Health inspection·December 15, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview and policy review, the facility failed to maintain the kitchen in a sanitary condition. This had the potential to affect all 52 residents residing in the facility. The census was 52. Residents Affected - Many Findings include: Tour of the kitchen 12/16/23 at 11:30 A.M. through 12:47 P.M. revealed the following concerns: 1. The ice machine had brown streaks running from the screws onto the white plastic in each corner of the ice machine making up the chute. 2. The fronts of the stainless steel appliances were dirty, smeared, sticky, with dry debris which included the top surfaces of the oven, salad bar, refrigerators, and dishwasher. 3. There was no evidence of the facility recorded food temperatures for breakfast, lunch and supper tray line between 09/01/23 and the lunch meal of 12/13/23. 4. There was no evidence of the facility recorded refrigerator and freezer temperatures to ensure acceptable refrigeration temperatures were maintained since 09/01/23. 5. The walk in refrigerator had a white liquid pooled on the floor. There were two mugs on a shelf with liquid that were uncovered and unidentifiable. 6. Observation of the lunch tray line at 11:50 A.M. revealed [NAME] #70 left the tray line, went to the salad bar, opened the lid with the handle using his right gloved hand, grabbed shredded cheese into his gloved hand, opened the cabinet door below with his left gloved hand, took a bag of shredded lettuce from the refrigerated cabinet and went back to the trayline. [NAME] #70 put the shredded cheese on the sandwich, opened the bag of lettuce, reached in the bag with his right gloved hand and took out lettuce. He placed the lettuce on the sandwich all without changing his gloves that touched the handles of the salad bar roll top and underneath cabinet. 7. Observation of the tray line at 11:56 A.M. revealed [NAME] #70 left the tray line, opened the door to the dry goods pantry using his gloved right hand, returned with a bag of sandwich buns, opened it and retrieved a bun with his right gloved hand without changing his glove that he used to open the pantry door. 8. Observation of the walk in freezer revealed bags of hamburger patties, chocolate chip cookies, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366170 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Sanctuary at Tuttle Crossing 4880 Tuttle Road Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)