The Sanctuary at Tuttle Crossing

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Apr 6, 2022

  Based on closed medical record review, review of medical transport records, review of hospital practitioner documentation, review of an emergency room history and physical, review of a hospital discharge summary, review of a facility self-reported incident, review of witness statements, and interviews with facility staff, the facility failed to hold anticoagulants when Resident #57 had indications of bleeding and failed to attempt to contact to alternate practitioners when the physician was not able to be reached. This resulted in Immediate Jeopardy on 02/25/22 at 4:30 A.M. when Resident #57 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57's physician was unable to be reached and no attempts were made to reach the Certified Nurse Practitioner (CNP) #131. […]

• Actual harm, isolatedF600Jan 9, 2026

  Based 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]. […]

• Actual harm, isolatedF684Jan 9, 2023

  Based on record review, staff interview, surgeon office interview, and review of the facility policy, the facility failed to routinely monitor a resident's surgical wound, notify the physician or surgeon's office of the deteriorating surgical wound, and failed to timely implement a physician order to start a skin treatment. Actual Harm occurred to Resident #55 when her lower back incision went without treatment for at least five days after the Nurse Practitioner noted drainage and slough present in the wound bed with mild dehiscence. Resident #55 subsequently went to the hospital and received treatment to the infected wound. This affected one (Resident #55) of three residents reviewed for non-pressure related skin conditions. […]

• Actual harm, isolatedF689Aug 19, 2021

  Based on observations, interviews with staff and resident representative, medical record review, review of the facility's investigation report, and review of the hospital records, the facility failed to ensure a resident was provided a safe transfer with a Hoyer mechanical lift and bed mobility during Activities of Daily Living. This resulted in Actual Harm when Resident #5 sustained a bump on the left forehead with bruising and a large hematoma to the face, when resident's head and face were suspected to be rolled into the wall during care or when the resident was transferred in a Hoyer lift with only one staff member. In addition, staff failed to report when bruising was first noticed to begin investigation and treatment. […]

• No harm, potential for more than minimal, widespreadF812Aug 14, 2025

  Based 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. Findings include: Observation of the kitchen on 08/14/25 at 9:35 A.M. revealed the freezer temperature was 12 degrees Fahrenheit on the outside thermometer and 9 degrees Fahrenheit on the inside thermometer. Further observations revealed the freezer had built-up chunks of ice on the floor with pieces of pasta embedded in the ice and a chunk of hair stuck to the ice on the floor. The walk-in refrigerator, when opened, had a strong mildew odor and an unknown black substance along the entire length of the side and back walls. […]