Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sanctuary At Wilmington Place during CMS and state inspections, most recent first.
A resident with COPD, dementia, and other comorbidities, who required supervision and assistance with a pureed diet and thin liquids, was left sitting in a chair with a covered breakfast tray in front of him for a period of time without feeding assistance. Staff practice was to place trays in rooms for residents needing help and then continue delivering other trays before returning to assist, resulting in a delay in feeding this dependent resident. Dietary leadership and the dietician confirmed that trays for residents needing assistance should not be delivered until staff are ready to provide direct supervision and help with eating.
A resident with dementia was later diagnosed with schizoaffective disorder bipolar type, but the facility did not complete an updated PASARR as required after the new diagnosis. The only PASARR on file was from admission, despite facility policy mandating prompt referral for Level II review when a new serious mental disorder is identified.
A resident with chronic respiratory failure and COPD did not have their oxygen tubing changed weekly as ordered by the physician. Observation and staff interview confirmed the tubing was not replaced according to the schedule, despite facility policy requiring weekly changes and infection control measures.
A nurse prepared medications for a resident with COPD, stroke, and dementia, but another LPN administered the medications, contrary to facility policy requiring the same nurse to both prepare and administer medications. Both staff confirmed this practice, which was observed during a medication pass and had the potential to affect all residents on the hall.
A resident with dementia, COPD, and stroke did not have physician-approved pharmacy recommendations implemented, including changes to pain and anticoagulant medications. Staff interviews and medical record review confirmed the orders were not carried out, and hospice was not notified to coordinate care.
A resident with COPD, stroke, and dementia did not receive multiple doses of Rivaroxaban as ordered because the medication was out of stock or unavailable, despite notifications to the pharmacy and reorders. The facility's policy requiring administration of medications as ordered was not followed.
A medication cart was found to contain an open, undated bottle of Rhopressa 0.02% Ophthalmic Solution for a resident with glaucoma and other chronic conditions. An LPN confirmed the medication should have been dated upon opening, in accordance with facility policy and manufacturer guidelines.
The facility did not implement or document required water management protocols to reduce Legionella risk, including missing system diagrams and unperformed chlorine testing. During a pressure ulcer dressing change for a resident with multiple health conditions, two LPNs failed to follow Enhanced Barrier Precautions, did not use gowns, and used improper wound cleaning technique. These failures in infection prevention and control had the potential to affect all residents.
A resident with multiple diagnoses and severely impaired cognition experienced two significant changes in condition—one involving low oxygen saturation and another involving unresponsiveness after medication. In both instances, although the physician was notified and care was provided, there was no documentation that the resident's POA was informed, contrary to facility policy.
A resident with multiple complex medical conditions was admitted and identified as being at risk for falls, but the facility did not timely develop or implement fall interventions. The resident experienced a fall resulting in a skin tear before any specific fall prevention measures were added to the care plan, despite facility policy requiring such interventions at admission.
A resident with multiple health conditions did not receive their prescribed guaifenesin medication on time, resulting in missed doses. The medication was ordered to be administered twice daily, but the first dose was delayed, as confirmed by the ADON. This incident highlights a failure to adhere to the facility's medication administration policy.
A resident with multiple health conditions did not receive medications as ordered, resulting in significant medication errors. The facility failed to administer furosemide and Medrol according to physician orders, despite having the medications in stock. The resident reported missing doses, and the ADON confirmed the errors, which were also evident in the MAR and a photograph of the Medrol pack.
The facility failed to provide appropriately sized briefs for two residents, leading to improper fit and discomfort. One resident, with conditions including cerebrovascular attack and morbid obesity, was given a two XL brief instead of the required three XL, leaving skin exposed. Another resident, with peripheral vascular disease and renal insufficiency, experienced skin irritation due to the lack of three XL briefs. Staff confirmed the absence of the correct size in supply rooms, violating the facility's policy on accommodating resident needs.
A resident with a surgical incision experienced bleeding on multiple occasions, as noted in PT and OT records, but the physician was not notified, contrary to the facility's policy. The Wound NP confirmed she was unaware of the bleeding, highlighting a failure in communication and adherence to the Notification of Changes policy.
A resident, dependent on staff for toileting and incontinent of bowel and bladder, did not receive appropriate incontinence care. During an observation, CNAs used a single towel for cleaning without turning it over for different areas and failed to clean urine from the resident's legs. Interviews confirmed the inadequate care, with one CNA citing a lack of supplies. The facility's perineal care policy, which requires using separate sections of a washcloth or new wipes for each stroke, was not followed.
A resident, who was cognitively intact and had significant medical conditions, requested the COVID-19 vaccine and completed a consent form. Despite this, the facility failed to administer the vaccine as requested, as confirmed by both the resident and the ADON. The facility's policy to educate and offer vaccines was not adhered to in this instance.
The facility failed to assist a resident with arranging transportation to physician appointments, resulting in missed orthopedic and cardiologist appointments due to transportation-related issues and a change in payor source that was not identified in time. This deficiency was confirmed by interviews with the resident and the DON.
Failure to Provide Timely Feeding Assistance to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with eating to a dependent resident who required supervision and assistance during meals. The resident had diagnoses including COPD, unspecified dementia, anxiety disorder, hypertension, overactive bladder, and spinal stenosis. The most recent MDS showed moderately impaired cognition and a need for supervision at meals, and the care plan documented that the resident required assistance with meals as needed. Physician orders specified a pureed diet with thin/regular liquids, upright positioning during meals, and total supervision during meals because the resident needed assistance with feeding. A quarterly nutrition assessment further documented that the resident required supervision at meals and was fully dependent at times. On the morning of the survey observation, the resident was observed sitting in a chair with eyes closed and a breakfast tray in front of him with the lid still on at 8:35 A.M., and again at 8:42 A.M. with the tray still unopened. At 8:51 A.M., a CNA entered the room to feed the resident and reported that another CNA had delivered the tray earlier. At 8:54 A.M., the second CNA confirmed she had placed the tray in the room around 8:35 A.M. and explained that staff typically place trays in rooms for residents needing assistance, then continue delivering other trays before returning to assist with eating. The Dietary Supervisor and Corporate Compliance staff confirmed that CNAs or other staff should not deliver trays to residents who need assistance with eating until they are ready to assist, and the Dietician confirmed the resident needed assistance and supervision at all times when eating. This sequence of actions resulted in a delay in feeding assistance for the dependent resident.
Failure to Update PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure an updated Pre-admission Screening and Resident Review (PASARR) was completed for a resident with a newly identified serious mental illness. Medical record review showed that the resident was admitted with diagnoses including dementia and later received a diagnosis of schizoaffective disorder bipolar type. The initial PASARR, completed at admission, indicated no serious mental illness, but after the new diagnosis was added, there was no documentation of an updated PASARR. Staff interview confirmed that only the original PASARR was on file, and facility policy requires prompt referral for a Level II review when a new serious mental disorder is identified.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed as ordered for a resident requiring continuous oxygen therapy. Medical record review showed that the resident, admitted with chronic respiratory failure with hypoxia, COPD, and a history of pulmonary embolism, had a physician's order for continuous oxygen at bedtime and for the oxygen tubing to be changed weekly on Sundays. During an observation, the oxygen tubing in the resident's room was found to be dated more than two weeks prior, indicating it had not been changed according to the order. Staff confirmed the date on the tubing, and facility policy required weekly changes of oxygen tubing and mask/cannula, as well as adherence to infection control measures.
Medications Not Administered by Preparing Nurse
Penalty
Summary
A deficiency occurred when a nurse prepared medications for a resident but did not administer them herself, instead handing them to another nurse to administer. Specifically, one LPN pulled and prepared medications from the medication cart for a resident with chronic obstructive pulmonary disease, cerebral infarction, and dementia, who was dependent on staff for medication administration. The prepared medications were then given to a second LPN, who administered them to the resident. Both nurses confirmed this sequence of events during interviews. Facility policy requires that medications be administered by licensed nurses in accordance with standards of practice, and that the nurse who prepares the medications should be the one to administer them. This practice was not followed, as observed during the medication pass. The incident was identified during a review of medication administration for one resident, but it had the potential to affect all residents on the same hall.
Failure to Implement Physician-Approved Pharmacy Recommendations
Penalty
Summary
The facility failed to implement pharmacy recommendations that were approved by the facility physician for a resident with diagnoses including dementia, COPD, and cerebral infarction. The contracted pharmacy conducted a new admission review and recommended changes to the resident's medication regimen, including adjusting the Lidocaine patch order, discontinuing Oxybutynin, and switching from Xarelto to Eliquis. The physician reviewed and approved these recommendations, ordering the changes as suggested by the pharmacy. Despite the physician's approval, the facility did not implement the medication changes for the resident. Medical record review confirmed that the approved pharmacy recommendations were not carried out, and interviews with staff, including the MDS nurse and DON, verified there was no documentation of the orders being implemented. Additionally, the hospice RN reported that hospice was not contacted regarding the approved medication changes, and if they had been informed, they would have coordinated with the hospice physician and approval department.
Failure to Administer Physician-Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident with diagnoses including COPD, stroke, and dementia, who had moderate cognitive impairment. Medical record review showed that the resident did not receive prescribed doses of Rivaroxaban 20 mg on four separate occasions in May 2025 due to the medication being out of stock or unavailable. Documentation indicated that the pharmacy was notified and reorders were sent, but there was no evidence the resident received the missed doses. The facility's policy requires medications to be administered as ordered and in accordance with standards of practice, but this was not followed in these instances.
Failure to Date Opened Ophthalmic Medication
Penalty
Summary
A deficiency was identified when a medication cart on the 400-hall was observed to contain an open container of Rhopressa 0.02% Ophthalmic Solution prescribed for a resident with diagnoses including open angle glaucoma, hypertension, Parkinson's Disease, and chronic kidney disease. The medication bottle, which was ordered to be administered as one drop in both eyes daily, was found to be opened but not dated. During the observation, an LPN confirmed that the bottle was indeed opened and undated, and acknowledged that it should have been dated at the time of opening. Review of the facility's medication storage policy indicated that all medications are to be stored according to manufacturer recommendations, which for Rhopressa includes a specific timeframe for use after opening.
Failure to Implement Water Management and Infection Control Protocols
Penalty
Summary
The facility failed to implement and document an effective Water Management Program (WMP) to reduce the risk of Legionella in the water system. Review of the facility's Legionella Environmental Assessment Form revealed it lacked a description or diagram of the water system, and there was no documentation of required monthly chlorine testing or visual inspections for biofilm. The Maintenance Supervisor confirmed that these assessments and tests had not been completed, despite the facility's policy stating that such control measures and documentation were required. Additionally, the facility did not ensure proper infection prevention and control practices during a pressure ulcer dressing change for a resident with multiple comorbidities, including diabetes, hypertension, heart failure, and anemia. The resident had a pressure ulcer on the sacrum and buttocks, and physician orders required twice-daily wound care. During an observed dressing change, there was no Enhanced Barrier Precautions (EBP) signage or PPE cart outside the room, and the LPNs involved did not wear gowns as required by EBP guidelines for residents with wounds. The wound was also cleansed from the outside toward the center, contrary to recommended technique. Staff interviews confirmed that the required EBP protocols were not followed, including the use of gowns and the correct wound cleaning technique. The failure to follow these infection control measures and to maintain a comprehensive WMP had the potential to affect all residents in the facility, as confirmed by the census of 59 residents.
Failure to Notify POA of Resident Health Changes
Penalty
Summary
The facility failed to notify a resident's responsible party or power of attorney (POA) of significant health changes, as required by facility policy. Medical record review for a resident with diagnoses including Parkinson's disease, anxiety, hypertension, and glaucoma, and with severely impaired cognition, showed two separate incidents where the resident experienced notable changes in condition: one involving low oxygen saturation and wheezing, and another where the resident was lethargic and unresponsive after medication administration. In both cases, while the physician was notified and interventions were initiated, there was no documented evidence that the resident's POA was informed of these changes. Staff interviews confirmed that no notification was made to the POA during these events, despite facility policy mandating such communication.
Failure to Timely Implement Fall Interventions for At-Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to timely develop and implement fall interventions for a resident who was at risk for falls. The resident, who had multiple diagnoses including encephalopathy, altered mental status, diabetes, depression, acute respiratory failure, chronic kidney disease, anemia, peripheral vascular disease, visual hallucinations, congestive heart failure, chronic atrial fibrillation, and obstructive sleep apnea, was admitted and assessed as being at risk for falls. The admission assessment indicated the need to follow the facility's fall protocol and to anticipate the resident's needs. However, no specific fall interventions were care planned until several days after admission. An incident occurred in which the resident was found on the floor with a skin tear, requiring treatment and assistance back to bed. Review of the care plan showed that fall interventions were not added until after this incident. Staff interviews confirmed that fall interventions were not care planned until after the fall, and facility policy required that fall interventions be initiated on the resident's baseline care plan. This lapse affected the resident's safety and represented a failure to provide adequate supervision and accident hazard prevention as required.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident. The resident, who had been admitted with diagnoses including chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder, was discharged from the hospital with a medication order for guaifenesin 600 mg to be taken every 12 hours. A subsequent physician order on 12/17/24 specified guaifenesin extended release 600 mg twice daily for seven days. However, the resident did not receive the first dose until 12/18/24 at 9:00 A.M., resulting in missed doses. This was confirmed by an interview with the Assistant Director of Nursing, who verified the delay in medication administration. The facility's policy on medication administration requires that medications be administered by licensed nurses as ordered by the physician, which was not adhered to in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, leading to significant medication errors for a resident. The resident, who had a medical history including chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder, was admitted with specific medication orders. These included a diuretic, furosemide 20 mg daily, and a steroid, Medrol dose pack, with detailed instructions. However, the facility did not administer these medications according to the physician's orders. The resident reported not receiving medications for several days post-admission, and the Assistant Director of Nursing confirmed the missed doses and incorrect administration of Medrol. The review of the medication administration record (MAR) showed discrepancies in the administration of Medrol and furosemide. The Medrol was not given according to the dose pack instructions, and the furosemide was not administered on the scheduled days despite being available in the facility's contingency medication supply. A photograph of the Medrol pack revealed that several tablets were not administered as per the instructions. The facility's policy on medication administration, which mandates that medications be given as ordered by the physician, was not followed, leading to this deficiency.
Failure to Provide Properly Sized Briefs for Residents
Penalty
Summary
The facility failed to provide appropriately sized briefs for residents who required and preferred a specific size, affecting two residents. Resident #7, who was admitted with diagnoses including cerebrovascular attack, coronary artery disease, and morbid obesity, was cognitively intact and dependent on staff for toileting. Despite her requests for a three XL brief, the facility only provided a two XL brief, which did not fit properly, leaving her skin exposed. Multiple staff members confirmed the lack of three XL briefs in the facility, and observations in the supply rooms verified their absence. Similarly, Resident #16, who was admitted with diagnoses including peripheral vascular disease, respiratory failure, and renal insufficiency, was frequently incontinent and also required a three XL brief. She reported that the facility often ran out of her size, resulting in her wearing a two XL brief that caused skin irritation. Observations confirmed the absence of three XL briefs in the supply rooms. The facility's policy on resident rights states that residents have the right to reasonable accommodation of their needs and preferences, which was not upheld in these cases.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that a change in condition was reported to the physician for a resident who was cognitively intact and had been admitted with multiple diagnoses, including aftercare for a displaced supracondylar fracture with intercondylar extension of the lower end of the right femur. The resident experienced bleeding from her surgical incision site on multiple occasions as documented in the Physical Therapy and Occupational Therapy notes. However, there was no evidence that the physician was notified of this bleeding, as required by the facility's policy on Notification of Changes. The deficiency was further confirmed through an interview with the Wound Nurse Practitioner, who verified that she was not informed about the bleeding from the resident's incision site. The facility's policy mandates prompt notification of the resident's physician and representative when there is a change requiring notification, which was not adhered to in this case. This oversight was identified during an investigation under Complaint Number OH00159578.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide appropriate and thorough incontinence care for Resident #7, who was dependent on staff for toileting and was incontinent of bowel and bladder. During an observation of incontinence care, it was noted that the CNAs used a bath towel to clean the resident, but did not turn the towel over to use a clean section for washing different areas. Additionally, when the resident urinated during the care, the CNAs did not adequately clean the urine from the resident's legs, as one CNA only used a clean cloth to wash down the front of the resident without wiping her legs. Interviews with the CNAs confirmed the inadequate care provided. CNA #186 admitted to using the same towel for cleaning due to a lack of available supplies, while CNA #188 acknowledged seeing urine running down the resident's legs and confirmed that she did not wash the resident's legs afterward. The facility's policy on perineal care, which emphasizes cleanliness and the prevention of infection and skin breakdown, was not followed, as the CNAs did not use separate sections of the washcloth or new disposable wipes for each cleaning stroke as required.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to a resident who had requested it. Resident #7, who was cognitively intact and had diagnoses including cerebrovascular attack, coronary artery disease, and morbid obesity, was admitted to the facility and had expressed a desire to receive the COVID-19 vaccine. The resident had completed a vaccine consent form on 11/05/24, indicating a request for two COVID-19 vaccines. However, a review of the progress notes and the Medication Administration Record (MAR) from 11/05/24 through 11/25/24 showed no evidence that the vaccines were administered. An interview with the resident on 11/21/24 confirmed that she had been requesting the vaccines since September 2024 but had not received them. The Assistant Director of Nursing (ADON) confirmed on 11/25/24 that the resident did not receive the vaccines. The facility's policy aimed to minimize COVID-19 risks by educating and offering vaccines to residents and staff, but this was not followed in this case.
Failure to Assist with Transportation to Physician Appointments
Penalty
Summary
The facility failed to ensure that residents were assisted with arranging transportation to physician appointments, affecting one resident out of three reviewed for appointments. Resident #52, who was admitted on 12/27/23, had diagnoses including type two diabetes mellitus, chronic obstructive pulmonary disease, chronic viral hepatitis, hypertension, and osteoarthritis of the hip. Despite being cognitively intact with a BIMS score of 14 out of 15, Resident #52 missed multiple orthopedic and cardiologist appointments due to transportation-related issues. The orthopedic appointments were scheduled but missed on 02/28/24, 03/11/24, 03/14/24, and 04/01/24, while the cardiologist appointment was missed on 04/16/24. There was no documented reason for the missed appointments on 02/28/24 and 04/16/24. Interviews with Resident #52 and the Director of Nursing (DON) confirmed the delays and issues in scheduling and attending these appointments. The DON acknowledged that the missed appointments on 04/01/24 and 04/16/24 were due to a change in payor source that was not identified in time. Facility staff were responsible for contacting transportation companies and providing the correct payor source information, which was not done, leading to the missed appointments. This deficiency was investigated under Complaint Number OH00152779.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Widows Home Of Dayton | 2 mi | ★★★★★ | 4 | 0 |
| Dunbar Health & Rehab Center | 2.3 mi | ★★★★★ | 0 | 0 |
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| Oaks Of West Kettering The | 2.6 mi | ★★★★★ | 15 | 0 |
| Kettering Heights Post Acute | 2.8 mi | ★★★★★ | 7 | 0 |
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