Tudor Oaks Health Center

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 5 residents (R4). R4 made an allegation of abuse by a staff member on 9/5/25 and the facility did not put measures into place to correct the abuse and ensure R4 and other residents were kept safe and free from any additional abuse by staff. The facility's abuse policy states, in part:* The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: .Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and or misappropriation of resident property is more likely to occur.* An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that 3 out of 5 residents reviewed (R11, R297, R298) were free from physical and verbal abuse. R11 was provided cares by an agency CNA (Certified Nursing Assistant) on 6/15/25. During this time, a facility CNA was present in the room and did not intervene when she witnessed the agency CNA being rough with R11. R297 and R298 were allegedly both physically and verbally abused by a facility Registered Nurse on 6/18/25. The facility staff did not ensure that R297 and R298 were kept safe and free from any additional abuse by immediately reporting the allegations of abuse.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that allegations of potential verbal and physical abuse involving 3 out of 5 residents (R11,R297, R298) reviewed were reported to the Nursing Home Administrator (NHA) or Designee and Law Enforcement. The facility did not contact the local law enforcement after they became aware that an agency CNA was witnessed to be rough with R11 when providing cares on 6/15/25. R297 was allegedly physically and verbally abused by a facility Registered Nurse (RN-H) on 6/18/25. This allegation was not immediately reported to the NHA . This allegation was not reported to Law Enforcement as a possible crime of abuse. R298 was allegedly physically abused by a facility Registered Nurse (RN-H) on 6/18/25. This allegation was not immediately reported to the NHA. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R298) of 3 allegations of abuse were investigated.* The facility did not conduct an investigation for R298's allegation of physical abuse.

Inspectors wroteBased on interview and record review, the facility did not ensure 6 of 10 residents (R34, R11, R23, R2, R9, and R13) reviewed received adequate supervision and assistance devices to prevent accidents. * R34's fall on 10/29/24 was not thoroughly investigated and a root cause was not determined to help prevent additional falls. On 5/16/25, R34 fell, was transferred to the hospital, and diagnosed with a hip fracture. R34 had been observed prior to this fall coming out the bathroom by herself. The facility did not implement interventions after observing R34 coming out of the bathroom prior to R34's fall. R34 was not assessed by a Registered Nurse (RN) prior to being placed in a wheelchair after the fall even though there was an RN available. The facility's investigation did not include a root cause analysis of R34's fall to help prevent additional falls. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 resident unit refrigerators in the facility. The facility did not ensure food was stored in a safe manner and, kitchen staff member had beard hair exposed and uncovered while preparing food, which had the potential to affect all 41 Residents currently living in the facility. *Temperature logs were not maintained for unit refrigerator/freezers. *Multiple food items were observed undated on the metal racks located in the facility's freezer. *Hand scoops were observed left in the ready to use sugar, flour, and rice flour bins. *Cook-Q was observed not wearing a beard hair guard on 6/11/25 while preparing food in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. * The facility was not computing baseline rates of infections for prevalent infections. * The eye wash station was not flushed weekly. * R12 has Stage 2 coccyx pressure injury. R12 was not placed on EBP (enhanced barrier precautions) staff was observed not wearing the appropriate PPE (personal protective equipment) during personal care & treatment observations and hand hygiene concerns were identified during R12's treatment observation. * Hand hygiene concerns were identified during R23's medication administration. * R24 was not placed on EBP. R24 has a heel pressure injury. * R38 was not placed on EBP. R38 has a Stage 2 coccyx pressure injury. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 4 (R12, R34, R39, & R41 ) of 4 residents were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the residents bed was not documented in the Transfer, Bed hold Notice and readmission Rights form.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R12) of 1 resident was clinically appropriate to self administer medications. * R12 was observed with 7 medication pills in a medication cup on the over bed table next to R12. R12's self administration assessment dated [DATE] documents that R12 not approved for the self-administration of medications.

Inspectors wroteBased on interview and record review, the facility did not protect 1 (R16) of 1 Resident by not implementing their written policies and procedures to prohibit and prevent the right to be free from verbal abuse from Registered Nurse (RN)-E. * Staff did not report allegations of verbal abuse made by R16 regarding RN-E to the Nursing Home Administrator (NHA)-A immediately. This allowed for additional potential allegations of verbal abuse to occur to other residents whom RN-E provided nursing care to for the remainder of the shift. Findings Include: The facility's undated Abuse, Neglect, and Exploitation documents: Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident property b. [...]

Inspectors wroteBased on record reviews and interviews, the facility did not ensure allegations of verbal abuse were immediately reported to the Administrator and/or Grievance Officer. This was observed with 1 (R16) of 1 Resident reviewed for alleged verbal abuse. * An allegation of verbal abuse by Registered Nurse (RN)-E towards R16 was reported by Certified Nursing Assistant (CNA)-G at approximately 4:30 AM to Licensed Practical Nurse (LPN)-F on 4/29/25. LPN-F informed Director of Nursing (DON)-B at approximately 7:00 AM, after RN-E's shift had ended at the facility. Findings Include: The facility's undated Abuse, Neglect, and Exploitation documents: .Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident property b. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegations involving potential verbal abuse were thoroughly investigated for 1 (R16) of 1 reviewed facility reported incidents (FRI). *An allegation of verbal abuse on 4/29/25 by Registered Nurse (RN)-E towards R16 was not thoroughly investigated. Findings Include: The facility's undated Abuse, Neglect, and Exploitation documents: Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident property b. Establish policies and procedures to investigate any such allegations c. [...]

Inspectors wrote2.) R12's diagnoses include dementia (loss of cognitive function that interferes with a person's daily life and activities), atrial fibrillation (irregular and rapid heart beat), and syncope (fainting) and collapse. R12's nurses note dated 12/12/24, at 11:45 a.m., documents : Arrived to unit on 12/12/2014 at 1045. Came from [Name] Assisted Living - [Name] house. Resident has fall in her AL (assisted living) apartment and sustained R (right) humerus fx (fracture), no repair. Has RUE (right upper extremity) sling. A&Ox4 (alert and orientated times four). Diabetic on insulin. LCTA (lungs clear to auscultation). No pacemaker. Slight nonpitting edema to BLE (bilateral lower extremity). Continent of bowel and bladder but wears depends or pads in underwear. Has hard time falling asleep. Has reading glasses, not present at time of admission. Natural teeth. [...]

Inspectors wrote2.) R12 was admitted to the facility on [DATE] with diagnoses that include dementia, depressive disorder, chronic kidney disease (progressive damage and loss of kidney function), atrial fibrillation(irregular and rapid heartbeat), malignant neoplasm of colon (cancer), and diabetes mellitus. R12's skin pressure injury care plan initiated 12/12/24 & revised 5/29/25 documents the following interventions: *Apply moisture barrier as needed. Initiated 12/12/24 & revised 12/16/24. *Braden skin risk evaluation completed on admission, Q (every) week for 4 weeks, quarterly, and with any significant change. Initiated 12/12/24. *CNA's (Certified Nursing Assistant) to observe skin with am (morning) and hs (hour sleep) cares and report any abnormalities to the nurse. Initiated 12/12/24 & revised 12/16/24. *Dressing changes per MD (Medical Doctor) order. Initiated 6/10/25. *Mild skin risk per Braden. [...]

Inspectors wrote2.) R11's diagnoses includes diabetes mellitus (high blood sugar). R11's diabetic mellitus care plan initiated & revised on 12/15/22 documents the following interventions: *Check all of body for breaks in skin and treat promptly as ordered by doctor. Initiated 12/15/22. *Diabetes medication/insulin as ordered by doctor. Monitor/document for side effects and effectiveness. Initiated 12/15/22 & revised 3/9/23. *Fasting serum blood sugar as ordered by doctor. Initiated 12/15/22. *Monitor/document/report to MD (Medical Doctor) PRN (as needed) s/sx (signs/symptoms) of hypoglycemia: sweating, tremor, increased heart rate (Tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Initiated 12/15/22. Monitor/document/report to MD PRN for s/sx of hyperglycemia: [...]

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R11, R34, & R13) of 5 residents drug regimen were free of unnecessary drugs. * R11 is prescribed Eliquis (Apixaban) 2.5 mg (milligrams), an anticoagulant, for history of pulmonary embolism (condition where one or more arteries in the lungs are blocked by a blood clot). There is no monitoring for signs/symptoms of anticoagulant complications. * R34 is prescribed Rivaroxaban 15 mg, an anticoagulant, for blood clots. There is no monitoring for signs/symptoms of anticoagulant complications. * R13 is prescribed Eliquis (Apixaban) 2.5 mg, an anticoagulant, for history of pulmonary embolism. There is no monitoring for signs/symptoms of anticoagulant complications.

Inspectors wrote2.) R12's diagnoses includes dementia (loss of cognitive function that interferes with a person's daily life and activities), atrial fibrillation (irregular and rapid heart beat), depressive disorder, diabetes mellitus (high blood sugar), and malignant neoplasm of colon (cancer). R12's significant change MDS (minimum data set) with an assessment reference date of 2/6/25 has a BIMS (brief interview mental status) score of 12 which indicates moderate cognitive impairment. Hospice care is checked for while a resident. R12's nurses note dated 2/7/25 documents Resident is being monitored for readmission. Resident is now on [Name] hospice. Resident out for breakfast today. VSS (vital signs stable). Taking in fluids. Denies pain. BGL (blood glucose level) 186 before breakfast. R12's hospice care plan initiated 2/13/25 documents the following interventions: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure staff postings displayed were accurate to the actual staffing of the facility. Review of staffing schedules and required staff postings from 5/9/2025 - 6/9/2025 revealed 14 of 30 days had discrepancies between the documents. This resulted in inaccuracies with the total number and the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift. This deficient practice has potential to affect 41 out of 41 residents.

Inspectors wrote2.) R3 was admitted to the facility on [DATE] with a primary diagnosis of parkinsonism. R3's admission Minimum Data Set (MDS) assessment completed 1/2025 documents that R3 has no cognitive impairment, upper extremity impairment on one side, wheelchair for mobility, does not walk and requires staff assistance with ADLs. R3's Care Area Assessment (CAA) for Falls documents under the Analysis of Findings section: The Fall CAA triggered related to recent fall at home with hospitalization. R3 requires maximum to moderate assist with most ADLs. There were falls reported at home prior to hospitalization and no falls in look back period. On 4/23/25 at 9:30 AM, Surveyor interviewed, and observed, R3 in R3's room. R3 was sitting in their wheelchair with their feet firmly on the ground. R3 had sneakers on their feet. R3 stated they had 2 falls in the facility. The first fall was from the wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed practical nurse (LPN) classified an incident in which a resident was found on the floor beside their bed as a fall for 1 (R1) of 4 sampled residents reviewed for accidents. As a result, the LPN did not implement all post-fall protocols in accordance with facility policies and practices, including the completion of a post-fall evaluation, a post-fall fall risk evaluation, immediate initiation of a fall investigation, communication of a fall to the oncoming shift, and listing the fall on the facility's fall tracking log. In addition, the facility failed to ensure certified nursing assistants (CNAs) transferred a resident using a Hoyer lift (a type of full-body mechanical lift) per the resident's assessment and plan of care for 1 (R2) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure staff provided two-person assistance when 1 (R1) of 3 sampled residents reviewed for falls. R1 was assessed to require extensive assistance of two persons with toilet use and bed mobility. On 10/07/23, Certified Nursing Assistant (CNA) J provided incontinence care to R1 alone. CNA J left R1 unattended lying on his side in bed. R1 rolled off the bed onto the floor, and sustained a laceration an hematoma to the left forehead.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, including misappropriation of resident property, were reported immediately, but not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 (R2) of 2 sampled residents. R2's caregiver reported a missing cell phone and cell phone charger to facility staff on 04/22/23. The facility did not report this allegation to the Nursing Home Administrator or the State Agency until 4/25/23.

Inspectors wroteBased on interview and record review the facility did not ensure all allegations of misappropriation were thoroughly investigated for 1 (R2) of 2 sampled residents. On 04/22/23, the facility was informed that R2's iPhone and charger were missing. The facility did not conduct a thorough investigation into the allegation to identify the timeline of events related to the missing item including who was informed R2's iPhone and charger were missing and when were they informed to allow for an investigation to be initiated timely and thoroughly conducted. This is evidenced by: The facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, states the following: [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure 2 (R3 and R1) of 3 Residents reviewed for accidents received adequate supervision, assistance and assistive devices necessary to prevent falls. *On 6/16/23, R3 was provided care with improper technique by a Certified Nursing Assistant leading to a fall with a hematoma to the left temple, cut to the left ear, and skin tears to the left arm, abrasion to the left knee, and swelling to the left elbow. *Surveyor observed R1's documented fall prevention intervention of dycem under the wheelchair cushion not in place. Findings Include: Surveyor reviewed the facility's Falls and Fall Risk, Managing policy and procedure revised 3/2018 and notes the following applicable: . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that Residents without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 1 (R2) of 3 Residents reviewed for pressure injuries. R2 developed a coccyx pressure injury which was identified on 12/03/22. The treatment was not implemented until 12/05/22. On 12/06/22, Facility staff assessed R2's pressure injury and incorrectly staged the pressure injury as Stage 2 when there was 70% slough. R2's pressure injury continued to be incorrectly staged, the care plan was not revised after R2 developed the pressure injury, and R2's heels were observed not being offloaded according to the plan of care.

Inspectors wroteBased on observation, staff interviews, and record review, the facility did not ensure food was prepared, stored, and served under sanitary conditions. These deficient practices had the potential to affect all 45 residents of the facility. Cook K did not follow a puree recipe affecting 1 of 3 residents receiving a pureed diet. Gloves were not changed appropriately leading to possible cross contamination of ready to eat food items with the potential to affect all 45 residents of the facility.

Inspectors wroteBased on record review and interviews with staff and residents, the facility did not ensure they made prompt efforts to resolve grievances. Resident Council members expressed concerns to Administration staff during Resident Council Meetings in September, October and November 2022 regarding the noise level heard from the hallway on 3rd (night shift). Individual interviews were conducted with residents during the survey and statements were made that residents (R14, R23 and R38) are still hearing loud talking and disturbances on night shift. The grievance documents do not identify how the grievances were investigated, if interviews with staff/residents were completed, or the outcome of the investigation. Resident Council Minutes did not include actions taken regarding the concerns voiced by residents. This is evidenced by: [...]

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R31, R20 and R2) of 12 residents reviewed have their care plan updated with interventions after a fall occurrence. R31, R20 and R2 had falls and the care plan was not updated with fall prevention interventions.

Inspectors wroteBased on interview and record review, the Facility did not ensure that 3 (R2, R24, & R4) of 3 Resident's who received as needed psychotropic medications were free from unnecessary drugs. * R2's, R24's, & R4's PRN Lorazepam (Ativan) does not have a stop date or rationale to extend the use of this medication past 14 days.

Inspectors wroteBased on interview and record review the Facility did not maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections. On 10/24/22, R149 experienced 3 loose stools, on 10/25/22, R149 self reported one loose stool and on 10/26/22 R149 had 2 loose stools. R149's physician was not consulted to inquire about a stool culture and there is no evidence R149 was placed on isolation. Starting on 11/1/22, R149 had a fever and emesis. The Facility did not test R149 for Covid. On 11/3/22, R149 was transferred to the hospital and was diagnosed with Covid 19. R149 returned to the facility on [DATE]. This has the potential to affect a pattern of Residents residing on team one. During the survey, there were 31 Residents residing on team one.

Inspectors wroteBased on observation, interview and record review, the facility did not develop a comprehensive resident centered care plan for 1 (R4) of 12 residents reviewed for a wanderguard. The facility did not develop a plan of care to identify elopement risk, interventions or monitoring related to the use of a wanderguard for R4. This is evidenced by: The facility policy, entitled Elopement - Prevention and Management Process, dated 6/2010, states: The facility (SNF (Skilled Nursing Facility), CBRF (Community Based Residential Facility), and RCAC (Residential Care Apartment Complex)) will have an Elopement Prevention and Management Process. Assessment for Risk of Elopement - Procedure #5. If it is indicated that the resident is at a risk for elopement, this information will be documented in the medical record and interventions noted in the plan of care. a. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure that 2 (R24 & R4 ) of 4 Residents reviewed received treatment and care in accordance with professional standards of practice. * Neuro checks were not consistently completed following unwitnessed falls for R24 & R4.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure 2 (R2 & R24) of 6 Residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. * R2's fall care plan interventions were not implemented. * R24 had a fall on 10/13/22 fall. The facility did not investigate the fall to determine the root cause.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 1 (R4) of 2 residents reviewed received appropriate treatment and services related to catheter care. R4's medical record did not indicate what type of catheter R4 had, did not include orders for the care and treatment of the suprapubic catheter.

Inspectors wroteBased on observation, record review, and interview, the facility did not recognize, evaluate, and address the needs of 1 (R39) of 2 Residents reviewed for weight loss. R39 sustained a severe weight loss over one month. The facility failed to address this weight loss timely and R39 continued to lose weight.

Inspectors wroteBased on record review and interview the facility did not ensure the attending physician reviewed and acted on irregularities identified by the pharmacist for 1 (R34) 5 Residents reviewed for unnecessary medications. The facility failed to act upon a pharmacist identified medication irregularity from October 2022 for R34.

Inspectors wroteBased on record review and interview, the Facility did not keep 1 (R24) of 2 residents reviewed for antibiotic use free from unnecessary drugs. * R24 received an antibiotic when they did not have appropriate signs and symptoms for use of the antibiotic.