Health inspection·December 30, 2024

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, hospital documentation review, staff interview, and review of a facility policy, the facility failed ensure medications were available to administer as ordered. This affected one (#13) of three residents received for medication administration. The census was 54. Findings Included: Review of Resident #13's medical record revealed an admission date of 12/15/24. Diagnoses included chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder. Review of a hospital discharge document dated 12/15/24 revealed Resident #13 had a medication order for the decongestant guaifenesin 600 mg one tablet every 12 hours. Review of a physician order dated 12/17/24 revealed Resident #13 was ordered guaifenesin extended release 600 mg one tablet twice daily for cough for seven days. Review of a nursing progress note dated 12/17/24 by Registered Nurse (RN) #219 revealed Resident #13's guaifenesin 600 mg extended release tablet twice a day for seven days for cough was on order. Review of Resident #13's December 2024 medication administration record (MAR) revealed the resident received the first dose of guaifenesin on 12/18/24 at 9:00 A.M. Interview on 12/30/24 at 4:00 P.M. with Assistant Director of Nursing (ADON) #262 verified Resident #13 missed doses of the ordered guaifenesin 600 extended release tablets and did not received the first dose until 12/17/24. Review of a facility policy titled, Medication Administration, dated 2024, revealed medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Master Complaint Number OH00161089 and Complaint Number OH00160325. Page 1 of 3 365789 365789 12/30/2024 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, hospital documentation review, resident and staff interview, review of a photograph of a medication package, review of a contingent medication inventory list, and review of a facility policy, the facility failed to ensure medications were administered as ordered to prevent significant medication errors. This affected one (#13) of three residents reviewed for medication administration. The facility census was 54. Residents Affected - Few Findings Included: Review of Resident #13's medical record revealed an admission date of 12/15/24. Diagnoses included chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder. Review of a hospital discharge document dated 12/15/24 revealed Resident #13 had medication orders for the diuretic furosemide 20 milligrams (mg) by mouth once a day and the steroid Medrol dose package (pack) four (4) mg with instructions to follow the dose pack. Review of physician orders dated 12/16/24 revealed Resident #13 was ordered Medrol 4 mg two (2) tablets in the morning scheduled for 9:00 A.M., 2 tablets by mouth at 2:00 P.M., 2 tablets by mouth at 6:00 P.M., 2 tablets by mouth at 8:00 P.M., and 2 tablets by mouth at 9:00 P.M. Review of a physician order dated 12/28/24 revealed Resident #13 was ordered Medrol 4 mg once daily until 12/30/24. Review of physician orders dated 12/30/24 revealed Resident #13 was ordered Medrol 4 mg once daily at 3:00 P.M. and 6:00 P.M. Review of a physician order dated 12/17/24 revealed Resident #13 was ordered furosemide 20 mg daily. Review of Resident #13's December 2024 medication administration record (MAR) revealed Resident #13's Medrol 4 mg was administered on 12/16/24 at 2:00 P.M., 6:00 P.M., 8:00 P.M., and 9:00 P.M.; on 12/28/24 at 6:00 A.M.; on 12/29/24 at 6:00 A.M.; and on 12/30/24 at 6:00 A.M. and 3:00 P.M. Further review of the December 2024 MAR revealed Resident #13 received furosemide 20 mg on 12/18/24 at 9:00 A.M. Interview on 12/30/24 at 2:36 P.M. with Resident #13 stated she did not receive her medications for several days after she was admitted to the facility. Interview on 12/30/24 at 4:00 P.M. with Assistant Director of Nursing (ADON) #262 verified Resident #13 missed doses of furosemide 20 mg and was not administered Medrol 4 mg correctly per physician order. ADON #262 verified furosemide 20 mg was in stock in the facility contingency medication supply and should have been pulled by the nurse. Review of photograph of a Medrol 4 mg medication pack, supplied by the facility on 12/31/24, revealed on the first day to take 2 tablets before breakfast, one tablet after lunch, and one tablet after supper, and two tablets at bedtime. The pack instructions continued on the second day take one tablet before breakfast, one tablet after lunch, one tablet after supper, and two tablets at bedtime. On the third day, take one tablet before breakfast, one tablet after lunch, one tablet after supper, and one tablet at bedtime. On the fourth day, take one tablet before breakfast, one tablet after lunch, and one tablet at bedtime. On the fifth day, take one tablet before breakfast, and one tablet at 365789 Page 2 of 3 365789 12/30/2024 Sanctuary at Wilmington Place 264 Wilmington Avenue Dayton, OH 45420

F 0760 Level of Harm - Minimal harm or potential for actual harm bedtime. On the sixth day, take one tablet before breakfast. Further review revealed eight Medrol 4 mg tablets were removed from the pack and 13 tablets remained not administered. Interview on 12/31/24 at 3:13 P.M. with Administrator confirmed the photograph of the Medrol 4 mg pack was Resident #13's medication that was left and not administered. Residents Affected - Few Review of facility document titled, Inventory on Hand, dated 12/30/24, revealed 16 furosemide 20 mg tablets were on hand at the facility stock. Review of the facility policy titled, Medication Administration, dated 2024, revealed medication are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Medications are to be administered as ordered in accordance with manufacturer specifications. This deficiency represents non-compliance investigated under Master Complaint Number OH00161089 and Complaint Number OH00160325. 365789 Page 3 of 3