Health inspection·December 30, 2024

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 2 of 3 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 12/30/2024 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 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365789 If continuation sheet Page 3 of 3