Sanctuary at Wilmington Place

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to notify the medical provider of resident seizure activity. This affected one (Resident #36) of three residents reviewed for notification of change in condition. The facility census was 57 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure staff provided timely incontinence care for dependent residents. This affected one (Resident #51) of four residents reviewed for incontinence care. The facility census was 57 residents.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure laboratory services were completed as ordered by the physician. This affected one (Resident #36) of three residents reviewed for laboratory services. The facility census was 57 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely assistance with eating for a dependent resident. This affected one (Resident #22) of four residents reviewed for feeding assistance. The facility census was 55.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to notify a resident's responsible party/power of attorney (POA) of health changes. This affected one (#30) of the three residents reviewed for notification. The facility census was 59.

Inspectors wroteBased on medical record review, facility policy review, and staff interview, the facility failed to ensure an updated Pre-admission Screening and Resident Review (PASARR) was completed. This affected one (#41) of the two residents reviewed for PASARR. The facility census was 59.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to timely develop and implement fall interventions to help reduce and/or eliminate falls. This affected one (#210) of the three residents reviewed for falls. The facility census was 59.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen tubing was changed as ordered. This affected one (#05) of the two residents reviewed for oxygen therapy. The facility census was 59.

Inspectors wroteBased on medical record review, observations, staff interviews, and policy review, the facility failed to ensure medications were administered by the nurse who prepared the medications. This affected one (#15) of the seven residents investigated for medication administration. This had the potential to affect all twelve Residents (#08, #11, #15, #20, #21, #22, #25, #28, #31, #32, #38, and #47) on 200-hall. The facility census was 59.

Inspectors wroteBased on medical record review, staff interview, and interview with contracted pharmacy staff, the facility failed to implement pharmacy recommendations agreed upon by the facility's physician. This affected one (#15) of the five residents reviewed for unnecessary medications. The facility census was 59.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to administer medications per physician orders. This affected one (#15) of the seven residents investigated for medication administration. The facility census was 59.

Inspectors wroteBased on observation, staff interview, record review and policy review, the facility failed to ensure medications were stored properly. This affected one (#30) of the 12 residents who resided on the 400-hall and received medications. The facility census was 59.

Inspectors wrote2) Review of the undated facility form titled Legionella Environmental Assessment Form with Maintenance Supervisor (MS) #58, revealed the facility's WMP included monthly chlorine testing and visual inspections for biofilm. The Legionella Assessment form did not include a description or diagram of the facility's water system. Interview on 06/02/25 at 2:29 P.M. with MS #58, verified there was no description or diagram of the facility's water system. MS #59 stated he had no documentation related to biofilm inspections or chlorine testing because they had not been completed. Review of the facility's undated Water Management Program revealed the facility would establish a WMP for reducing risk of pathogens in the facility's water systems. The policy indicated a variety of control measures may be used, such as visual inspections and disinfectant level control. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure the appropriate size brief was provided to the residents who require and prefer a specific size brief. This affected two (#8 and #16) of two residents reviewed for briefs. The facility census was 60.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure a change of condition was reported to the physician. This affected one (#64) of three residents reviewed for change of condition. The facility census was 60.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided appropriately and thoroughly. This affected one (Resident #7) of three residents reviewed for incontinence. The facility census was 60.

Inspectors wroteBased on medical record review, staff and resident interview, and policy review, the facility failed to ensure residents were administered the COVID-19 vaccine when requested. This affected one (#7) of three residents reviewed for vaccines. The facility census was 60.

Inspectors wroteBased on medical record review and resident and staff interviews, the facility failed to ensure residents were assisted with arranging transportation to physician appointments. This affected one (#52) of three residents reviewed for appointments. The censes was 57.

Inspectors wroteBased on medical record review, staff, resident, and Certified Nurse Practitioner (CNP) #19 interviews and policy review, the facility failed to appropriately assessment and implement a physician ordered treatment for a residents newly identified skin breakdown on the residents toes on the left foot. This resulted in Actual Harm when Resident #22's newly identified open areas on the resident's left toes were not assessed, and a physician ordered treatment was not implemented subsequently resulting in worsening of the area and hospitalization. This affected one (#22) of three residents reviewed for skin breakdown. Facility census was 53.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, observations and resident and staff interviews, the facility failed to ensure residents received timely incontinence care. This affected one (#22) of three residents reviewed for incontinence care. Facility census was 53.

Inspectors wroteBased on review of staffing schedule and staff interview, the facility failed to ensure Registered Nurse (RN) services were used for at least eight consecutive hours a day seven days a week. This had the potential to affect all 58 residents in the facility. The facility census was 58.

Inspectors wroteBased on review of personnel files and staff interview, the facility failed to complete nurse aide performance reviews at least every 12 months for two State Tested Nurse Aides. This had the potential to affect all 58 residents in the facility. The facility census was 58.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure hair nets were worn appropriately, proper hand hygiene was followed, and food items were maintained in a sanitary manner in the kitchen. This had the potential to affect all 58 residents who received meals from the kitchen. The facility census was 58.

Inspectors wroteBased on review of personnel files, staff interview, and policy review, the facility failed to ensure the facility was administered in a manner to prevent the falsification of documentation. This had the potential to affect all 58 residents who resided at the facility. The facility census was 58.

Inspectors wrote2. Review of Resident #15's medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #15's significant change MDS assessment, dated 10/05/22, revealed Resident #15 was cognitively intact. Review of Resident #15's code status care plan, dated 10/31/22, revealed Resident #15 was a Do Not Resuscitate Comfort Care Arrest (DNRCCA). Interventions included code status orders reviewed as needed, offer religious services per advanced care planning preferences, and review advanced care planning wishes upon admission, quarterly and as needed. [...]

Inspectors wroteBased on review of menu spreadsheets, observation, staff interview, and policy review, the facility failed to ensure residents received meals according to the menu spreadsheet. This affected all 52 residents residing in the facility who received a regular or mechanical soft diet. The facility identified six residents (#3, #14, #16, #19, #20, and #104) who did not receive a regular or mechanical soft diet. The facility census was 58.

Inspectors wrote2. Review of Resident #15's medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #15's significant change MDS assessment, dated 10/05/22, revealed Resident #15 was cognitively intact. Review of Resident #15's code status care plan, dated 10/31/22, revealed Resident #15 was a Do Not Resuscitate Comfort Care Arrest (DNRCCA). Interventions included code status orders reviewed as needed, offer religious services per advanced care planning preferences, and review advanced care planning wishes upon admission, quarterly and as needed. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents and/or resident representatives were provided Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) when required. This affected two (#33 and #46) out of three residents reviewed for beneficiary notices. The facility census was 58.

Inspectors wroteBased on staff interview, medical record review, and policy review, the facility failed to provide residents and/or resident representatives with bed hold notices upon transfer to the hospital. This affected two (#15 and #43) out of six residents reviewed for hospitalizations. The facility census was 58.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure medications were administered according to physician order. This affected one (#26) out of five residents reviewed for unnecessary medications. The census was 58.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a monthly medication reviews were completed monthly by a licensed pharmacist. This affected two (#26 and #39) of five residents reviewed for unnecessary medications. The census was 58.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure a resident with dental issues received routine dental care. This affected one (#43) out of two residents reviewed for dental services. The facility census was 58.

Inspectors wroteBased on review of personnel files, staff interview, and policy review, the facility failed to implement their abuse policy. This had the potential to affect all 58 residents in the facility. The facility census was 58.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the daily nurse staffing information was posted every day. This had the potential to affect all 58 residents in the facility. The facility census was 58.

Inspectors wroteBased on record review and staff and resident interview, the facility failed to provide adequate pain control for a resident after her admission to the facility. This resulted in actual harm when nursing staff failed to ensure Resident #110 received an as needed (PRN) pain medication when she rated her pain a 10 out of 10 (a scale indicating zero for no pain and ten being the worse pain ever) and when interviewed described it as excruciating pain resulting in crying. This affected one (#110) of six residents reviewed for pain during the annual survey. The facility identified 24 residents on a pain management program. The facility census was 60.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the kitchen was maintained in a sanitary manner, food was stored off the floor, and food was dated and labeled. This affected 59 of 60 residents who receive food from the kitchen (Residents #11 received nothing by mouth).

Inspectors wroteBased on observation, record review, resident and staff interview, review of Centers for Disease and Control Prevention (CDC) guidelines and policy review, the facility failed to ensure standard infection control practices were followed for the residents. This affected one (#4) of three residents reviewed for infections. The facility additionally failed to provide monitoring of their water management plan to assist in the prevention of Legionella. This had the potential to affect all 60 residents residing in the facility. Findings Include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cellulitis of upper and multiple myeloma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/19/19, revealed the resident was cognitively intact and had no delusions, hallucinations or behaviors. [...]

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to store medications, inhalation medications and nutritional supplements according to their expiration dates. This had the potential to affect six residents (#11, #15, #26, #31, #44 and #110) who were identified as having used inhalation medications and seven residents (#20, #27, #33, #38, #43, #45 and #111) as having used nutritional supplements by the facility. The facility census was 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to have an accurate advance directive status for one (#40) of 24 residents reviewed in the initial pool during the annual survey. The facility census was 60.

Inspectors wroteBased on record review and facility staff interview, the facility failed to accurately assess residents on their Minimum Data Set assessments. This affected two (#11 and #48) of 20 resident records reviewed. The total facility census was 60.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure annual performance reviews were completed for state tested nurse aides (STNA). This affected two of two personnel records reviewed for annual performance reviews. This had the potential to affect all 60 residents residing in the facility. Findings Include: 1. Review of the personnel record for STNA #702 revealed a hire date of 06/04/18. The personnel record for STNA #702 lacked any evidence that an annual performance review was completed. 2. Review of the personnel record for STNA #704 revealed a hire date of 08/10/18. The personnel record for STNA #704 lacked any evidence that an annual performance review was completed. Interview with Staff Scheduler #600 on 11/26/19 at 2:45 P.M. verified there was no evidence of annual performance reviews completed for STNA #702 and STNA #704.