The Sanctuary at Tuttle Crossing

Inspectors wroteBased on record review, hospital record review, law enforcement interview, and facility policy review, the facility failed to ensure Resident #51 was free from abuse. Actual harm occurred to Resident #51 when Resident #21 made physical contact with Resident #51. Resident #51 fell to the ground and sustained a hematoma to the back of his head. Resident #51 was transported to the emergency room, where he was diagnosed with a falx subdural hematoma and a fracture of his C5 and C6 vertebra. This affected one (Resident #51) of three residents reviewed for abuse allegations. The facility census was 49. Findings Include:Resident #51 was admitted to the facility on [DATE]. His diagnoses were Parkinson's disease without dyskinesia, dementia, psychotic disturbance, mood disturbance, anxiety disorder, repeated falls, and major depressive disorder. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to report an allegation of abuse in a timely manner. This affected one (Resident #51) of three residents reviewed for abuse. The census was 49. Findings Include: Resident #51 was admitted to the facility on [DATE]. His diagnoses were Parkinson's disease without dyskinesia, dementia, psychotic disturbance, mood disturbance, anxiety disorder, repeated falls, and major depressive disorder. Review of his minimum data set (MDS) assessment, dated 12/02/25, revealed he had a severe cognitive impairment. Review of Resident #51 progress notes, dated 12/13/25, revealed staff heard Resident #51 yelling from his room on 12/12/25. He was found lying on the floor with his head and torso outside of the room and his legs inside the room. [...]

Inspectors wroteBased on record reviews, interviews, review of Wound Physician notes, and policy review, the facility failed to ensure pressure ulcer treatment orders were initiated and ordered timely and accurately. This affected three residents (#20, #40, and #50) of three residents reviewed for pressure ulcer care. The facility census was 59.

Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute, and serve food in a safe and sanitary manner. This had the potential to affect all 49 residents residing in the facility. The facility census was 49.

Inspectors wroteBased on observation, staff interview, review of a facility sanitation audit, review of a service log and quote, and review of a facility policy, the facility failed to store frozen foods at the appropriate temperatures to prevent spoilage. This had the potential to affect all 57 residents residing in the facility who received food from the facility kitchen. The facility identified one resident (Resident #117) who did not eat food from the kitchen. The census was 58.

Inspectors wroteBased on observation, review of medical records, staff interview, and review of the Centers for Disease Control and Prevention (CDC) webpage, the facility failed to ensure residents with wounds were maintained on enhanced barrier precautions with appropriate orders, care plans, signage, and personal protective equipment in place when providing direct cares. This affected four (#21, #25, #46, and #111) of seven residents reviewed for infection control precautions. The census was 58.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to honor a resident's choice for bathing opportunities. This affect one (#117) of one residents reviewed for choices. The census was 58.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide residents with Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) document when therapy services were ending and the resident had skilled days remaining. This affected one (#158) of three residents reviewed for beneficiary notices. The facility census was 58.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to provide application of splinting devices as recommended by therapy and failed to ensure physician orders were in placed for use of the devices. This affected one (#35) of two residents reviewed for range of motion. The facility census was 58.

Inspectors wroteBased on observation, staff interview, and review of a user guide, the facility failed to ensure residents who required transfer assistance using a mechanical lift were provided with adequate assistance to prevent accidents. This affected two (#22 and #107) of two residents observed for safe transfers. The facility census was 58.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to ensure physician orders were followed for residents who received nutritional tube feedings. This affected one (#117) of one residents reviewed for tube feedings. The census was 58.

Inspectors wroteBased on medical record review, staff interviews, and facility policy review, the facility failed to conduct a medication regimen reviews at least monthly. This affected two (#28 and #32) of five residents reviewed for unnecessary medications. The facility census was 58.

Inspectors wroteBased on observation, medical record review, staff interview, review of a user guide, review of manufacturer instructions, and facility policy review, the facility failed to prime an insulin pen needle prior to selecting the ordered dose and administering the medication to a resident and failed to administer antibiotic and anticoagulant medications as ordered which resulted in significant medication errors. This affected three (#26, #44, and #113) of eight residents reviewed for medication administration. The facility census was 58.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure resident who agreed to receive dental services was provided with the services in a timely manner. This affected one (#43) of one residents reviewed for dental services. The facility census was 58.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure documentation of a resident discharging from the facility against medical advice (AMA) was documented in the medical record. This affected one (#54) of three residents reviewed for discharges. The facility census was 58.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure resident call systems functioned appropriately. This affected one (#9) of two residents reviewed for call lights. The facility census was 58.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a shower room in a clean and sanitary manner. This affected three (Residents #181, #195, and #208) of three residents reviewed for clean environment and had the potential to effect 34 residents who used the shower room on the 200 hall. The facility censes was 49.

Inspectors wroteBased on staff interview, observation, record review, and facility policy review, the facility failed to maintain infection control procedures to prevent the development of infections when staff failed to wash or sanitize their hands before a dressing change and after gloves changes during a dressing change. This affected one (Resident #32) of three Residents reviewed for wounds. The facility census was 50.

Inspectors wroteBased on observations, staff interview and policy review, the facility failed to maintain the kitchen in a sanitary condition. This had the potential to affect all 52 residents residing in the facility. The census was 52.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to develop and implement appropriate interventions for a resident with dementia. This affected one (#16) of three residents reviewed for dementia care. The facility census was 53.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure therapeutic diets were served according to physician order. This affected one (#19) of three residents reviewed for diet order and preferences. The facility identified five residents with physician ordered pureed diets. The facility census was 53.

Inspectors wroteBased on observation, staff interview, and facility record review, the facility failed to employ a qualified director of food and nutrition services to provide oversight for the sanitation of the kitchen and serving of physician ordered diets. This had the potential to affect all residents except one resident (#46), who ate nothing by mouth. The facility census was 51.

Inspectors wroteBased on record review, observations, staff interview, review of a cleaning schedule, and review of the facility policies, the facility failed to maintain the kitchen in a clean and sanitary manner, obtain food temperatures in a sanitary manner, and store food appropriately. This had the potential to affect all residents except one (Resident #46) who did not eat food from the kitchen. The facility census was 51.

Inspectors wroteBased on observation, staff interview, record review, and review of a product guide, the facility failed to prepare puree food in a palatable manner. This had the potential to affect three residents (#5, #7, and #31) of three residents identified by the kitchen to be on a puree diet. The facility census was 51.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure pureed food was prepared to an appropriate smooth texture prior to serving to residents on a pureed diet. This affected six residents (#15, #19, #29, #36, #55, and #65) out of six residents who were on a prescribed pureed diet. The facility census was 61. Findings Include: Observation on 02/06/23 at 3:44 P.M. with the Dietary Manager #139 of the pureed [NAME] sandwiches for the dinner meal revealed the DM #139 placed three pounds of sliced corned beef, an unknown amount of processed cheese slices, one fourth cup of sauerkraut, and one tablespoon of Thousand Island dressing into the puree blender. The DM #139 pureed the bread ahead of time and did not add any bread in to the blender. The DM #139 then added an unknown amount of water and a teaspoon of thickener to the mixture and continued blending. [...]

Inspectors wroteBased on staff interview and medical record review, the facility failed to provide written notification of the resident's transfer to the hospital and the reason for the transfer to the resident or resident representative and the Office of the State Long-Term Care Ombudsman. This affected one (Resident #18) of one resident reviewed for hospitalization. The facility census was 50.

Inspectors wroteBased on observation, family interview, staff interview, and record review, the facility failed to ensure residents who were dependent on staff for assistance received showers or baths as scheduled. This affected two (Residents #50 and #108) of five residents reviewed for activities of daily living. The facility identified 49 residents required assistance from staff with bathing. The facility census was 51.

Inspectors wroteBased on staff interview, observation, and record reviews, the facility failed to ensure activities were provided on weekends for cognitively impaired residents. This affected four residents (#1, #23, #35, and #46) of four residents reviewed for activities. This had the potential to affect 39 residents who the facility identified were cognitively impaired. The facility census was 51.

Inspectors wroteBased on observation of meal service, staff interview, review of the facility policy, and record review, the facility failed to ensure Resident #5 and #17 were served mechanically-altered diets as physician ordered. This affected two (#5 and #17) of 50 residents who consumed food from the kitchen. The facility census was 51.

Inspectors wroteBased on record review, observation, staff interviews, and review of the facility policy, the facility failed to dispose of garbage in the kitchen appropriately and maintain covered trash cans. This had the potential to affect all residents except one (Resident #46) who did not eat food from the kitchen. The facility census was 51.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure medications were administered as ordered by the physician. Observation of medication administrations by two nurses, revealed 31 medications were observed given to seven residents. Six medications errors were identified, which resulted in a medication error rate of 19.35 percent. This affected two residents (#11 and #43) of seven residents observed during medication administration. The facility census was 60.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to provide a transfer/discharge notice to two residents and/or their representatives when they were transferred to the hospital. This affected two residents (#13 and #17) of two reviewed for hospitalizations. The facility census was 60.

Inspectors wroteBased on medical record review, observations and staff interviews, the facility failed to implement fall precautions as ordered. This affected one resident (#37) out of one resident reviewed for falls. The facility census was 60.

Inspectors wroteBased on review of medical record and interview the facility failed to obtain ordered laboratory tests for one resident (#17) of one reveiwed for laboratory tests. The facility census was 60.

Inspectors wroteBased on observation, staff interviews and review of the facility policy, the facility failed to safeguard resident's information contained on individual medication packets. This affected six residents (#11, #15, #19, #27, #36 and #43) of seven residents observed during medication administration pass. The facility census was 60.