Tudor Oaks Health Center

In the surveyor’s words

From the most serious findings on record at Tudor Oaks Health Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 16, 2025

  Based 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. […]

• Actual harm, isolatedF689Apr 23, 2025

  Based on interview and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 3 residents (R1 and R3) reviewed for falls. *R1 had four unwitnessed falls that were not thoroughly investigated to determine a root cause and develop interventions that addressed the cause to prevent future falls. R1 had a fifth unwitnessed fall that resulted in a displaced left femoral neck fracture. *R3 did not have wheelchair pedals on when moving in R3's wheelchair. […]

• Actual harm, isolatedF686Jan 5, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jun 16, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jun 16, 2025

  Based 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. […]