Inspection Reports for
Sanctuary at Wilmington Place the
264 WILMINGTON AVENUE, DAYTON, OH, 45420
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
177% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Jan 27, 2026
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to provide timely assistance with eating for a dependent resident.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2621161.
Findings
The facility failed to provide timely assistance with eating for Resident #22, who required supervision and assistance during meals. Observations and interviews confirmed delays in feeding assistance contrary to facility policy and physician orders.
Deficiencies (1)
F 0677: Provide care and assistance to perform activities of daily living for any resident who is unable. The facility failed to provide timely assistance with eating for Resident #22, resulting in delayed feeding despite orders and care plans.
Report Facts
Facility census: 55
Residents reviewed for feeding assistance: 4
Resident affected: 1
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 9
Date: Jun 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation into multiple allegations including failure to notify responsible parties of resident health changes, failure to update PASARR assessments, failure to implement fall interventions, improper medication administration, failure to implement pharmacy recommendations, medication storage issues, infection prevention and control program deficiencies, and failure to implement a Water Management Program.
Complaint Details
This deficiency report represents non-compliance investigated under Master Complaint Number OH00164992 and Complaint Numbers OH00162762 and OH00164992.
Findings
The facility was found to have multiple deficiencies including failure to notify resident's responsible party of health changes, failure to update PASARR for residents with new mental health diagnoses, delayed fall interventions, improper medication administration and storage, failure to implement pharmacy recommendations, failure to prevent medication errors, inadequate infection prevention practices during wound care, and failure to develop and implement a Water Management Program to reduce Legionella risk.
Deficiencies (9)
F 0580: The facility failed to notify a resident's responsible party of health changes affecting one resident. The facility census was 59.
F 0644: The facility failed to ensure an updated PASARR was completed for a resident with a new diagnosis of schizoaffective disorder. The facility census was 59.
F 0689: The facility failed to timely develop and implement fall interventions for a resident at risk for falls. The facility census was 59.
F 0695: The facility failed to ensure oxygen tubing was changed as ordered for a resident receiving oxygen therapy. The facility census was 59.
F 0755: The facility failed to ensure medications were administered by the nurse who prepared them, affecting one resident and potentially others on the same hall. The facility census was 59.
F 0756: The facility failed to implement pharmacy recommendations approved by the physician for a resident's medications. The facility census was 59.
F 0760: The facility failed to administer medications per physician orders for a resident, with multiple doses of Rivaroxaban not given due to being out of stock. The facility census was 59.
F 0761: The facility failed to ensure medications were stored properly; an opened ophthalmic solution bottle was undated. The facility census was 59.
F 0880: The facility failed to ensure Enhanced Barrier Precautions were used during a resident's pressure ulcer dressing change and failed to develop and implement a Water Management Program to reduce Legionella risk. The facility census was 59.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 59
Medication doses not administered: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #53 | Licensed Practical Nurse | Prepared medications for Resident #15 but did not administer them |
| LPN #42 | Licensed Practical Nurse | Administered medications to Resident #15 prepared by LPN #53 |
| MDS Nurse #59 | Minimum Data Set Nurse | Verified pharmacy recommendations were not implemented for Resident #15 |
| Director of Nursing | Director of Nursing | Verified lack of documentation for pharmacy recommendation implementation and medication administration failures |
| Hospice RN #123 | Hospice Registered Nurse | Reported hospice was not contacted regarding pharmacy recommendations for Resident #15 |
| LPN #39 | Licensed Practical Nurse | Observed with undated opened medication bottle for Resident #30 |
| LPN #54 | Licensed Practical Nurse | Observed failing to follow Enhanced Barrier Precautions during Resident #24's dressing change |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Jun 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify responsible parties of resident health changes and failure to timely develop and implement fall interventions.
Complaint Details
This deficiency represents non-compliance investigated under Master Complaint Number OH00164992 for notification failure and Complaint Number OH00162762 for fall prevention failure.
Findings
The facility failed to notify a resident's power of attorney of significant health changes and failed to timely implement fall prevention interventions for a resident at risk of falls. Both deficiencies affected one resident each and were investigated under separate complaint numbers.
Deficiencies (2)
F 0580: The facility failed to notify Resident #30's power of attorney of changes in health condition on 09/23/24 and 02/21/25 as required by policy.
F 0689: The facility failed to timely develop and implement fall interventions for Resident #210, who was found on the floor with a skin tear after no fall interventions were care planned until five days after admission.
Report Facts
Facility census: 59
Residents reviewed for notification: 3
Residents reviewed for falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #59 | Interviewed regarding failure to notify Resident #30's POA and fall intervention care planning | |
| MDS Coordinator #59 | Interviewed regarding fall intervention care planning for Resident #210 |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Dec 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Master Complaint Number OH00161089 and Complaint Number OH00160325 regarding medication administration issues at the facility.
Complaint Details
This deficiency represents non-compliance investigated under Master Complaint Number OH00161089 and Complaint Number OH00160325.
Findings
The facility failed to ensure medications were available and administered as ordered, resulting in missed doses and medication errors affecting Resident #13. The issues involved delayed administration of guaifenesin and incorrect administration of Medrol and furosemide medications.
Deficiencies (2)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of each resident and ensure medications were available to administer as ordered. Resident #13 missed doses of guaifenesin 600 mg extended release tablets, receiving the first dose late on 12/18/24.
F 0760: The facility failed to ensure residents were free from significant medication errors. Resident #13 missed doses of furosemide 20 mg and was not administered Medrol 4 mg correctly per physician orders, with unused medication remaining in the medication pack.
Report Facts
Facility census: 54
Medrol tablets removed: 8
Medrol tablets remaining: 13
Furosemide tablets on hand: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) #262 | Verified missed doses and medication administration issues for Resident #13 | |
| Registered Nurse (RN) #219 | Documented medication orders and administration notes for Resident #13 | |
| Administrator | Confirmed photograph of Medrol medication pack left unused |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 4
Date: Nov 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints regarding resident care issues including inappropriate brief sizes, failure to report changes in condition, inadequate incontinence care, and failure to administer requested COVID-19 vaccines.
Complaint Details
This inspection was conducted under Complaint Numbers OH00158992 and OH00159578. The complaints involved failure to provide appropriate briefs, failure to report change of condition, inadequate incontinence care, and failure to administer COVID-19 vaccines as requested.
Findings
The facility failed to provide appropriate size briefs to residents requiring them, did not notify the physician of a resident's bleeding surgical site, provided inadequate incontinence care, and failed to administer COVID-19 vaccines to a resident who requested them. These deficiencies affected multiple residents and represent non-compliance.
Deficiencies (4)
F 0558: The facility failed to provide appropriate size briefs to residents who require and prefer a specific size, affecting two residents. The facility census was 60.
F 0580: The facility failed to notify the physician of a resident's bleeding surgical incision site, affecting one resident. The facility census was 60.
F 0690: The facility failed to provide appropriate and thorough incontinence care to a resident, including using the same towel for cleaning and not washing urine from the legs. The facility census was 60.
F 0887: The facility failed to administer COVID-19 vaccines to a resident who requested them, despite documented consent. The facility census was 60.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP #189 | Wound Nurse Practitioner | Verified staff did not notify her of bleeding from Resident #64's incision site |
| CNA #169 | Certified Nursing Aide | Reported Resident #7 was wearing a two XL brief instead of the required three XL |
| CNA #186 | Certified Nursing Aide | Observed incontinence care and verified lack of appropriate brief size for Resident #7 |
| CNA #188 | Certified Nursing Aide | Observed incontinence care and verified urine was not properly cleaned from Resident #7's legs |
| DM #116 | Dietary Manager | Verified no three XL briefs were found in supply rooms |
| ADON #141 | Assistant Director of Nursing | Confirmed Resident #7 did not receive COVID-19 vaccines |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 4
Date: Nov 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints regarding resident care issues including inappropriate brief sizes, failure to report changes in condition, inadequate incontinence care, and failure to administer requested COVID-19 vaccines.
Complaint Details
The deficiencies represent non-compliance investigated under Complaint Numbers OH00158992 and OH00159578, involving issues with resident briefs, change of condition reporting, incontinence care, and COVID-19 vaccination.
Findings
The facility failed to provide appropriate size briefs to residents requiring them, did not notify the physician of a resident's bleeding surgical site, provided inadequate incontinence care, and failed to administer COVID-19 vaccines to a resident who requested them. These deficiencies affected multiple residents and represent non-compliance.
Deficiencies (4)
F 0558: The facility failed to provide appropriate size briefs to residents who require and prefer a specific size, affecting two residents. Three XL briefs were not available in the facility supply rooms.
F 0580: The facility failed to notify the physician of bleeding from a resident's surgical incision site, affecting one resident. Progress notes and therapy notes lacked documentation of notification.
F 0690: The facility failed to provide appropriate and thorough incontinence care for one resident. Staff used the same towel to clean front and back and did not wash urine off the resident's legs.
F 0887: The facility failed to administer COVID-19 vaccines to a resident who requested them. Documentation showed no evidence of vaccine administration despite resident requests.
Report Facts
Facility census: 60
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP #189 | Wound Nurse Practitioner | Named in failure to notify physician of bleeding surgical site |
| CNA #169 | Certified Nursing Aide | Named in brief size deficiency observation |
| CNA #186 | Certified Nursing Aide | Named in brief size deficiency and incontinence care observations |
| CNA #188 | Certified Nursing Aide | Named in brief size deficiency and incontinence care observations |
| DM #116 | Dietary Manager | Verified absence of three XL briefs in supply rooms |
| ADON #141 | Assistant Director of Nursing | Confirmed resident did not receive COVID-19 vaccines |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to ensure residents were assisted with arranging transportation to physician appointments.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00152779.
Findings
The facility failed to ensure Resident #52 was transported to scheduled orthopedic and cardiologist appointments due to delays and issues with payor source information. Several appointments were missed without documented reasons, and the Director of Nursing confirmed delays and transportation problems.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care by not assisting Resident #52 with arranging transportation to physician appointments, resulting in missed orthopedic and cardiologist visits.
Report Facts
Residents Affected: 1
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed delays in scheduling and transportation issues for Resident #52 |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 3
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of medication misappropriation, inadequate incontinence care, and failure to provide appropriate foot care resulting in harm.
Complaint Details
This deficiency is based on incidental findings discovered during the course of this complaint investigation under Complaint Number OH00147600.
Findings
The facility failed to timely report suspected medication misappropriation, provide timely incontinence care, and appropriately assess and treat a resident's foot wounds, resulting in actual harm and hospitalization. These deficiencies affected specific residents reviewed during the investigation.
Deficiencies (3)
F 0609: The facility failed to timely report an allegation involving misappropriation of Resident #18's medications to the Ohio Department of Health as required.
F 0677: The facility failed to ensure Resident #22 received timely incontinence care, resulting in skin redness and an open area on the right thigh fold.
F 0687: The facility failed to appropriately assess and implement physician-ordered treatment for Resident #22's newly identified skin breakdown on the left toes, resulting in worsening wounds, surgical amputation, and hospitalization.
Report Facts
Facility census: 53
Medication sign-outs: 34
Medication wastes: 11
Resident #22 BIMS score: 11
Open area size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #16 | Licensed Practical Nurse | Named in medication misappropriation finding |
| Director of Nursing | Director of Nursing | Interviewed regarding medication misappropriation and wound care findings |
| Registered Nurse #12 | Registered Nurse | Interviewed regarding medication misappropriation and observed dressing change |
| State Tested Nursing Assistant #11 | STNA | Observed providing incontinence care to Resident #22 |
| Certified Nurse Practitioner #19 | CNP | Interviewed regarding assessment of Resident #22's foot wounds |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 14
Date: Dec 27, 2022
Visit Reason
The inspection was conducted to investigate complaints related to advanced directives accuracy, notification of Medicare/Medicaid coverage, abuse policy implementation, bed hold notices, care plan completeness, nurse staffing, nurse aide performance reviews, medication administration, pharmacy reviews, dental care, menu compliance, food safety, and falsification of documentation.
Complaint Details
This inspection was complaint-related, investigating multiple allegations including inaccurate advanced directives, failure to provide required notices, abuse policy violations, staffing issues, medication errors, dental care deficiencies, food safety concerns, and falsification of documentation.
Findings
The facility had multiple deficiencies including inaccurate advanced directives documentation, failure to provide required notices to residents, incomplete abuse policy implementation, missing bed hold notices, incomplete care conferences, insufficient RN coverage, missing nurse aide performance reviews, failure to post daily nurse staffing data timely, medication administration errors, missing monthly pharmacy reviews, lack of routine dental care for a resident, menu discrepancies, food safety violations, and falsification of employee physical exam documentation.
Deficiencies (14)
F578: The facility failed to ensure resident advanced directives were accurate for two residents (#4 and #15).
F582: The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage to two residents (#33 and #46).
F607: The facility failed to implement abuse policies by not completing reference checks for three employees.
F625: The facility failed to provide bed hold notices to two residents (#15 and #43) upon hospital transfer.
F657: The facility failed to develop complete care plans timely and failed to conduct required care conferences for two residents (#10 and #39).
F727: The facility failed to ensure an RN was on duty for eight consecutive hours on 12/10/22.
F730: The facility failed to complete nurse aide performance reviews annually for two aides (#02 and #14).
F732: The facility failed to post daily nurse staffing information every day; posted data was two days old.
F755: The facility failed to ensure medications were administered according to physician orders for Resident #26.
F756: The facility failed to ensure monthly medication reviews were completed by a licensed pharmacist for two residents (#26 and #39).
F790: The facility failed to ensure a resident (#43) with dental issues received routine dental care.
F803: The facility failed to ensure residents received meals according to the menu; served less food than listed.
F812: The facility failed to maintain food safety standards including improper food storage, lack of date marking, and staff not following hygiene protocols.
F835: The facility failed to prevent falsification of documentation; multiple employee physicals had photocopied signatures of a nurse practitioner.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 58
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 52
Employees affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #83 | Nurse Practitioner | Signature photocopied on multiple employee physical exam forms without authorization |
| Corporate Registered Nurse #81 | Corporate Registered Nurse | Verified multiple findings including advanced directives inaccuracies and staffing issues |
| Licensed Practical Nurse #55 | Licensed Practical Nurse | Administered medication contrary to physician order for Resident #26 |
| Human Resources #32 | Human Resources | Verified missing reference checks and performance reviews, and falsification of documentation |
| Dietary Manager #05 | Dietary Manager | Verified menu discrepancies and food safety violations |
| Unit Manager #47 | Unit Manager | Confirmed inaccurate advanced directives in care plan for Resident #4 |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 7
Date: Nov 26, 2019
Visit Reason
Annual survey inspection to assess compliance with regulatory requirements for nursing home operations and resident care.
Complaint Details
This inspection substantiated Complaint Number OH00108453 related to pain management and Complaint Number OH00108401 related to infection control and water management.
Findings
The facility was found deficient in multiple areas including inaccurate advance directive documentation, inaccurate Minimum Data Set assessments, inadequate pain management, failure to complete annual performance reviews for nurse aides, improper medication storage including expired medications, unsanitary kitchen conditions, and failure to implement proper infection control and water management practices.
Deficiencies (7)
F 0578: The facility failed to have an accurate advance directive status for one resident (#40) during the annual survey.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments for residents #11 and #48, missing key clinical information.
F 0697: The facility failed to provide adequate pain management for Resident #110, resulting in actual harm due to delayed administration of pain medication.
F 0730: The facility failed to complete annual performance reviews for two state tested nurse aides (STNA #702 and #704).
F 0761: The facility failed to store medications and nutritional supplements according to expiration dates, including expired inhalation medications and supplements.
F 0812: The facility failed to maintain the kitchen in a sanitary manner, with food stored on the floor and unlabeled or undated food items.
F 0880: The facility failed to ensure standard infection control practices for Resident #4 with suspected shingles and failed to monitor their water management plan for Legionella prevention.
Report Facts
Residents reviewed for advance directive: 24
Facility census: 60
Residents reviewed for pain management: 6
Residents on pain management program: 24
Personnel records reviewed for annual performance reviews: 2
Expired nutritional supplement containers: 20
Expired nutritional supplement containers: 4
Expired medication boxes: 2
Residents affected by expired inhalation medications: 6
Residents affected by expired nutritional supplements: 7
Food items stored on floor: 6
Food cases stored on freezer floor: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #701 | Licensed Practical Nurse | Interviewed regarding advance directive status and medication storage |
| Director of Nursing | Director of Nursing | Interviewed regarding advance directive discrepancy, pain management failure, and infection control |
| LPN #100 | Licensed Practical Nurse | Interviewed regarding delayed pain medication administration |
| LPN #99 | Licensed Practical Nurse | Named in relation to failure to fax medication orders and delayed pain medication |
| Staff Scheduler #600 | Staff Scheduler | Interviewed regarding lack of annual performance reviews for STNAs |
| LPN #975 | Licensed Practical Nurse | Interviewed regarding expired inhalation medications |
| Food Service Manager #31 | Food Service Manager | Interviewed regarding unsanitary kitchen conditions and food storage |
| LPN #910 | Licensed Practical Nurse | Interviewed regarding infection control for Resident #4 |
| STNA #920 | State Tested Nursing Assistant | Observed and interviewed regarding Resident #4 skin condition |
| Maintenance Director #604 | Maintenance Director | Interviewed regarding lack of water management monitoring |
Viewing
Loading inspection reports...
