Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

SANCTUARY AT WILMINGTON PLACE

DAYTON, OH · 63 certified beds · Last Life Safety survey June 2, 2025

CMS Certification Number 365789 · first certified April 1990

Ownership

Operated by AMERICAN HEALTH FOUNDATION · Non profit - Corporation

Ownership changed May 1, 2016 (change of ownership)from SANCTUARY AT WHISPERING MEADOWS INC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within OH

35 citations — more than 92% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 15 citations; the earlier surveys in the window averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was June 2025. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

5 of the 35 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 35 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	35
Median facility in OH	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
November 26, 2019	6
December 27, 2022	14
June 2, 2025	15

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2025-06-02
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2025-06-02
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2025-06-02
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	2	2025-06-02
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	2	2025-06-02
K-0920	Ensure proper usage of power strips and extension cords.	2	2025-06-02
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	2	2025-06-02
K-0712	Have simulated fire drills held at unexpected times.	2	2025-06-02

What the citations cover

Citations by CMS category

Smoke Deficiencies 11
Gas, Vacuum, and Electrical Systems Deficiencies 7
Miscellaneous Deficiencies 6
Emergency Preparedness Deficiencies 5
Other 6

Citations by CMS category
Category	Citations
Smoke Deficiencies	11
Gas, Vacuum, and Electrical Systems Deficiencies	7
Miscellaneous Deficiencies	6
Emergency Preparedness Deficiencies	5
Egress Deficiencies	3
Services Deficiencies	2
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

June 2, 2025 — 15 citations

Citations issued on June 2, 2025
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (July 23, 2025)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (July 23, 2025)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (July 23, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (August 30, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (July 23, 2025)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (July 23, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (August 30, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 23, 2025)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (July 23, 2025)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 30, 2025)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (August 30, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (July 23, 2025)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (August 30, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (July 23, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (August 30, 2025)

December 27, 2022 — 14 citations

Citations issued on December 27, 2022
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (February 10, 2023)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (February 10, 2023)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (February 10, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has plan of correction (February 10, 2023)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (February 10, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (February 10, 2023)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (February 10, 2023)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (February 10, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (February 10, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (February 10, 2023)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (February 10, 2023)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (February 10, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (February 10, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (February 10, 2023)

November 26, 2019 — 6 citations

Citations issued on November 26, 2019
Tag	What the surveyor checks	Status
K-0131	Meet requirements for sections of health care facilities separated by fire resistive construction.	Deficient, Provider has date of correction (December 21, 2019)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (December 21, 2019)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (December 21, 2019)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (December 21, 2019)
K-0916	Have a battery powered remote alarm panel in a location accessible by operating personnel.	Deficient, Provider has date of correction (December 21, 2019)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (December 21, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.