Inspection·April 25, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure medications were discarded after their expiration date. This affected one (#59) of three residents observed for medication administration and also affected four (#1, #38, #72, and #368) of 30 residents who received medication from the 200 hall medication cart. The facility census was 114. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of [DATE]. Diagnoses included type two diabetes mellitus (DM II), Alzheimer's disease, and atrial fibrillation. Review of the physician order dated [DATE] revealed Resident #59 was ordered Novolog Solution 100 unit/milliliter (ml), inject per sliding scale subcutaneously two times a day for diabetes. Observation on [DATE] at 2:48 P.M. of medication cart on 400 hall revealed Resident #59's Novolog vial was opened on [DATE], indicating the insulin was expired. Interview on [DATE] at 2:53 P.M. with Licensed Practical Nurse (LPN) #138 verified Resident #59's insulin was expired. 2. Review of the medical record for Resident #72 revealed an admission date of [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, traumatic subarachnoid hemorrhage without loss of consciousness. Review of the physician order dated [DATE] revealed Resident #72 was ordered Pro-stat one time a day for nutrition support, preventative measure 30 milliliters (ml) via PEG tube daily. Observation on [DATE] at 3:14 P.M. of medication cart on 200 hall revealed Resident #72 was given over-the-counter Pro-stat that had expired on [DATE]. Interview on [DATE] at 3:17 P.M. with LPN #128 verified Resident #72's Pro-stat was expired and needed to be discarded. 3. Review of the medical record for Resident #368 revealed an admission date of [DATE]. Diagnoses congestive heart failure (CHF), type two diabetes mellitus (DM II), and peripheral vascular disease (PVD). (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 7 Event ID: 366432 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 366432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231 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)