Sanctuary at Tuttle Crossing The

Based on observation, medical record review, and staff interview, the facility failed to ensure safe storage of prescription medication. This affected one (#24) of four residents reviewed for medication administration and storage. The facility census was 28.

Findings include:

Review of the medical record revealed Resident #24 was admitted to the facility on 04/16/25 with diagnoses including chronic kidney disease, gastroesophageal reflux disease without esophagitis, anemia, and major depressive disorder.

Review of the initial health assessment for Resident #24, dated 03/28/25, revealed the resident should not self-administer medications due to medical, physical, or cognitive reasons, and medications should be managed by pharmacy service and administered by the facility nursing staff.

Observation and interview on 11/19/25 at 12:18 P.M. revealed Licensed Practical Nurse (LPN) #109 was administering medication to Resident #24. Resident #24 stated to LPN #109 she did not want to take her Senna (a laxative). Resident #24 pointed to two cups on the counter, both of which had a Senna tablet, and one of the cups also had a blue pill which LPN #109 identified as Resident #24's antidepressant, Zoloft 50 milligram (mg) tablet. LPN #109 confirmed the medications in Resident #24's room, collected the medicine in the two cups, and coordinated with the unit manager, Registered Nurse (RN) #222, to destroy the medications.

Interview on 11/20/25 at 12:18 P.M. with RN #206 stated Resident #24 sometimes did not want to take her medicine right away and the resident will tell the nurse to put it aside. RN #206 stated if she were to find medication in the room, she would collect it and destroy it.

Interview on 11/20/25 at 1:30 P.M. with the Director of Nursing (DON) stated if medication was found in the room, it should be collected and destroyed.

This deficiency is a recite to the annual survey completed 02/19/25.

Based on review of resident trust documents, staff interview, and policy review, the facility failed to ensure authorizations for the facility to manage resident personal fund accounts were witnessed and the witness was in no way connected to the facility or the Administrator. This affected two (#30 and #26) of three residents reviewed for resident funds. The facility census was 28.

Findings include:

1. Review of an undated document titled, Resident Agreement Resident Personal Account

Based on medical record review, resident and staff interview, review of the incident log, and review of a witness statement, the facility failed to document on the incident log an incident in which a was found unresponsive on the floor requiring intervention. This affected one (#38) of five residents reviewed for incidents. The facility census was 28.

Findings include:

Review of the medical record revealed Resident #38 was admitted to the facility on 09/06/23 with diagnoses including dementia, type II diabetes with diabetic neuropathy, and chronic pain.

Interview with Resident #31 on 11/20/25 at 9:05 A.M. stated he was sad as a result of seeing Resident #38 deceased on the floor across the hall in the early morning hours.

Review of facility incident log revealed no entry of Resident #38 being found deceased on the floor.

Interview with Assistant Administrator (AA) #101 confirmed Resident #38 died and confirmed the incident was not on the incident log. AA #101 noted the police came to the facility when emergency services were called.

Review of a handwritten witness statement from 10/20/25 by Registered Nurse (RN) #228 revealed Resident #38 was found unresponsive on the floor in his room and RN #228 initiated cardiopulmonary resuscitation (CPR).

Interview on 11/20/25 at 1:30 P.M. with the Director of Nursing (DON) confirmed Resident #38 was found on floor unresponsive; however, because the resident died, they did not put the incident on the incident log.

Based on fire drill documentation review, staff interview, and policy review, the facility failed to ensure residents capable of self-evacuation were actually evacuated to safe areas or to the facility exterior in at least two fire drills a year on each shift as required. This had the potential to affect all 28 residents residing in the facility. The facility census was 28.

Findings include:

Review of facility fire drill documents revealed the facility conducted fire drills on 02/27/25, 03/27/25, 04/25/25, 05/29/25, 06/17/25, 07/11/25, 08/29/25, 09/02/25, and 10/31/25 and there was no evidence any residents participated in the fire drills including evacuation to a safe area of the building.

Interview with the Administrator on 11/19/25 at 4:50 P.M. confirmed there was no documentation providing evidence of any resident evacuations.

Review of facility policy titled, Fire and Disaster Safety Plan

Based on fire drill document review and staff interview, the facility failed to appropriately evaluate the fire drills to include require information for each drill. This had the potential to affect all 28 residents residing in the facility. The facility census was 28.

Findings include:

Review of facility fire drill documentation revealed fire drills were held on 02/27/25, 03/27/25, 04/25/25, 05/29/25, 06/17/25, 07/11/25, 08/29/25, 09/02/25, and 10/31/25 revealed none of the nine documents indicated how long the evacuation took or what the weather conditions were on each day. Additionally, documentation from 08/29/25 and 10/31/25 had empty checkboxes for the pre-printed evaluative questions on the form including: were doors monitored for potential eloping residents, did staff know how to conduct a resident headcount after fire alarm, was fire alarm restored, were the exit signs inspected and functioning properly and rating of the the response and attitude of personnel. On the 05/29/25 and 06/17/25 documents, the spaces to check off that doors were monitored for potential eloping residents were left blank.

Interview with the Administrator on 11/19/25 at 4:50 P.M. confirmed the fire drill documents did not include evacuation time or weather conditions and there were documents with information left blank.

Based on personnel file review and staff interview, the facility failed to provide annual fire prevention training for regularly scheduled staff members as required. This had the potential to affect all 28 residents residing in the building. The facility census was 28.

Findings include:

Review of the personnel file for Registered Nurse (RN) #208 revealed a hire date of 12/18/20. Review of the personnel file for RN #206 revealed a hire dated of 04/03/24. Further review of both RNs personnel files revealed no documentation of annual fire prevention training as required.

Interview with the Administrator and Maintenance Director (MD) #216 confirmed the facility employees had not received training in fire prevention from the fire department or state fire marshal in the past twelve months.

Based on record review and staff interview, the facility failed to ensure a certified nursing assistant had first-aid training within the first 60 days of hire. This affected one of five employee records reviewed for first-aid training. It had the potential to affect 27 residents residing in the facility.

Findings include:

Review of the personnel file revealed Certified Nursing Assistant (CNA) #17's first day of work was 10/02/24. There was no documentation of first-aid training completed within the first 60 days of hire.

Interview with the Administrator on 02/19/25 at 4:00 P.M. confirmed CNA #17 did not complete first-aid training within the first 60 days of hire.

Based on observation, staff interview, and facility policy review, the facility failed to ensure safe storage of insulin pens. This affected two (Residents #6 and #12) of five residents reviewed for medication storage. This had the potential to seven residents who had insulin pens stored in the medication carts. The facility census was 27.

Findings include:

Observation and interview on 02/19/25 at 9:25 A.M. revealed Licensed Practical Nurse (LPN) #9 was completing medication pass. Observation of the medication cart revealed two unopened and not refrigerated insulin pens for Residents #12 and #6. The insulin pens instructions stated to refrigerate until opened. LPN #9 confirmed the insulin pens for Residents #12 and #6 were unopened and not refrigerated and stated the insulin pens should be kept in the refrigerator.

Review of the undated policy titled Medication Storage revealed medications should be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations.

Based on observations, staff interview, review of manufacturer instructions, and facility policy review, the facility failed to ensure resident's insulin pens were dated when opened. This affected three (Residents #6, #16, and #36) of five residents reviewed for medication storage. This had the potential to seven residents who had insulin pens stored in the medication carts.

Findings include:

Observation of the medication cart on 02/19/25 at 9:25 A.M. revealed Resident #6 had two opened insulin pens and were not dated when opened. Resident #16 had one insulin pen that was opened and undated in the cart. Resident #36 had two insulin pens that were opened and undated in the cart.

Interview on 02/19/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #9 confirmed Residents #6, #16, and #36's insulin pens were opened with no date. LPN #9 confirmed when a medication was opened, the date was to be placed on that medication. LPN #9 stated insulin pens were only good for about 28 days after being opened.

Review of the facility's undated policy titled Medication Storage revealed medications are to be stored according to manufacture's recommendations.

Review of the manufacturer's instructions on the insulin pens revealed they are to be discarded after being opened for 28 days.

Based on observation, staff interviews, and policy review, this facility failed to ensure dietary staff completed hand hygiene to ensure safe handling of food as well as ensure the ice machine was free of black colored substance. This has the potential to affect all 27 residents residing in the facility who receive food from the kitchen.

Findings include:

Observation and interview on 02/19/25 at 10:45 A.M. revealed a black substance inside the top of the ice maker machine located in the kitchen. Interview with Dietary Assistant (DA) #23 confirmed there was a black substance inside the top of the ice maker machine.

Observation on 02/19/25 at 11:30 A.M. revealed DA #21 was observed to lick fingers to separate resident menu slips while also handling plates to be delivered to residents. Following several repeated observations, this action was pointed out to Dietary Manager (DM) #19. DM #19 noted to DA #21 in kitchen to wash hands. DA #21 stated the papers stick together. No hand washing was observed following DM #19's instruction to wash hands.

Observation on 02/19/25 at 11:33 A.M. revealed DA #21 was observed to reach down to the floor of kitchen with gloved hands and pick up a towel that had fallen to floor. DA #21 proceeded to continue making sandwich with same gloved hands. DA #21 verified picking item off floor with gloved hand and not changing gloves.

Review of the facility's undated policy titled Food Safety Requirements revealed food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Based on fire drill review and staff interview, the facility failed to ensure resident participated in fire drills. This had the potential to affect all 27 residents residing at this facility.

Findings include:

Review of facilities completed fire drill from 02/2024 to 01/2025 revealed there was no evidence any residents participated in the fire drills including evacuating to a safe area of the building.

Interview with the Administrator on 02/19/25 at 5:30 P.M. confirmed the completed fire drills lacked evidence of residents being evacuated or participating in the fire drill.

Based on review of facility fire drills, staff interview and review of facility policy, the facility failed to ensure fire drills were completed quarterly on each shift. Additionally, the facility failed to ensure residents were evacuated at least two times per year on the evening shift. This had the potential to affect all 27 residents of the facility. The facility census was 27. Findings include: Review of facility fire drills from April 2023 though April 2024 revealed the facility conducted a fire drill on 08/12/23 on day shift. The next day shift fire drill was not conducted until 12/19/23. Further review revealed on the evening shift, a fire drill was conducted on 06/06/23, with another drill on the evening shift not conducted until 01/30/24. Additional review revealed the only resident evacuation on the evening shift for the period under review was on 01/30/24. There was no evidence of a second resident evacuation on the evening shift. Interview on 05/01/24 at 12:45 P.M. with Maintenance Director (MD) #33 and the Administrator verified the facility failed to complete quarterly fire drills on the day and evening shifts and only evacuated residents on the evening shift once during the review period. The Administrator confirmed MD #33 was responsible for scheduling, conducting, and documenting fire drills in accordance with the facility's fire drill policy. Review of the facility policy titled Fire DrillsBased on review of facility fire drills, staff interview and review of facility policy, the facility failed to ensure fire drills were completed quarterly on each shift. Additionally, the facility failed to ensure residents were evacuated at least two times per year on the evening shift. This had the potential to affect all 27 residents of the facility. The facility census was 27.

Findings include:

Review of facility fire drills from April 2023 though April 2024 revealed the facility conducted a fire drill on 08/12/23 on day shift. The next day shift fire drill was not conducted until 12/19/23. Further review revealed on the evening shift, a fire drill was conducted on 06/06/23, with another drill on the evening shift not conducted until 01/30/24. Additional review revealed the only resident evacuation on the evening shift for the period under review was on 01/30/24. There was no evidence of a second resident evacuation on the evening shift.

Interview on 05/01/24 at 12:45 P.M. with Maintenance Director (MD) #33 and the Administrator verified the facility failed to complete quarterly fire drills on the day and evening shifts and only evacuated residents on the evening shift once during the review period. The Administrator confirmed MD #33 was responsible for scheduling, conducting, and documenting fire drills in accordance with the facility's fire drill policy.

Review of the facility policy titled Fire Drills