to the hospital for nausea and vomiting. Resident #43 was still in the emergency department awaiting an open bed. Review of Resident #43's progress note, dated 11/03/22, revealed Resident #43 was transported to the facility. Review of Resident #43's medical record revealed no evidence a bed hold notice was provided to Resident #43 when Resident #43 was discharged to the hospital on [DATE] and 11/01/22. Interview with CRN #81 on 12/19/22 at 12:01 P.M. verified Resident #43 did not receive a bed hold notice for the discharges to the hospital on [DATE] and 11/01/22. Review of the facility's undated Bed Hold Prior to Transfer policy revealed the facility will provide written information to the resident or representative regarding bed hold policies prior to transferring a resident to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 7 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #15's medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #15's significant change MDS assessment, dated 10/05/22, revealed Resident #15 was cognitively intact. Review of Resident #15's code status care plan, dated 10/31/22, revealed Resident #15 was a Do Not Resuscitate Comfort Care Arrest (DNRCCA). Interventions included code status orders reviewed as needed, offer religious services per advanced care planning preferences, and review advanced care planning wishes upon admission, quarterly and as needed. Review of Resident #15's code status in the paper chart on 12/18/22, revealed Resident #15 was a DNRCC. Further review of the code status form revealed Resident #15's code status form was faxed to the facility from the physician's office on 10/13/22. Review of Resident #15's electronic orders on 12/18/22 revealed Resident #15 had an order to be a DNRCCA from 10/18/22 to 12/18/22 in the electronic record. Interview with Corporate Registered Nurse (CRN) #81 on 12/21/22 at 3:15 P.M. verified Resident #15's DNRCCA code status was not accurate in Resident #15's care plan. 3. Medical record review for Resident #10 revealed an admission date of 08/03/17. Resident #10's diagnoses included stroke, coronary artery disease, heart failure, diabetes, depression and schizophrenia. Review of Resident #10's annual MDS assessment, dated 12/05/22, revealed Resident #10 was cognitively intact. Review of Resident #10's care conferences since 01/01/22 revealed Resident #10 had a care conference on 04/07/22 and 07/14/22. There was no evidence Resident #10 had a care conference since 07/14/22. Interview with Resident #10 on 12/18/22 at 11:59 A.M. revealed it had been awhile since she had a care conference. Interview with Social Service Designee (SSD) #49 on 12/19/22 at 10:51 A.M. revealed she started in March 2022 and went out on medical leave in August 2022 and came back in September 2022. SSD #49 stated she left a list of care conferences that needed to be completed. SSD #49 confirmed Resident #10 only had two care conferences completed for 2022 and stated Resident #10 was supposed to have care conferences completed quarterly. 4. Medical record review for Resident #39 revealed an admission date of 12/26/21. Resident #39's medical diagnoses included non-Hodgkin lymphoma, diabetes, and peripheral vascular disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 8 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0657 Level of Harm - Minimal harm or potential for actual harm Review of Resident #39's annual MDS assessment, dated 11/19/22, revealed Resident #39 was cognitively intact. Review of Resident #39's care conferences since 01/01/22 revealed Resident #39 had a care conference held on 04/05/22. There was no evidence Resident #39 had a care conference since 04/05/22. Residents Affected - Some Interview with Resident #39 on 12/18/22 at 11:18 A.M. revealed he doesn't get invited to care conferences. Interview with SSD #49 on 12/19/22 at 2:00 P.M. verified there was no evidence Resident #39 had a care conference completed since 04/05/22. Review of policy titled Care-Planning-Resident Participation, undated, revealed the facility supported the resident's right to be informed of and participate in his or her care planning. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident or representative. Based on medical record review, staff and resident interview, and policy review, the facility failed to care plans were revised to reflect accurate advanced directives. This affected two (#4 and #15) out of five residents reviewed for care plan revisions. Additionally, the facility failed to ensure care conference were completed. This affected two (#10 and #39) out of two residents reviewed for care conferences. The facility census was 58. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 10/19/22 with a diagnoses including but not limited to fracture of shaft of left femur, fracture of shaft of right femur, major depressive disorder, and chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity. Review of Resident #4's Minimal Data Set (MDS) assessment, dated 10/23/22, revealed Resident #4 had intact cognition. Review of Resident #4's care plan, dated 10/27/22, revealed there was a plan in place for advanced care planning needs for resident code status of full code. The interventions included code status and orders reviewed as needed, review advanced care planning wishes upon admission, quarterly and as needed, review and coordinate advanced care planning choices with Resident #4 and/or responsible party. Review of Resident #4's medical record on 12/18/22 revealed Resident #4's code status in the paper chart was Do Not Resuscitate Comfort Care (DNRCC). Resident #4's electronic medical record indicated Resident #4's code status was full code. Interview with Unit Manager #47 on 12/29/22 at 9:04 A.M. confirmed Resident #4's code status in her care plan was inaccurate and had not been revised. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 9 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staffing schedule and staff interview, the facility failed to ensure Registered Nurse (RN) services were used for at least eight consecutive hours a day seven days a week. This had the potential to affect all 58 residents in the facility. The facility census was 58. Findings include: Review of the staffing schedule, dated 12/10/22, revealed no Registered Nurse (RN) was present in the facility on 12/10/22. Interview with Corporate Registered Nurse (CRN) #81 on 12/20/22 at 10:03 A.M. verified the facility did not have an RN present in the facility for eight consecutive hours on 12/10/22. This deficiency represents non-compliance investigated under Complaint Number OH00138026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 10 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files and staff interview, the facility failed to complete nurse aide performance reviews at least every 12 months for two State Tested Nurse Aides. This had the potential to affect all 58 residents in the facility. The facility census was 58. Residents Affected - Many Findings include: Review of State Tested Nurse Aide (STNA) #02's personnel file revealed STNA #02 was hired at the facility on 10/01/19. Further review of STNA #02's personnel file revealed STNA #02 did not have any performance reviews completed from 10/01/21 to 12/21/22. Review of STNA #14's personnel file revealed STNA #14 was hired at the facility on 05/24/16. Further review of STNA #14's personnel file revealed STNA #14 did not have any performance reviews completed from 05/24/21 to 12/21/22. Interview on 12/21/22 at 10:50 A.M. with Human Resources (HR) #32 verified STNA #02 and STNA #14 did not have performance reviews completed at least once every 12 months. Review of the facility's undated Evaluation policy revealed the facility will complete formal written work performance evaluations of employees annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 11 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to ensure the daily nurse staffing information was posted every day. This had the potential to affect all 58 residents in the facility. The facility census was 58. Residents Affected - Many Findings include: Observation of the daily nurse staffing information on the receptionist desk on 12/20/22 at 11:27 A.M. revealed the posted daily nurse staffing data was from 12/18/22. Interview with Administrative Assistant #34 on 12/20/22 at 11:27 A.M. verified the daily nurse staffing data that was posted on 12/20/22 was from 12/18/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 12 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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. Based on medical record review and staff interview, the facility failed to ensure medications were administered according to physician order. This affected one (#26) out of five residents reviewed for unnecessary medications. The census was 58. Findings include: Medical record review for Resident #26 revealed an admission date of 09/30/20. Resident #26's medical diagnoses included respiratory failure, heart failure, hypertension, orthostatic hypotension, and peripheral vascular disease. Review of Resident #26's physician orders, dated 11/27/22, revealed an order for Midodrine HCl (medication used to treat orthostatic hypotension) oral tablet, give 10 milligram (mg) by mouth every eight hours related to hypotension. Hold if systolic (the first number in a blood pressure reading) blood pressure was above 110. Review of Resident #26's Medication Administration Record (MAR) from 12/01/22 through 12/21/22 revealed for the 6:00 A.M. dose of Midodrine, Resident #26's blood pressure (BP) on 12/07/22 was 125/75, on 12/08/22 was 119/70, on 12/12/22 was 121/80, on 12/14/22 was 128/45, on 12/15/22 was 115/64, on 12/16/22 was 120/78, and on 12/17/22 was 130/84. The Midodrine HCl was marked as given to Resident #26 on all of these instances. Review of Resident #26's MAR from 12/01/22 through 12/21/22 revealed for the 2:00 P.M. dose of Midodrine, Resident #26's BP on 12/03/22 was 128/99, on 12/07/22 was 119/70, on 12/08/22 was 114/83, on 12/09/22 was 127/92, on 12/12/22 was 122/82, on 12/13/22 was 123/83, on 12/16/22 was 131/94, and on 12/17/22 was 129/75. The Midodrine HCl was marked as given to Resident #26 on all of these instances. Review of Resident #26's MAR from 12/01/22 through 12/21/22 revealed for the 10:00 P.M. dose of Midodrine, Resident #26's BP on 12/06/22 was 125/75, on 12/07/22 was 119/70, on 12/11/22 was 121/80, on 12/13/22 was 128/85, on 12/14/22 was 115/64, on 12/15/22 was 120/78, and on 12/16/22 was 130/84. The Midodrine HCl was marked as given to Resident #26 on all of these instances. Interview with Licensed Practical Nurse (LPN) #55 on 12/21/22 at 12:41 P.M. confirmed she gave Midodrine to Resident #26 on multiple occasions when Resident #26's systolic BP was above 110, because she didn't know the order had changed and had parameters. LPN #55 indicated no one had told her the order changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 13 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review and staff interview, the facility failed to ensure a monthly medication reviews were completed monthly by a licensed pharmacist. This affected two (#26 and #39) of five residents reviewed for unnecessary medications. The census was 58. Findings include: 1. Medical record review for Resident #26 revealed an admission date of 09/30/20. Medical diagnoses included respiratory failure, heart failure, hypertension, orthostatic hypotension, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/21/22, revealed Resident #26 was cognitively intact. Resident #26's required extensive assistance for bed mobility, transfers, toilet use, and supervision for eating. Review of the monthly pharmacy reviews since 01/01/22 revealed there was no evidence of a monthly pharmacy review having been completed by a licensed pharmacist since June 2022. Interview with the Minimum Data Set Licensed Practical Nurse (MDSLPN) #82 on 12/21/22 at 1:20 P.M. confirmed Resident #26 did not have a monthly pharmacy review since June 2022. 2. Medical record review for Resident #39 revealed an admission date of 12/26/21. Diagnoses included non-Hodgkin lymphoma, cancer, anemia, heart failure, hypertension, and peripheral vascular disease. Review of Resident #39's annual MDS assessment, dated 11/19/22, revealed Resident #39 was cognitively intact. Resident #39 required supervision for bed mobility, transfers, eating, and toilet use. Review of Resident #39's monthly pharmacy reviews since 01/01/22 revealed there was no evidence of a review having been completed by a licensed pharmacist in May 2022, June 2022, and October 2022. Interview with the MDSLPN #82 on 12/21/22 at 1:20 P.M. confirmed Resident #39 did not have a pharmacy medication review completed in May 2022, June 2022, and October 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 14 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure a resident with dental issues received routine dental care. This affected one (#43) out of two residents reviewed for dental services. The facility census was 58. Residents Affected - Few Findings include: Review of Resident #43's medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including heart failure, diverticulosis of large intestine without perforation or abscess without bleeding, type two diabetes mellitus with diabetic polyneuropathy, unspecified osteoarthritis, cervicalgia, rectal abscess, other specified abdominal hernia with obstruction, peptic ulcer, major depressive disorder, and hypertension. Review of Resident #43's quarterly Minimum Data Set (MDS) assessment, dated 10/11/22, revealed Resident #43 was cognitively intact. Resident #43 had a broken or loosely fitting full or partial denture that was chipped, cracked, uncleanable, or loose. Review of Resident #43's dental care plan, dated 09/24/21, revealed Resident #43 had a potential for dental problems due to some missing or broken teeth. Interventions included refer Resident #43 to the dentist as needed and dental consultation or follow up as ordered and as needed. Review of Resident #43's dental visits from 03/26/21 to 12/19/22 revealed Resident #43 had no dental visits between 03/26/21 and 12/19/22 while at the facility. Interview with Resident #43 on 12/18/22 at 9:10 A.M. revealed Resident #43 had not seen the dentist at the facility and had multiple missing teeth as well as teeth that needed to be pulled. Resident #43 stated he wanted to pursue getting dentures. Observation of Resident #43 on 12/18/22 at 9:10 A.M. revealed Resident #43 had multiple missing teeth and teeth that appeared to be broken and brown in color in his mouth. Interview with Corporate Registered Nurse (CRN) #81 on 12/19/22 at 2:43 P.M. verified Resident #43 had not been seen by the dentist, but a new order was written on 12/19/22 to have Resident #43 seen at the next mobile dental visit. Review of the facility's Routine Dental Services policy revealed the facility will assist residents in obtaining routine dental care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 15 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of menu spreadsheets, observation, staff interview, and policy review, the facility failed to ensure residents received meals according to the menu spreadsheet. This affected all 52 residents residing in the facility who received a regular or mechanical soft diet. The facility identified six residents (#3, #14, #16, #19, #20, and #104) who did not receive a regular or mechanical soft diet. The facility census was 58. Findings include: Review of the undated menu spreadsheet revealed regular diets and mechanical soft diets were to receive four ounces (oz) of ham and cheese strata, a slice of toast, and six oz of cold cereal or oatmeal. Observation of tray line on 12/19/22 at 7:52 A.M. revealed [NAME] #09 was serving regular diets and mechanical soft diets three oz of ham and cheese strata, a slice of toast, and six oz of cold cereal or oatmeal. Interview with Dietary Manager #05 and [NAME] #09 on 12/19/22 at 8:13 A.M. verified the residents on regular diets and mechanical soft diets were served three oz of ham and cheese strata instead of the four oz of ham and cheese strata that was listed on the menu spreadsheet. Review of the undated Therapeutic Diet Spreadsheet policy revealed the therapeutic diet spreadsheet shall be available and followed at all meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 16 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure hair nets were worn appropriately, proper hand hygiene was followed, and food items were maintained in a sanitary manner in the kitchen. This had the potential to affect all 58 residents who received meals from the kitchen. The facility census was 58. Findings include: 1. Observation of the kitchen on 12/18/22 at 8:33 A.M. revealed a gallon zip lock bag of raw chicken which was open to air and dated 12/22/22 sitting on a pan in the walk in refrigerator. The observation further revealed an open undated bag of shredded cheese, an open undated package of American singles, an open undated and unlabeled bag of white substance, and an open undated package of bologna sitting on the shelf in the walk in refrigerator. Further observation of the kitchen revealed an opened undated box of hamburger patties which was open to air and an opened and undated box of tilapia filets in the walk in freezer. Interview with [NAME] #09 on 12/18/22 at 8:33 A.M. verified there was a gallon zip lock bag of raw chicken which was open to air and dated 12/22/22 sitting on a pan in the walk in refrigerator. [NAME] #09 also verified there was also an open undated bag of shredded cheese, an open undated package of American singles, an open undated and unlabeled bag of white substance which he identified as mashed potatoes, and an open undated package of bologna sitting on the shelf in the walk in refrigerator. The interview further verified an opened undated box of hamburger patties which was open to air and an opened and undated box of tilapa filets in the walk in freezer. Review of the undated Date Marking for Food Safety policy revealed food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. Review of the facility's Storage of Potentially Hazardous Foods policy revealed potentially hazardous foods shall be stored in a manner that prevents cross contamination and foodborne illnesses. Food shall be dated and labeled and properly covered or wrapped tightly. 2. Observation of the kitchen on 12/19/22 at 7:45 A.M. revealed Administrative Assistant #34 walked into the kitchen without wearing a hair net. Administrative Assistant #34 did not wash her hands upon entering the kitchen and proceeded to walk across the kitchen while holding onto and touching the preparation table in front of the stove while she was walking towards the ice machine with a personal cup in the other hand. Interview with Dietary Manager #5 on 12/19/22 at 7:45 A.M. verified Administrative Assistant #34 did not wash her hand and did not have a hair net on, and was in the kitchen holding onto the preparation table in front of the stove. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 17 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, staff interview, and policy review, the facility failed to ensure the facility was administered in a manner to prevent the falsification of documentation. This had the potential to affect all 58 residents who resided at the facility. The facility census was 58. Residents Affected - Many Findings include: Review of the Administrator's personnel file revealed the Administrator was hired at the facility on 08/22/22. Further review of the Administrator's personnel file revealed the Administrator had a physical date of 08/20/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form. Review of State Tested Nurse Aide (STNA) #22's personnel file revealed STNA #22 was hired at the facility on 06/01/22. Further review of STNA #22's personnel file revealed STNA #22 had a physical date of 06/02/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form. Review of STNA #67's personnel file revealed STNA #67 was hired at the facility on 11/28/22. Further review of STNA #67's personnel file revealed STNA #67 had a physical date of 12/28/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form. The date on the form had not occurred at the time of the review and was in the future. Review of Registered Nurse (RN) #25's personnel file revealed RN #25 was hired at the facility on 10/11/22. Further review of RN #25's personnel file revealed RN #25 had a physical date of 10/06/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form. Review of the Director of Nursing (DON)'s personnel file revealed the DON was hired at the facility on 07/18/22. Further review of the DON's personnel file revealed the DON had a physical date of 07/14/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form. Review of Licensed Social Worker (LSW) #49's personnel file revealed LSW #49 was hired at the facility on 03/24/22. Further review of LSW #49's personnel file revealed LSW #49 had a physical date on 03/24/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form. Interview on 12/21/22 at 10:50 A.M. with Human Resources (HR) #32 and the Administrator verified the Administrator, STNA #22, STNA #67, RN #25, the DON, and LSW #49 had physical forms with Nurse Practitioner #83's signature photo copied on the form while the rest of the form was filled out in original ink. Telephone interview with Nurse Practitioner #83 on 12/21/22 at 12:07 P.M. verified Nurse Practitioner #83 did not conduct physicals on the Administrator, the DON and LSW #49. Nurse Practitioner #83 stated she could not remember staff names but did not think she completed physicals on STNA #22, STNA #67, or RN #25 because she had not completed physicals at the facility in a long time. Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 18 of 19 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 365789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420 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 0835 Practitioner #83 was not aware her signature was photocopied on a physical form at the facility. Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 12/21/22 at 12:31 P.M. verified she did not receive a physical upon hire at the facility, but stated she sees her personal physician regularly. Residents Affected - Many Review of the undated Falsification of Documentation policy revealed the facility will ensure all documentation is timely, accurate, and truthful. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 19 of 19