Inspection Reports for
Sanctuary at Tuttle Crossing the
4880 TUTTLE ROAD, DUBLIN, OH, 43017
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
126% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Jan 9, 2026
Visit Reason
The inspection was conducted to investigate a complaint regarding abuse involving Resident #51 and Resident #21 at the facility.
Complaint Details
This deficiency represents non-compliance investigated regarding complaint number 2709090.
Findings
The facility failed to protect Resident #51 from abuse by Resident #21, resulting in actual harm including a subdural hematoma and vertebral fractures. The facility also failed to report the abuse allegation in a timely manner.
Deficiencies (2)
F 0600: The facility failed to protect Resident #51 from abuse by Resident #21, resulting in actual harm including a subdural hematoma and fractures of C5 and C6 vertebrae. Resident #51 was found on the floor with injuries after Resident #21 made physical contact with him.
F 0610: The facility failed to report an allegation of abuse involving Resident #51 in a timely manner, delaying notification to required agencies. This affected one of three residents reviewed for abuse.
Report Facts
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #215 | Licensed Practical Nurse | Reported the abuse incident and assessed Resident #51 after the injury. |
| Administrator | Administrator | Interviewed Resident #21 and reported the abuse incident to authorities. |
| Director of Nursing | Director of Nursing | Confirmed knowledge of the abuse incident and reporting delays. |
| Licensed Practical Nurse #225 | Licensed Practical Nurse | Witnessed Resident #51 lying on the floor and Resident #21 over him. |
| Law Enforcement Detective #600 | Detective | Investigated the abuse incident involving Resident #51 and Resident #21. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: Dec 23, 2025
Visit Reason
The inspection was conducted due to complaints regarding pressure ulcer care and treatment at the facility.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2685037 and Complaint Number 2669759.
Findings
The facility failed to ensure timely and accurate initiation of pressure ulcer treatment orders for three residents with pressure ulcers. This resulted in delayed or incorrect treatments for pressure ulcers, representing non-compliance with care standards.
Deficiencies (1)
F 0686: The facility failed to initiate and order pressure ulcer treatment timely and accurately for three residents, resulting in delayed Hydrocolloid paste treatment and use of incorrect barrier cream treatment.
Report Facts
Residents affected: 3
Facility census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding pressure ulcer treatment orders and facility practices |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to food safety and sanitation concerns in the facility's kitchen.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2577530.
Findings
The facility failed to store, prepare, distribute, and serve food in a safe and sanitary manner, with issues including improper freezer temperatures, ice buildup with contaminants, mildew odor and black substance in the refrigerator, and food holding temperatures below safe levels. These deficiencies potentially affected all 49 residents receiving meals from the kitchen.
Deficiencies (1)
F 0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards. Observations included freezer temperatures below standard, ice buildup with food and hair contamination, mildew odor and black substance in the walk-in refrigerator, water dripping inside the refrigerator, and food tray temperatures below 135 degrees Fahrenheit.
Report Facts
Facility census: 49
Freezer temperature outside thermometer: 12
Freezer temperature inside thermometer: 9
Food tray temperature - chicken: 119
Food tray temperature - vegetables: 128
Food tray temperature - stuffing: 137
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: May 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to malfunctioning resident call light systems.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00165633.
Findings
The facility failed to ensure that resident call systems functioned properly, affecting one of two residents reviewed. The call light for Resident #9 did not activate despite multiple attempts, and staff confirmed the malfunction.
Deficiencies (1)
F 0919: The facility failed to ensure a working call system was available in each resident's bathroom and bathing area. Resident #9's call light button did not activate despite multiple attempts.
Report Facts
Residents affected: 1
Facility census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #146 | Confirmed Resident #9's call light was not working and stated she would notify maintenance and the Administrator | |
| Administrator | Confirmed Resident #9's call light system was broken and stated alternative solutions would be offered |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 12
Date: May 15, 2025
Visit Reason
Annual inspection survey conducted to evaluate compliance with healthcare regulations and standards at The Sanctuary at Tuttle Crossing nursing home.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00165633.
Findings
The facility was found deficient in multiple areas including honoring resident bathing choices, providing required beneficiary notices, ensuring appropriate use of splinting devices, safe resident transfers, following physician orders for nutritional feedings, conducting monthly medication regimen reviews, preventing medication errors, providing timely dental services, maintaining proper freezer temperatures for food safety, documenting discharges against medical advice, implementing infection control precautions, and ensuring functioning resident call systems.
Deficiencies (12)
F 0561: The facility failed to honor a resident's choice for bathing opportunities, resulting in fewer showers and no bed baths offered as per policy.
F 0582: The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) when therapy services ended while skilled days remained.
F 0688: The facility failed to provide and apply splinting devices as recommended by therapy and lacked physician orders for their use.
F 0689: The facility failed to ensure mechanical lift transfers were performed with adequate staff assistance, using only one staff member instead of two.
F 0692: The facility failed to follow physician orders for nutritional tube feedings, missing multiple feedings due to equipment problems.
F 0756: The facility failed to conduct monthly medication regimen reviews by a licensed pharmacist for some residents.
F 0760: The facility failed to prime insulin pen needles before administration and missed doses of antibiotic and anticoagulant medications.
F 0791: The facility failed to provide timely dental services to a resident who requested them, due to improper filing of consent documentation.
F 0812: The facility failed to maintain the walk-in freezer at appropriate temperatures, with temperatures ranging from 7 to 20 degrees F instead of 0 degrees F or below, risking food spoilage.
F 0842: The facility failed to document a resident discharging against medical advice (AMA) in the medical record as required.
F 0880: The facility failed to implement enhanced barrier precautions for residents with wounds, lacking appropriate orders, care plans, signage, and readily available personal protective equipment.
F 0919: The facility failed to ensure a resident call light system was functioning properly, resulting in a resident unable to activate the call light.
Report Facts
Residents affected: 58
Missed nutritional feedings: 3
Missed antibiotic doses: 2
Missed anticoagulant doses: 6
Freezer temperature range: 7
Freezer temperature range: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed bathing policy and deficiencies, medication regimen reviews, and infection control practices |
| Regional Nurse #196 | Regional Nurse | Confirmed bathing schedule and deficiencies |
| Physical Therapist #194 | Physical Therapist | Provided therapy recommendations and education on splint use |
| Licensed Practical Nurse #146 | Licensed Practical Nurse | Confirmed splint non-use and call light malfunction |
| Certified Nurse Aide #149 | Certified Nurse Aide | Observed using mechanical lift alone for resident transfer |
| Certified Nurse Aide #198 | Certified Nurse Aide | Observed using mechanical lift alone for resident transfer |
| Business Office Manager #186 | Business Office Manager | Confirmed missing beneficiary notices and AMA documentation |
| Registered Nurse #198 | Registered Nurse | Observed insulin administration without priming pen |
| Dietitian #179 | Dietitian | Reported freezer temperature logs and sanitation audit |
| Dietitian #197 | Dietitian | Authored sanitation audit noting freezer issues |
| Human Resources #148 | Human Resources | Confirmed dental service consent paperwork issue |
| Administrator | Administrator | Confirmed freezer temperature issues and call light malfunction |
| Licensed Practical Nurse #130 | Licensed Practical Nurse | Confirmed lack of enhanced barrier precaution signage and PPE availability |
| Registered Nurse #149 | Registered Nurse | Confirmed lack of enhanced barrier precaution signage and PPE availability |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the cleanliness and safety of the 200 hall shower room.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00158140.
Findings
The facility failed to maintain the 200 hall shower room in a clean and sanitary manner, with stained and loose flooring and missing tile. Three residents refused to use the shower room due to its filthy condition, potentially affecting 34 residents who use the room.
Deficiencies (1)
F 0921: The facility failed to maintain the 200 hall shower room in a clean and sanitary manner. The floor was stained, loose, and a tile was missing, causing residents to refuse use.
Report Facts
Residents affected: 3
Potentially affected residents: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding plans to fix the shower room | |
| State Tested Nurse Aide (STNA) #302 | Interviewed about the condition of the 200 hall shower room | |
| Licensed Practical Nurse (LPN) #301 | Interviewed about residents refusing to use the shower room |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
This visit was conducted as an incidental finding under Complaint Number OH00150978 to investigate infection prevention and control practices.
Complaint Details
This is an incidental finding investigated under Complaint Number OH00150978.
Findings
The facility failed to maintain proper infection control procedures when a Licensed Practical Nurse did not wash or sanitize hands before and after glove changes during a dressing change for Resident #32. This failure potentially exposed residents to infection risks.
Deficiencies (1)
F 0880: The facility failed to maintain infection control procedures when staff did not wash or sanitize hands before and after glove changes during a dressing change for Resident #32.
Report Facts
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #11 | Named in infection control deficiency for failure to perform hand hygiene during dressing change |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 6
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation focusing on the facility's kitchen sanitation and food safety practices.
Complaint Details
This deficiency is based on incidental findings discovered during the course of this complaint investigation.
Findings
The facility failed to maintain the kitchen in a sanitary condition, including dirty appliances, unrecorded food and dishwasher temperatures, improper glove use by staff, and unsealed food items. These issues had the potential to affect all 52 residents.
Deficiencies (6)
F 0812: The facility failed to maintain the kitchen in a sanitary condition, including brown streaks in the ice machine and dirty stainless steel appliances.
There was no evidence of recorded food temperatures for breakfast, lunch, and supper tray lines between 09/01/23 and 12/13/23.
No evidence of recorded refrigerator and freezer temperatures to ensure acceptable refrigeration since 09/01/23.
Staff failed to change gloves when handling different food items and surfaces, risking cross-contamination.
Unsealed bags of food items were left open to the air in the walk-in freezer.
Dishwasher temperatures did not meet minimum requirements; wash cycle never reached 150°F and rinse cycle reached 180°F only on the third cycle.
Report Facts
Residents affected: 52
Dishwasher temperature cycles observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DM #71 | Dietary Manager | Verified lack of temperature recordings, dirty appliances, glove use violations, and dishwasher temperature issues |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Oct 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00146837 regarding concerns about dementia care and dietary compliance.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146837.
Findings
The facility failed to develop and implement appropriate interventions for a resident with dementia who wandered into other residents' rooms. Additionally, the facility failed to ensure therapeutic diets were served according to physician orders, serving a resident a regular texture meal instead of the ordered pureed diet.
Deficiencies (2)
F 0744: The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, specifically not addressing wandering into other residents' rooms and inadequate staff awareness of this behavior.
F 0805: The facility failed to ensure therapeutic diets were served according to physician orders, serving a resident regular texture grilled cheese sandwiches instead of the ordered pureed diet.
Report Facts
Facility census: 53
Residents with physician ordered pureed diets: 5
Residents reviewed for dementia care: 3
Residents reviewed for diet order and preferences: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding wandering behaviors and dietary waiver | |
| Corporate Nurse (CN) #100 | Interviewed regarding wandering behaviors and dietary waiver | |
| State Tested Nurse Aide (STNA) #66 | Interviewed regarding resident wandering and diet service | |
| Licensed Practical Nurse (LPN) #95 | Interviewed regarding resident wandering | |
| Licensed Practical Nurse (LPN) #99 | Interviewed regarding resident wandering | |
| Dietary Manager (DM) #72 | Interviewed regarding diet service and waiver documentation |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Aug 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to provide nourishing snacks to residents at bedtime and concerns about food storage, preparation, and distribution practices.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00144724.
Findings
The facility failed to ensure nourishing snacks were offered to residents at bedtime and did not have a policy for snacks. Additionally, food was not stored, prepared, and distributed in a sanitary manner, with multiple sanitation and food safety violations observed.
Deficiencies (2)
F 0809: The facility failed to ensure nourishing snacks were offered to residents at bedtime, affecting 40 of 41 residents on the 200 unit who receive meals from the kitchen. Staff interviews and observations confirmed snacks were rarely offered after dinner and before bedtime.
F 0812: The facility failed to procure food from approved sources and store, prepare, and serve food in a sanitary manner, potentially affecting 52 of 53 residents receiving meals from the kitchen. Observations included sticky counters, unclean kitchen equipment, undated food items, and uncovered beard on a dietary aide.
Report Facts
Residents affected by snack deficiency: 40
Residents affected by food sanitation deficiency: 52
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in relation to snack availability and kitchen observations | |
| Dietary Aide #70 | Observed working in kitchen without beard cover | |
| Licensed Practical Nurse (LPN) #106 | Provided observations of kitchen and snack availability | |
| State Tested Nursing Assistant (STNA) #104 and #130 | Provided interviews regarding snack availability |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Jul 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to wound care and enteral feeding practices at the facility.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00143955.
Findings
The facility failed to ensure ordered wound care was completed for residents and did not follow proper infection prevention practices during wound treatment. Additionally, the facility failed to label enteral feeding bags properly, compromising resident safety.
Deficiencies (2)
F 0684: The facility failed to ensure ordered wound care was completed for Resident #15 and failed to prevent potential wound infection for Resident #55. Documentation was missing for treatments on specified dates and improper glove use was observed during wound care.
F 0693: The facility failed to ensure enteral feeding bags were labeled for Resident #35, making it unclear what formula was infusing or when the feeding was initiated. No policy was provided regarding enteral feeding procedures.
Report Facts
Facility census: 57
Residents reviewed for wound care: 3
Residents with enteral feedings identified: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) #390 | Verified lack of documentation for wound care treatments on 06/27/23 and 06/28/23 | |
| Licensed Practical Nurse (LPN) #315 | Observed performing wound care without changing gloves or performing hand hygiene | |
| Licensed Practical Nurse (LPN) #300 | Verified unlabeled enteral feeding bag and lack of policy for enteral feeding procedures |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 9
Date: Nov 29, 2022
Visit Reason
Complaint investigations were conducted related to failure to provide timely notification of resident transfers, failure to provide scheduled bathing assistance, lack of weekend activities for cognitively impaired residents, and multiple deficiencies in food and nutrition services including dietary management, food preparation, and kitchen sanitation.
Complaint Details
This inspection was complaint-related, investigating multiple complaints including failure to notify resident transfers (Resident #18), failure to provide scheduled bathing (Residents #50 and #108), failure to provide weekend activities for cognitively impaired residents, and multiple food and nutrition service deficiencies. Complaint numbers OH00131746, OH00137083, and OH00133795 are referenced.
Findings
The facility was found deficient in notifying residents and representatives of hospital transfers, providing scheduled bathing assistance, offering weekend activities for cognitively impaired residents, employing a qualified dietary manager, preparing palatable and properly textured pureed and mechanically altered diets, maintaining kitchen cleanliness and sanitation, and properly disposing of garbage.
Deficiencies (9)
F 0623: The facility failed to provide written notification to Resident #18 and the resident representative of hospital transfers on multiple dates.
F 0677: The facility failed to ensure residents dependent on staff received showers or baths as scheduled, affecting Residents #50 and #108.
F 0679: The facility failed to provide activities on weekends for cognitively impaired residents, affecting four residents and potentially 39 others.
F 0801: The facility failed to employ a qualified director of food and nutrition services to oversee kitchen sanitation and diet orders.
F 0804: The facility failed to prepare puree food in a palatable manner, resulting in food with a strong taste of thickener obscuring flavor.
F 0805: The facility failed to ensure pureed food was prepared to an appropriate smooth texture prior to serving, affecting six residents on pureed diets.
F 0808: The facility failed to ensure Residents #5 and #17 were served mechanically altered diets as ordered by physicians.
F 0812: The facility failed to maintain the kitchen in a clean and sanitary manner, including improper food storage, unsanitary food temperature checks, and incomplete cleaning schedules.
F 0814: The facility failed to properly dispose of garbage and maintain covered trash cans in the kitchen.
Report Facts
Facility census: 50
Residents requiring bathing assistance: 49
Residents affected by bathing deficiency: 2
Residents affected by activities deficiency: 4
Residents potentially affected by activities deficiency: 39
Residents affected by puree food preparation deficiency: 3
Residents affected by puree food texture deficiency: 6
Residents affected by therapeutic diet deficiency: 2
Facility census for food service deficiencies: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary [NAME] #209 | Dietary staff / acting kitchen manager | Named in multiple findings related to food preparation, dietary management, and sanitation |
| Administrator | Interviewed regarding notification failures and dietary management | |
| Director of Nursing | Interviewed regarding bathing assistance deficiencies | |
| Corporate Nurse (CN) #268 | Corporate Nurse | Interviewed regarding bathing documentation |
| Activities Director #238 | Activities Director | Interviewed regarding lack of weekend activities |
| Dietary Manager #139 | Dietary Manager | Observed and interviewed regarding puree food preparation |
| Speech Therapist (ST) #165 | Speech Therapist | Consulted on puree food texture appropriateness |
| Dietary Aide #219 | Dietary Aide | Interviewed regarding cleaning schedule awareness |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 5
Date: Jun 13, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfers, fall prevention, medication administration, laboratory testing, and safeguarding resident information.
Findings
The facility failed to provide timely transfer/discharge notices to residents and their representatives, did not implement ordered fall precautions, had a medication error rate exceeding 5%, failed to obtain ordered laboratory tests, and did not safeguard resident-identifiable information on medication packets.
Deficiencies (5)
F 0623: The facility failed to provide transfer/discharge notices to two residents and/or their representatives when transferred to the hospital.
F 0689: The facility failed to implement fall precautions as ordered for one resident, including not placing non-skid strips as required.
F 0759: The facility failed to ensure medications were administered as ordered, resulting in a 19.35% medication error rate affecting two residents.
F 0773: The facility failed to obtain ordered laboratory tests for one resident as required by physician orders.
F 0842: The facility failed to safeguard resident-identifiable information on medication packets, disposing of them in trash with visible identifiers.
Report Facts
Medication error rate: 19.35
Residents affected by transfer notice deficiency: 2
Residents affected by fall precaution deficiency: 1
Residents affected by medication error deficiency: 2
Residents affected by laboratory test deficiency: 1
Residents affected by safeguarding deficiency: 6
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #256 | Licensed Practical Nurse | Involved in medication administration errors and disposal of medication packets |
| LPN #300 | Licensed Practical Nurse | Disposed of medication packets containing resident identifiers |
| Housekeeper #325 | Housekeeper | Collected trash from medication carts containing resident information |
| Director of Nursing | Director of Nursing | Verified deficiencies related to transfer notices, fall precautions, laboratory tests, and medication packet disposal |
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