Sanctuary at Wilmington Place

In the surveyor’s words

From the most serious findings on record at Sanctuary at Wilmington Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 24, 2022

  Based on a closed medical record review, observation, staff interview, family interview, review of the Emergency Medical Services (EMS) run report, review of the facility investigation, review of the Self-Reported Incident (SRI), review of the facility procedure guide for Cardiopulmonary Resuscitation (CPR), review of the facility policy for Basic Life Support/CPR, review of the Abuse Policy and Procedure, review of the Condition Change of Resident Policy and review of the American Heart Association Journal, the facility failed to ensure a resident was free from neglect when staff did not respond timely or correctly to a medical emergency for Resident #54 who had a change in condition, was not promptly assessed, and who did not receive immediate and appropriate CPR when the resident was… […]

• Immediate jeopardy, isolatedF678Feb 24, 2022

  Based on a closed medical record review, observation, staff interview, family interview, review of the Emergency Medical Services (EMS) run report, review of the facility investigation, review of the facility procedure guide for Cardiopulmonary Resuscitation (CPR), review of the facility policy for Basic Life Support/CPR, and review of the American Heart Association Journal, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) for one resident (#54) found unresponsive, without a pulse, and who was identified as a Full Code. […]

• Actual harm, isolatedF687Nov 16, 2023

  Based 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. Findings include: Review of medical record for Resident #22 revealed an admitted [DATE] and was recently readmitted on [DATE]. […]

• Actual harm, isolatedF692Mar 19, 2021

  Based on medical record review, hospital record review, staff and Certified Nurse Practitioner (CNP) interview, and review of the Medscape resource, the facility failed to follow a physician's orders [REDACTED]. Actual harm occurred to Resident #55 when the facility failed to implement nutrition interventions, obtain physician ordered laboratory work, and report abnormal laboratory values to the physician. The resident was admitted to the hospital for acute kidney injury and dehydration. This affected one (Resident #55) of three residents reviewed for dehydration. The facility identified five residents who were at risk for dehydration. The facility census was 53. Findings include: Review of Resident #55's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. […]

• No harm, potential for more than minimal, widespreadF727Dec 27, 2022

  Based 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. Findings include: Review of the staffing schedule, dated 12/10/22, revealed no Registered Nurse (RN) was present in the facility on 12/10/22. Interview with Corporate Registered Nurse (CRN) #81 on 12/20/22 at 10:03 A.M. verified the facility did not have an RN present in the facility for eight consecutive hours on 12/10/22. This deficiency represents non-compliance investigated under Complaint Number OH00138026.