Health inspection·November 16, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incidents (SRI's), staff interviews and policy review, the facility failed to timely report an allegation involving misappropriation of resident's medications to the Ohio Department of Health as required. This affected one (#18) out of three residents reviewed for misappropriation. Facility census was 53. Findings include: Review of medical record for Resident #18 revealed admission date of 09/13/23. Diagnoses include wedge compression fracture, hypertension and depression. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had impaired cognition. He required partial assistance for eating and substantial assistance for bed mobility, transfers and toileting. Review of Resident #18's physician orders revealed an order for Oxycodone (narcotic for pain) five milligram (mg) capsule every six hours as needed for pain with a start date of 09/13/23. Further review of the controlled substance record sign out sheet from 09/27/23 through 10/16/23 revealed Licensed Practical Nurse (LPN) #16 signed for Resident #18's Oxycodone a total of 34 times and wasted the medication with another nurse 11 times. Review of facility SRI's revealed there was no SRI regarding an allegation involving potential misappropriation of medications involving Resident #18 or LPN #16. Interviews on 11/16/23 with the Director of Nursing (DON) revealed it had been brought to her attention by Registered Nurse (RN) #12 and LPN #18 that they felt LPN #16 was wasting a lot of narcotic medications specifically for Resident #18 and there was the possibility of misappropriation of narcotics. The DON stated she reviewed the narcotic sheets on LPN #16's assignment for items of suspicion and noted there were several incidents of medications being wasted by LPN #16, but the second nurse present during the medication wasting varied. The DON shared she contacted the Corporate DON and the facility pharmacy to review the narcotic log documentation. The DON stated LPN #16 was interviewed and denied misappropriation of medication. LPN #16 was given a urine drug screen at the facility on 10/18/23 which was negative. The DON verified a SRI for potential misappropriation of medication was not done. Review of a facility's undated Abuse Policy revealed misappropriation of resident property, means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's (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 5 Event ID: 365789 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 11/16/2023 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)