Sanctuary Wadsworth

In the surveyor’s words

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

• Actual harm, isolatedF686Aug 27, 2026

  Based on record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and effective pressure ulcer prevention program to prevent pressure ulcers from developing and/or worsening. The facility failed to ensure proper and appropriate wound care treatments were provided, failed to ensure pressure ulcer prevention measures were obtained and implemented timely, and failed to ensure ongoing monitoring/weekly skin checks were completed to prevent the worsening of pressure ulcers and/or the development of new pressure ulcers.Actual harm occurred on 08/11/26 when Resident #70, who was at risk for pressure ulcer development and required substantial staff assistance for activities of daily living, was assessed to have a new in-house deep tissue… […]

• Actual harm, isolatedF686Jul 20, 2026

  Based on record review, observation, interviews, and facility policy review, the facility failed to assess and treat Resident #10's pain prior to or during wound care to her sacrum. Actual Harm occurred on 07/09/26 when Resident #10 was observed to verbalize pain every four seconds during a 23-minute continuous observation of care and her pain was not assessed or treated until care was complete, at which time her pain was rated as a 10 out of 10 (on a scale of 1 to 10 with 10 being the greatest amount of pain one could experience). This affected one (Resident #10) of two residents observed for wound care. […]

• No harm, potential for more than minimal, widespreadF812Jul 20, 2026

  Based on observation, interview and policy review the facility failed to ensure a sanitary kitchen and resident refrigerators were maintained to prevent food spoilage. This had the potential to affect all 59 residents receiving meals from the kitchen, as five residents (Residents #4, #27, #31, #63, and #64) received nothing by mouth. The facility census was 64.Findings include: 1. Observation on 07/08/26 at 11:08 A.M. during lunch meal service revealed Dietary #514 had a hair net on but hair on the back of her neck was not restrained and the line of the hair net was approximately an inch above the exposed hair. At the time of the observation Dietary Manager #510 confirmed the observation. Observation on 07/08/26 at 12:31 P.M. […]

• No harm, potential for more than minimal, widespreadF835Jul 20, 2026

  Based on record reviews, review of personnel records, interviews, and facility policy review, the facility administration failed to effectively administer the facility when they failed to maintain professional standards of practice by falsifying clinical documentation and instructing staff to do the same, thereby compromising the integrity of facility records and resident care. This had the potential to affect 21 residents (Residents #1, #3, #6, #9, #14, #17, #18, #22, #26, #28, #32, #33, #37, #41, #43, #47, #51, #53, #56, #58 and #64), who received blood glucose monitoring. This also had the potential to affect the clinical documentation all 64 residents residing in the facility. The facility census was 64. […]

• No harm, potential for more than minimal, widespreadF761Jul 29, 2021

  Based on observation, interview and record review, the facility failed to monitor medication storage refrigerators on a daily bases and maintain the refrigerator temperature at the recommended temperature of 36 to 46 degree Fahrenheit (F). The facility also failed to monitor and expose of 13 expired Insyte Autoguards (used to start intravenous lines) that were located in the Intravenous (IV) cart. This had the potential to affect 13 residents (Resident #1, #2, #5, #20, #25, #32, #42, #45, #47, #50, #207, #258, and #261) of 13 residents reviewed for medication storage, with the potential to affect all 53 residents in the facility. Findings include: 1. Observation on [DATE] at 8:30 A.M. […]