Tuttle Care Center

In the surveyor’s words

From the most serious findings on record at Tuttle Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jul 24, 2026

  Based on observation, record review, and interview, the facility failed to: a. disinfect a glucometer after each use for 2 (#20 and #37) of 2 sampled residents reviewed for glucose monitoring;b. perform hand hygiene between performing FSBS for 2 (#20 and #37) of 2 sampled residents reviewed for glucose monitoring;c. sanitize a blood pressure cuff used between residents for 1 (#12) of 1 sampled resident who received blood pressure monitoring; andd. ensure a barrier was placed on a wired linen cart to prevent cross contamination during linen transport. The administrator identified 42 residents resided in the facility. Findings: 1. On 07/22/26 at 3:54 p.m., LPN #2 was observed to don a pair of gloves to perform a FSBS with a single use lancet on Resident #37. […]

• No harm, potential for more than minimal, patternF584Jul 24, 2026

  Based on observation and interview, the facility failed to ensure: a. the shower room on the South hall was maintained clean and in good repair, and shower curtains were free from debris and an unknown black substance for 1 (South hall) of 2 shower rooms observed,b. the exhaust fan was free from lint/debris in 1 (South hall) of 2 shower rooms observed, c. shower wall tiles were not missing with exposed sheetrock for 1 (South hall) of 2 shower rooms observed, andd. a mechanical lift was free from dirt and debris for 1 of 2 lifts observed on the South hall. The administrator identified 21 residents resided on the South hall. Findings: On 07/20/26 at 1:55 p.m., a mechanical lift on the South hall was observed to have a buildup of dirt and debris. […]

• No harm, potential for more than minimal, patternF605May 30, 2025

  Based on record review and interview, the facility failed to ensure a physician's response to a gradual dose reduction was implemented for 1 (#18) of 5 sampled residents reviewed for unnecessary medication. The administrator identified 44 residents resided in the facility. Findings: A physician's order, dated 01/20/23, showed sertraline hydrochloric acid (Zoloft) (an antidepressant) 100 mg, give one tablet by mouth one time a day for depression. A Consultant Pharmacist/Physician Communication form, dated 08/26/24, showed a pharmacist gradual dose reduction recommendation for sertraline (Zoloft) 100 mg daily. The communication form showed a physician's response dated 09/09/24, to reduce Zoloft to 75 mg by mouth daily. […]

• No harm, potential for more than minimal, patternF656May 30, 2025

  Based on record review and interview, the facility failed to ensure a care plan was developed to address anxiety and post traumatic stress disorder for 1 (#44) of 1 sampled resident's care plan reviewed for serious mental health diagnosis. The administrator identified 44 residents resided in the facility. Findings: Resident #44's admission MDS assessment, with an ARD of 03/19/25, showed they had psychatric disorders of anxiety and post traumatic stress disorder. Resident #44's care plan, initiated on 03/27/25, did not address the diagnoses of anxiety and post traumatic stress disorder. Resident #44's admission Record, dated 04/29/25, showed they were admitted on [DATE] with diagnoses of anxiety and post traumatic stress disorder. […]

• No harm, potential for more than minimal, patternF582Feb 16, 2023

  Based on record review and interview, the facility failed to provide the ABN form to residents who received skilled services and afterwards stayed in the facility for three (#3, 31, and #32) of three residents sampled for beneficiary protection notification review. The MDS coordinator identified 22 residents who had been discharged from skilled services in the last six months. Findings: According to Res #3's medical record, Res #3 started skilled services on 11/01/22 and was discharged on [DATE]. The ABN form was not provided. According to Res #31's medical record, Res #31 started skilled services on 02/02/23 and was discharged on [DATE]. The ABN form was not provided. According to Res #32's medical record, Res #32 started skilled services on 10/28/22 and was discharged on [DATE]. […]