The Sanctuary At Tuttle Crossing
Inspection Findings
F-Tag F0686
F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
pressure ulcer of sacral region stage four, type two diabetes mellitus without complications. Review of Resident #40's Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. The resident was assessed to require partial/moderate assistance with bed mobility, substantial/maximal assistance with transfers and total dependence on toilet hygiene and shower/bathing. The resident was also assessed to have a stage four pressure ulcer on admission. Review of the plan of care dated 09/22/25 for Resident #40 revealed the resident was at risk for/had an actual alteration in skin integrity related to being admitted with a pressure ulcer to the sacrum with an intervention including, but not limited to, providing treatments per physician's orders. Review of the Skin Risk assessment dated [DATE REDACTED] for Resident #40 revealed the resident was at high risk for skin breakdown. Review of the pressure ulcer admission assessment dated [DATE REDACTED] for Resident #40 revealed a sacrum unstageable pressure ulcer measured 4 centimeters (cm) by 6 cm by undetermined depth. Review of the physician order dated 09/22/25 for Resident #40 revealed an order to clean the sacral wound with wound wash, pat dry, cover with foam border dressing and change every three days and as needed. The order was discontinued on 09/25/25. Review of the Wound Physician #1500 note dated 09/23/25 revealed Resident #40 had a sacrum stage four pressure ulcer measured 5.5 cm by 7 cm by 1 cm with a treatment order for Mesalt with a gauze dressing daily and as needed. Review of the physician order dated 09/23/25 for Resident #40 revealed an order for Mesalt with a gauze dressing daily and as needed. Interview on 12/23/25 at 9:44 A.M. with the Director of Nursing (DON) verified Resident #40 had two active orders for the sacrum stage IV pressure ulcer from 09/23/25 through 09/25/25. 3.Review of
the medical record for Resident #50 revealed an admission date of 05/18/22. Diagnoses included, but were not limited to, systolic heart failure, chronic kidney disease stage three, peripheral vascular disease and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of the Skin Risk assessment dated [DATE REDACTED] for Resident #50 revealed the resident was at high risk for skin breakdown. Review of Resident #50's Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. The resident was assessed to require total dependence for toilet hygiene, shower/bathing, bed mobility, and transfers. This resident was assessed to be at risk for developing pressure ulcers and to have two stage three pressure ulcers currently. Review of the plan of care, revised 12/02/25, for Resident #50 revealed actual skin alterations related to the sacrum and right ischium pressure ulcers with interventions including, but not limited to, wound treatments per orders. Review of the Wound Physician #1500 note dated 12/02/25 for Resident #50 revealed a sacrum stage three pressure ulcer measured 4.5 centimeters (cm) by 0.6 cm by 0.2 cm and a right ischium stage three pressure ulcer measured 1 cm by 1.7 cm by 0.2 cm with treatments for both to be Hydrocolloid paste (triad) twice a day and as needed. Review of the physician orders dated 12/04/25 for Resident #50 revealed for the sacrum and right ischium stage three pressure ulcers to use Hydrocolloid paste (triad) twice a day and as needed. Interview on 12/23/25 at 9:43 AM with
the Director of Nursing (DON) verified Resident #50 did not have a treatment order for the sacrum and right ischium stage three pressure ulcers from 12/02/25 through 12/04/25. Review of the undated facility policy titled Pressure Injury Prevention and Management revealed evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. This deficiency represents non-compliance investigated under Complaint Number 2685037 and Complaint Number 2669759.
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THE SANCTUARY AT TUTTLE CROSSING in DUBLIN, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DUBLIN, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE SANCTUARY AT TUTTLE CROSSING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.