Tuff Memorial Home

In the surveyor’s words

From the most serious findings on record at Tuff Memorial Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 30, 2021

  Based on interview and document review, the facility failed to provide adequate supervision for 1 of 1 wandering resident (R1), who accessed the kitchen area when staff left the door open and kitchen unattended, and fell down the back stairwell. This resulted in actual harm as R1 sustained fractures of her shoulder blade, wrist, 5 ribs, a laceration to the left side of her head and bleeding on her brain. The immediate jeopardy began on 11/22/21, when the facility failed to provide adequate supervision for R1 who was able to access a restricted area through the kitchen in her wheelchair and fell down a stairwell resulting in fractures of shoulder blade, wrist, and 5 ribs including a laceration to the left side of her head and was identified on 11/30/21. […]

• No harm, potential for more than minimal, widespreadF867Aug 27, 2025

  Based on interview and document review, the facility failed to have evidence of measurable goals and documentation of an analysis and evaluation of the data, submitted to the QAPI committee to ensure Performance Improvement Projects (PIPS) areas identified had oversight and a documented action plan. This had the potential to affect all 40 residents living in the facility.Findings include: Review of the QAPI meetings identified in: March 13, 2025, QAPI minutes identified the Restorative program was identified as a PIP, but no measurable goals or action plan was discussed or put in place. April 9, 2025, contained a blank table with labels of Action Plan; Person's Responsible, Target Date, Outcome; and Notes. […]

• No harm, potential for more than minimal, widespreadF851Sep 27, 2023

  Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the staffing schedules and timecard verifications for 42 randomly selected days from June 2023 through September 2023 identified the facility had licensed nursing staff, 24 hours per day 7 days per week, and 8 consecutive hours per 24 hours of registered nurse (RN) coverage documented. […]

• No harm, potential for more than minimal, widespreadF865Sep 27, 2023

  Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 39 residents. Findings include: Review of the monthly QAPI meeting minutes from March 2023 through July 2023 identified department heads were bringing data forth to QAPI on various topics such as infection control, falls, elopements, incident reports etc, however, there was no documented benchmarks for goals the facility was trying to achieve, nor analysis of data brought forth, identified actions the facility was going to take to achieve their goals, and monitoring to determine if goals… […]

• No harm, potential for more than minimal, widespreadF867Sep 27, 2023

  Based on observation, interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 39 residents. Findings include: Observation on 9/26/23 at 5:41 p.m. of the facility identified there was no information posted about any PIP project the facility was actively working on. Interview on 9/27/23 at 7:07 a.m., with the dietary manager (DM) identified she was unaware of any PIP project the facilities QAPI committee had in place. She attends QAPI. […]