Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tudor Oaks Health Center during CMS and state inspections, most recent first.
A resident reported being treated roughly by a CNA who was not attentive during care, leading to a substantiated abuse allegation. Although the incident was investigated and reported, there was no evidence that the facility implemented measures to prevent further abuse or ensure resident safety.
Three residents were not protected from physical and verbal abuse, including rough care by a CNA and aggressive treatment by an RN. In both cases, staff who witnessed or were informed of the abuse did not immediately intervene or report the incidents to facility leadership, resulting in delays in protecting the residents and allowing the alleged abusers to continue working.
The facility did not ensure that allegations of verbal and physical abuse involving three residents were promptly reported to the NHA or designee and to law enforcement, as required by policy. In one case, a resident reported rough care by a CNA, and in two other cases, a RN was alleged to have aggressively handled and verbally abused two residents with significant cognitive and physical impairments. These incidents were not reported to law enforcement or the state agency, and staff failed to follow proper reporting procedures.
A facility failed to investigate an allegation of physical abuse after a CNA reported that a nurse handled a resident with hemiplegia aggressively, causing visible pain. Despite a written statement and facility policy requiring immediate investigation, no inquiry was conducted because the resident did not complain and the CNA's report was considered emotionally charged by administration.
Several residents did not receive adequate supervision or assistance devices to prevent accidents, with multiple falls and a resident-to-resident altercation not thoroughly investigated. In one case, a resident with dementia and high fall risk suffered a hip fracture after staff failed to implement additional interventions or conduct a root cause analysis. Other residents experienced falls due to improper transfer techniques, lack of care plan updates, and missing or incorrectly placed safety devices. These deficiencies resulted in actual harm for one resident and the potential for more than minimal harm for others.
Surveyors found that food was not stored, prepared, or served according to professional standards, with missing temperature logs, undated food items, dirty and improperly stored scoops in bulk food bins, and a staff member preparing food without a beard guard. These deficiencies in food safety practices had the potential to affect all residents.
Surveyors identified multiple failures in the infection prevention and control program, including not tracking baseline infection rates for prevalent infections, inconsistent flushing of the eye wash station, and failure to implement Enhanced Barrier Precautions (EBP) for residents with stage 2 pressure injuries. Staff were observed providing care without proper PPE and not following hand hygiene protocols during medication administration. Additionally, a resident's catheter bag and tubing were repeatedly found resting on the floor without a privacy cover or barrier, in violation of facility policy.
Four residents were transferred to the hospital without receiving written notification of the reason for transfer, bed-hold policies, or the specific daily rate for holding their bed. Instead, staff relied on verbal consent and did not provide the required written documentation at the time of transfer, and the bed-hold forms in the medical records lacked the necessary rate information.
A resident with moderate cognitive impairment and a diagnosis of dementia, who was not approved for self-administration of medications, was left unsupervised with a cup containing seven pills by an LPN at the resident's request. Facility policy requires interdisciplinary team approval for self-administration, but this was not followed, as confirmed by observation, staff interviews, and record review.
Two residents did not have their care plans promptly updated after significant changes in their condition, including a new transfer status and the development of a stage 2 pressure injury. Although interventions were implemented, the official care plans were not revised in a timely manner to reflect these changes, as required by facility policy.
Three residents experienced deficiencies in pressure injury prevention and care, including lack of timely assessment and care plan updates for new or worsening wounds, failure to provide pressure relief while seated, and inadequate monitoring of skin integrity under a wanderguard. Nursing staff did not consistently perform or document required skin assessments, and interventions were not promptly implemented or revised in response to changes in residents' skin condition.
Three residents with diabetes and related complications did not receive or have documentation of daily diabetic foot checks as required by professional standards and the facility's own policy. Nursing staff confirmed that only weekly skin checks were performed, and daily foot checks were not part of routine practice, resulting in a deficiency related to diabetic foot care.
Three residents prescribed anticoagulants for conditions such as pulmonary embolism and atrial fibrillation were not monitored for signs and symptoms of complications, despite facility policy requiring such monitoring. Nursing staff acknowledged that monitoring was based on judgment and not consistently documented, and care plans or physician orders did not always include interventions for monitoring adverse effects.
The facility did not ensure proper collaboration and communication with hospice providers for three residents, resulting in missing hospice care plans, visit notes, and provider schedules. Staff were unclear about who was responsible for coordinating hospice care, and documentation was inconsistent or incomplete, leading to gaps in continuity of care.
A resident with severe cognitive impairment was subjected to verbal abuse by an RN during toileting care. Although a CNA promptly reported the incident to an LPN, the LPN did not immediately notify administrative staff, allowing the RN to continue working and interact with other residents for the remainder of the shift. The facility also failed to collect all relevant staff statements regarding the incident.
A resident with dementia and multiple medical conditions was subjected to alleged verbal abuse by an RN during toileting assistance. The incident was promptly reported by a CNA to an LPN, but the LPN failed to immediately notify facility leadership as required by policy, allowing the RN to continue working until the end of the shift and potentially exposing other residents to further risk.
A resident with severe cognitive impairment was subjected to alleged verbal abuse by an RN, which was overheard and reported by a CNA. The LPN on duty did not immediately report the allegation to facility leadership, allowing the RN to continue working until the end of the shift. The facility failed to collect statements from all staff present, did not update the resident's care plan to address psychosocial needs, and did not notify the resident's psychologist about expressions of distress, resulting in an incomplete investigation and lack of appropriate resident protection.
Surveyors found that daily nurse staffing postings did not accurately reflect the actual number and type of staff present for multiple days. Discrepancies included incorrect counts of RNs, LPNs, and CNAs, as well as inaccurate reporting of hours worked, due to a lack of ongoing review and updates to the postings as staffing changes occurred.
Two residents experienced falls resulting in injury due to the facility's failure to provide adequate supervision and implement consistent fall prevention interventions. One resident, with multiple medical conditions and on hospice, had five unwitnessed falls, with interventions inconsistently documented and not always in place, leading to a hip fracture. Another resident with parkinsonism fell from a wheelchair and sustained a head injury because wheelchair foot pedals were not applied during transport. In both cases, care plans were not promptly or thoroughly updated, and root cause analysis was lacking.
A facility failed to classify a resident's fall and did not follow post-fall protocols, leading to a lack of investigation and documentation. Additionally, CNAs used an incorrect transfer method for another resident, contrary to the care plan, resulting in a near-fall incident. Staff interviews revealed non-compliance with facility policies.
Failure to Implement Preventive Measures After Substantiated Abuse
Penalty
Summary
A resident alleged that a Certified Nursing Assistant (CNA) was rough while providing care, specifically when rolling the resident in bed. The resident reported that the CNA was wearing ear buds and was not listening to the resident's attempts to communicate about pain and how care should be performed. Documentation indicated that the resident was tearful after the interaction. The facility contacted local police and conducted interviews with residents and staff following the allegation. Despite substantiating the abuse allegation, the facility did not provide documentation or evidence to surveyors that measures were put in place to prevent recurrence of abuse or to ensure the safety of the resident and others. The facility's abuse policy requires immediate investigation and implementation of actions to prevent further abuse, but there was no evidence that such preventive measures were taken after the incident.
Failure to Protect Residents from Physical and Verbal Abuse
Penalty
Summary
Three residents were not protected from physical and verbal abuse as required by facility policy. In one instance, a resident receiving care from an agency CNA was treated roughly, with the CNA pulling the resident's legs apart and being rough while cleaning, despite the resident voicing pain and asking the CNA to stop. Another CNA was present during this incident but did not intervene to stop the rough treatment, only reporting the concern after the care was completed. The facility's Social Services Director and Nursing Home Administrator confirmed that the witnessing CNA was expected to intervene immediately to protect the resident but did not do so. In two separate cases, a registered nurse was alleged to have physically and verbally abused two residents with significant cognitive and physical impairments. One resident, who had severe dementia and was dependent for care, was rolled and wiped aggressively, causing distress and pain, while the nurse made inappropriate verbal remarks. The incident was witnessed by a CNA, who reported it to another nurse. However, instead of immediately escalating the report to facility leadership, the CNA and nurse left written statements under the DON's office door, who was not present at the time. This delayed the initiation of an investigation and allowed the accused nurse to continue working subsequent shifts before the allegations were addressed. The second resident, who also had significant neurological and physical impairments, was similarly treated aggressively by the same nurse. The CNA's statement described the nurse rolling the resident onto their affected side and wiping them aggressively, causing visible pain. Again, the report was not immediately brought to the attention of facility leadership, and the nurse continued to work. In both cases, the facility failed to ensure immediate protection of the residents from further potential abuse, as required by their own policies.
Failure to Report Alleged Abuse and Neglect to Authorities
Penalty
Summary
The facility failed to ensure that allegations of potential verbal and physical abuse involving three residents were reported to the Nursing Home Administrator (NHA) or designee and to law enforcement as required by facility policy and regulation. In one instance, a resident complained that a Certified Nursing Assistant (CNA) was rough during care, including pulling the resident's legs apart and being rough while cleaning, which caused the resident to express pain and distress. Although the incident was reported internally and the CNA was removed pending investigation, law enforcement was not contacted, contrary to policy requirements for reporting suspected abuse. In two additional cases, a Registered Nurse (RN) was alleged to have verbally and physically abused two residents on the same night. One resident, who had severe cognitive impairment and was dependent for care, was reportedly rolled aggressively and wiped in a manner described as aggressive, with the RN making an inappropriate statement to the resident. The incident was not immediately reported to the NHA, and law enforcement was not notified. The second resident, who had hemiplegia, hemiparesis, and dementia, was also allegedly rolled and wiped aggressively by the same RN, causing visible signs of pain. This allegation was not reported to the state agency or law enforcement, and there was no documented investigation for this resident. Staff interviews and record reviews revealed that statements regarding these incidents were left under the Director of Nursing's (DON) office door while the DON was absent, and there was confusion among staff about reporting procedures. The NHA and Director of Social Services only became aware of the incidents after being informed by another CNA during an unrelated meeting. The facility's failure to report these allegations to the appropriate authorities within the required timeframes constitutes a deficiency in following abuse reporting protocols.
Failure to Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to investigate an allegation of physical abuse involving one resident, despite having a policy that requires immediate investigation of all reports or suspicions of abuse, neglect, or exploitation. According to the facility's policy, an investigation should be initiated when any such allegation is reported, including identifying responsible staff, interviewing all involved parties, and thoroughly documenting the process. In this case, a Certified Nursing Assistant (CNA) reported that a Registered Nurse (RN) rolled a resident aggressively onto his affected side and wiped him in a manner that caused visible pain. The CNA documented this incident in a written statement and submitted it to the Director of Nursing. However, there was no evidence that an investigation was initiated for this allegation. The resident involved had significant medical conditions, including hemiplegia and hemiparesis following a stroke, heart failure, diabetes mellitus, and dementia. Despite the CNA's detailed statement and the facility's policy, both the Director of Social Services and the Nursing Home Administrator confirmed that no investigation was conducted, citing the resident's lack of complaint and questioning the emotional tone of the CNA's statement. The surveyor found no documentation or evidence of an investigation into the alleged abuse, which constitutes a failure to respond appropriately to an allegation of abuse as required by facility policy.
Failure to Prevent Accidents and Inadequate Fall Investigations
Penalty
Summary
The facility failed to ensure that six residents received adequate supervision and assistance devices to prevent accidents, as required by policy. Multiple incidents were not thoroughly investigated, and root causes were not determined, which led to missed opportunities for implementing effective interventions. For example, one resident with dementia and a high fall risk experienced multiple falls, including one resulting in a hip fracture. After being observed ambulating alone, no additional interventions were implemented, and the resident was not assessed by an RN prior to being placed in a wheelchair post-fall, despite RN availability. The facility's investigations into these falls did not include comprehensive root cause analyses. Another resident fell from a wheelchair, but the investigation did not address how the resident was seated, whether the resident was interviewed, or why the fall care plan was not developed until months later. Additionally, the resident was not transferred according to the established plan of care at the time of the fall. In another case, a resident-to-resident altercation was not investigated, and no revisions were made to the care plan following the incident. The facility also failed to investigate how a resident rolled out of bed multiple times despite interventions such as body pillows, and did not consistently determine the root cause of these falls. Further deficiencies included a resident who experienced multiple unwitnessed falls, with investigations failing to determine if previous interventions were in place or to identify root causes. The resident's wander alert bracelet was also improperly placed. Another resident's fall interventions, such as a fall mat and body pillows, were not in place or were incorrectly positioned at the time of a fall, and care plan updates were delayed. In several cases, care planned interventions, such as toileting schedules, were not followed, and falls were not thoroughly investigated to ensure interventions were in place. These failures resulted in actual harm for one resident and the potential for more than minimal harm for others.
Deficient Food Storage, Preparation, and Staff Hygiene Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and service practices. Observations revealed that temperature logs were not maintained for unit refrigerators and freezers, and there were no thermometers present in these units. Several food items, including ice cream, yogurt, ribeye, fries, onion rings, tamale pie filling, chicken, pork loins, pancakes, potatoes, and beef top round, were found undated in both the kitchen and unit freezers. Additionally, water was observed dripping from the freezer into the refrigerator, and there was no documentation to show that temperatures were being monitored as required by the facility's own policies. Further inspection showed that hand scoops were left inside bins of sugar, flour, and rice flour, with the scoops in direct contact with the food. The bins themselves were dirty on the outside, with dried and sticky food residue present. The facility's policies require scoops to be kept covered and outside the bins, and for bins to be regularly cleaned and sanitized, but these procedures were not being followed. Staff interviews confirmed that there was no regular cleaning schedule for these bins and that responsibility for dating and storing food items was inconsistently assigned between kitchen and nursing staff. Additionally, a kitchen staff member was observed preparing food without a beard guard, despite having visible facial hair. The facility's policy mandates the use of beard covers when around exposed foods, but the staff member and executive chef did not consider a two-day beard growth to be an issue. The staff member was later observed to be clean-shaven, but no explanation was provided for the initial non-compliance. These failures in food safety practices had the potential to affect all residents in the facility.
Infection Control Program Deficiencies and Lapses in Precaution Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple deficiencies observed during survey. The infection preventionist was not calculating baseline rates of infections for prevalent infections, instead only tracking an overall infection rate. This omission was confirmed during interviews and review of infection control documentation, where it was noted that individual rates for specific infections were not being tracked until after the surveyor's inquiry. Additionally, the facility did not consistently flush the eye wash station weekly as required, with documentation missing for two weeks in May and no designated backup staff to perform the task in the primary staff member's absence. Several residents with stage 2 pressure injuries or other qualifying conditions were not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. For example, one resident with a stage 2 coccyx pressure injury was not on EBP, and staff were observed providing personal care and wound treatment without wearing gowns or following proper PPE protocols. Similar lapses were observed with other residents who had stage 2 pressure injuries, where EBP signage and PPE were not present, and staff were not aware of or did not implement EBP. Interviews with staff revealed a lack of clarity regarding which wounds required EBP and who was responsible for initiating these precautions. Hand hygiene deficiencies were also identified, particularly during medication administration. A nurse was observed failing to perform hand hygiene before donning gloves and between tasks, including when handling medications and administering eye drops. Additionally, a resident with an indwelling catheter was repeatedly observed with the catheter bag and tubing resting directly on the floor without a privacy cover or barrier, contrary to facility policy and infection control standards. These failures in infection prevention practices had the potential to affect all residents in the facility.
Failure to Provide Written Bed-Hold Notification and Rate at Time of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer/discharge, bed-hold policies, and the specific daily rate for bed-hold to four residents and/or their representatives at the time of transfer to the hospital. In each case, the facility's process involved obtaining verbal consent for bed-hold from the resident or their representative, but did not include providing the required written documentation as outlined in the facility's own policy. The documentation reviewed by the surveyor consistently lacked the specific daily rate for holding the bed, and written notices were not given to the residents or their representatives at the time of transfer. For example, one resident with multiple diagnoses including dementia, atrial fibrillation, and diabetes was transferred to the hospital on two separate occasions. In both instances, the transfer, bed-hold notice, and readmission rights forms were completed after the transfer, with only verbal consent documented and no written notice or specific daily rate provided. Another resident with dementia and heart failure was transferred following a fall, and the resident's power of attorney was notified verbally, but again, no written notice or bed-hold rate was provided. Interviews with staff confirmed that the process relied on verbal communication and that written notices were not routinely sent to residents or their representatives. Additional cases included a resident with myelodysplastic syndrome and another with chronic obstructive pulmonary disease, both of whom were transferred to the hospital. In these cases, the bed-hold forms in the medical records did not specify the daily rate, and staff interviews revealed that the rate was only provided at admission, not at the time of transfer. The surveyor confirmed with the nursing home administrator that the daily rate was not included on the transfer documents, and that written notification was not provided as required.
Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
A resident with a diagnosis of dementia and a moderate cognitive impairment, as indicated by a BIMS score of 11, was observed with a cup containing seven medication pills on the over bed table in their room. The resident's self-administration of medication assessment documented that they were not approved to self-administer medications. Despite this, an LPN left the medications with the resident at the resident's request, and documented the medications as administered on the MAR. There was no licensed nurse or medication tech present in the room at the time the medications were left with the resident. Facility policy requires that residents may only self-administer medications if the interdisciplinary team determines it is clinically appropriate, and this determination must be documented in the resident's record. The resident's assessment indicated they were not approved for self-administration, yet staff allowed the resident to have unsupervised access to their medications. The incident was confirmed through observation, staff interviews, and record review, with no explanation provided by the facility for the failure to follow policy and assessment findings.
Failure to Timely Revise Care Plans After Resident Status Changes
Penalty
Summary
The facility failed to ensure that care plans were promptly and accurately revised following significant changes in the condition or care needs of two residents. For one resident with dementia, atrial fibrillation, and a recent right humerus fracture, the mobility care plan was not updated after therapy changed the resident's transfer status from a two-person assist to a one-person assist with a wheeled walker. Despite therapy's recommendation being documented, the care plan continued to reflect the original intervention, and this discrepancy was identified after the resident experienced a fall during a transfer with staff assistance. Another resident with Alzheimer's, dementia, and severe malnutrition developed a stage 2 pressure injury to the right heel. Although nursing staff documented the injury and new interventions were ordered, the resident's care plan was not revised to include these interventions until several weeks later. The care plan was only updated after a significant delay, despite the facility's policy requiring care plan revisions upon status changes. The delay in updating the care plan meant that the interventions for the pressure injury were not reflected in the resident's official care plan documentation in a timely manner. Interviews with facility staff confirmed that care plan revisions were not completed immediately following changes in resident status, and that updates to task sheets did not automatically update the care plan. The surveyor was unable to locate documentation of the interventions in the resident's CNA Kardex or determine when certain interventions were initiated, further highlighting the lack of timely care plan updates.
Failure to Prevent and Manage Pressure Injuries and Monitor Skin Integrity
Penalty
Summary
Surveyors identified that the facility failed to provide necessary treatment and services to prevent and treat pressure injuries for three residents. One resident was admitted with moisture-associated skin damage (MASD) and later developed open areas on the buttocks, which were not reassessed as stage 2 pressure injuries in a timely manner. Weekly skin assessments were not completed as required, and the care plan was not revised after the development of new open areas. The resident was also observed sitting in a recliner without a pressure-relieving cushion, despite reporting discomfort and using a bed pillow for relief. Another resident developed a pressure injury on the coccyx, but comprehensive assessments were not completed when the injury was first identified. There were multiple nursing notes documenting an open area on the coccyx, but no detailed assessment or treatment was initiated until over a month later. The care plan was not updated promptly, and the resident was repeatedly observed sitting in a personal recliner without a pressure-relieving cushion, contrary to care plan interventions for pressure relief. A third resident wore a wanderguard directly on the skin without a sock underneath, and there was no documentation of daily skin checks under the device, despite the risk for skin breakdown. The care plan and physician orders did not initially include interventions to monitor skin integrity under the wanderguard, and nursing staff confirmed that skin checks were not being performed. The deficiency was only addressed after surveyor intervention, with no evidence of prior monitoring or documentation.
Failure to Perform and Document Diabetic Foot Checks
Penalty
Summary
The facility failed to ensure that residents with diabetes mellitus received routine diabetic foot checks in accordance with professional standards of practice. Three residents with diabetes, each with additional risk factors such as diabetic neuropathy, chronic kidney disease, and polyneuropathy, did not have documentation of daily diabetic foot checks in their medical records. The care plans for these residents either lacked specific interventions for daily foot checks or did not address foot checks at all, despite the presence of diabetes and related complications. Interviews with nursing staff, including a Registered Nurse/Unit Manager, revealed that only weekly skin checks were performed during shower checks, and daily diabetic foot checks were not conducted or documented. The staff indicated that Certified Nursing Assistants were expected to document these checks, but no evidence of such documentation was found for the residents in question. When asked, the staff confirmed that daily foot checks for residents with diabetes were not part of their routine practice. The facility's own Skin Integrity-Foot Care policy requires foot care and treatment to be provided in accordance with professional standards, including systematic prevention and management of foot ulcers and regular monitoring. However, the policy was not followed for the residents identified, as there was no documentation or evidence of daily diabetic foot checks being completed. The deficiency was confirmed through record review and staff interviews, with no additional information provided by the facility to explain the lack of compliance.
Failure to Monitor for Anticoagulant Complications
Penalty
Summary
The facility failed to ensure that the drug regimens of three residents prescribed anticoagulant medications were free from unnecessary drugs by not monitoring for signs and symptoms of anticoagulant complications as required. For each of these residents, the care plans and physician orders included the use of anticoagulants such as Eliquis (Apixaban) and Rivaroxaban for conditions like pulmonary embolism, atrial fibrillation, and blood clots. However, there was no evidence in the medical records, medication administration records, progress notes, or assessments that staff were monitoring for adverse effects such as bleeding, bruising, changes in mental status, or abnormal vital signs. Interviews with nursing staff and review of facility policy revealed that while staff were aware of the need to monitor for complications associated with anticoagulant therapy, this monitoring was not documented or ordered in the residents' records. The facility's policy on high-risk medications specifically requires staff to monitor and document for adverse consequences of anticoagulant use, including bleeding and thromboembolism, and to alert staff through the care plan. Despite this, the surveyor was unable to locate any documentation of such monitoring for the three residents in question. Additionally, one resident's care plan did not include any interventions related to anticoagulant monitoring, and there was no physician order to monitor for complications. Nursing staff confirmed that monitoring was based on nursing judgment and not consistently documented. The facility did not provide any explanation for the lack of daily monitoring for signs and symptoms of anticoagulant complications in these residents.
Failure to Ensure Hospice Collaboration and Documentation
Penalty
Summary
The facility failed to ensure proper collaboration and communication with hospice providers for three residents receiving hospice services. For each of these residents, the current hospice plan of care, visit notes, and schedules of hospice providers were not consistently available to facility staff. In addition, the facility did not designate a staff member to coordinate the plan of care with the hospice provider, and in some cases, did not develop a facility hospice care plan at all. These deficiencies were identified through interviews and record reviews, which revealed gaps in documentation, lack of clear processes for communication, and inconsistent maintenance of hospice records. One resident with multiple diagnoses, including dementia, atrial fibrillation, diabetes, and colon cancer, was receiving hospice care, but the facility's records lacked up-to-date hospice communication notes and schedules after a certain date. The hospice binder contained some documentation, but there were missing notes for recent hospice visits, and staff interviews indicated uncertainty about who was responsible for ensuring hospice notes were provided and uploaded into the medical record. There was also no clear designation of a hospice liaison among facility staff, and the process for communication with hospice was inconsistent. Another resident with Alzheimer's disease and other conditions was also on hospice, but the hospice binder contained no communication notes after a certain date, and the interdisciplinary team form was not filled out. Staff interviews revealed that hospice visit forms were sometimes uploaded into the medical record, but not consistently, and there was no designated hospice liaison. The process for documenting and communicating hospice care was unclear, and schedules for hospice visits were not consistently provided. These findings were consistent across multiple residents, indicating a systemic issue with hospice collaboration and documentation within the facility.
Failure to Immediately Report and Respond to Allegation of Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to implement its written policies and procedures to prohibit and prevent verbal abuse, resulting in a resident not being protected from such abuse by a registered nurse. The incident involved a resident with chronic kidney disease, anemia, chronic congestive heart failure, and dementia, who was assessed as having severely impaired decision-making abilities. During the early morning hours, a certified nursing assistant overheard a registered nurse making inappropriate and verbally abusive remarks to the resident during toileting care. The certified nursing assistant immediately reported the incident to an LPN, who did not escalate the allegation to the nursing home administrator, director of nursing, or director of social services until the end of the shift. As a result of the delayed reporting, the registered nurse continued to work the remainder of the shift, providing care and passing medications to other residents, which allowed for the possibility of further incidents of verbal abuse. The facility's policy required immediate reporting of abuse allegations to the appropriate administrative staff, but this was not followed. The surveyor confirmed through interviews and record reviews that the LPN was aware of the allegation at approximately 4:30 AM but did not notify the required personnel until after the shift ended, and the registered nurse was not removed from resident care areas until then. Further review revealed that the facility did not collect or investigate statements from all staff present during the shift, which could have provided additional information or identified a pattern of abusive behavior by the registered nurse. The director of social services confirmed that some staff statements were not submitted to the state survey agency, considering them hearsay. The incident left both the resident and the reporting certified nursing assistant visibly distressed, and the facility did not immediately place the resident on the follow-up report board for monitoring after the allegation was made.
Failure to Immediately Report Alleged Verbal Abuse
Penalty
Summary
An allegation of verbal abuse was made against a registered nurse (RN) who was reported to have made inappropriate comments to a resident during toileting assistance in the early morning hours. The certified nursing assistant (CNA) who overheard the comments immediately reported the incident to the licensed practical nurse (LPN) on duty. However, the LPN did not immediately escalate the allegation to the Nursing Home Administrator (NHA), Director of Nursing (DON), or Director of Social Services (DSS) as required by facility policy. Instead, the LPN waited until the end of the shift to inform the DON, allowing the RN accused of verbal abuse to continue working and have contact with other residents until the shift ended. The resident involved had significant medical conditions, including chronic kidney disease, anemia, congestive heart failure, and dementia, with a severely impaired ability to make daily decisions as indicated by a low BIMS score. The resident required substantial assistance with activities of daily living and was described as typically happy and thankful, making the reported behavior and distress during the incident notable. The incident was documented in the resident's electronic health record, including the resident's emotional distress and statements expressing a wish to die, which were addressed by the RN in the documentation. Interviews with staff confirmed that the LPN was made aware of the alleged abuse at approximately 4:30 AM but did not notify facility leadership until after the shift ended. The RN remained on duty and continued to provide care, including passing medications, until leaving the facility at the end of the shift. The delay in reporting the allegation was contrary to the facility's written policies, which require immediate reporting of abuse allegations to the appropriate authorities to ensure resident protection and compliance with regulatory requirements.
Failure to Investigate Alleged Verbal Abuse and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a registered nurse and a resident with severe cognitive impairment. The incident occurred when a certified nursing assistant overheard the nurse making inappropriate comments to the resident during early morning care. The certified nursing assistant immediately reported the incident to an LPN, who did not escalate the report to facility leadership until the end of the shift, allowing the alleged perpetrator to continue working and have contact with other residents. The nurse was not immediately removed from resident care areas, contrary to facility policy. The investigation into the incident was incomplete. Statements from three staff members who were present during the shift were not collected or submitted to the state survey agency, and the facility did not follow up on these missing statements. Additionally, the facility did not update the resident's care plan to address any psychosocial issues that may have arisen from the incident. The director of social services did not notify the resident's psychologist about the resident's expressions of distress, including statements about not wanting to live, which were documented in the medical record but not communicated to the appropriate mental health professional. The resident involved had a history of chronic kidney disease, anemia, congestive heart failure, and dementia, with a severely impaired mental status and dependence on staff for most activities of daily living. At the time of the incident, the resident had recently experienced a decrease in antidepressant medication and was noted to be more confused and anxious. Despite these changes and the resident's expressions of emotional distress following the alleged verbal abuse, there was no documented follow-up or emotional support provided, and the facility did not ensure that all required investigative and protective actions were taken as outlined in their own policies.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that daily nurse staffing postings accurately reflected the actual staffing present in the building. Over a 30-day review period, surveyors identified discrepancies on 14 days between the posted staffing information and the actual staff schedules. These discrepancies included incorrect numbers and types of licensed and unlicensed nursing staff, as well as inaccurate reporting of actual hours worked per shift. The facility's policy required that nurse staffing sheets be updated daily and reflect real-time changes such as callouts and absences, but this was not consistently done. Interviews revealed that the night shift was responsible for posting the new staffing information each day, while nursing staff were expected to update postings as changes occurred. However, the staff member responsible for filing postings and schedules admitted to no longer reviewing the postings for accuracy against the schedules. This lapse resulted in multiple instances where the posted information did not match the actual staffing, potentially affecting all 41 residents in the facility during the review period.
Failure to Prevent Falls and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for two residents reviewed for falls. One resident, admitted with pulmonary heart disease and chronic diastolic heart failure and receiving hospice services, experienced five unwitnessed falls within a little over a month. Three of these falls occurred during self-toileting attempts, and interventions such as a toileting plan, fall mat, and bed in the lowest position were inconsistently documented between the care plan and the Kardex. The resident's care plan did not reflect all interventions implemented, and there was a lack of thorough root cause analysis after each fall. The final fall resulted in a displaced left femoral neck fracture, and the fall mat was not in place at the time. Additionally, the resident was not assessed by an RN before being moved after the fall. Another resident, admitted with parkinsonism and a history of falls, fell forward from a wheelchair and sustained a head injury requiring sutures. At the time of the incident, the resident was being transported by staff without wheelchair foot pedals in place, despite requiring staff assistance for mobility and not propelling the wheelchair independently. The care plan was updated to include the use of foot pedals for out-of-facility appointments only after the fall occurred. Staff interviews confirmed that the pedals were not applied at the time of the fall, and the incident happened quickly as the resident was being wheeled out of the room. In both cases, the facility's failure to implement and document individualized interventions, ensure consistent communication between care plans and task lists, and provide adequate supervision directly contributed to the residents' falls and injuries. The lack of thorough investigation and timely updates to care plans following each incident further contributed to the deficiencies identified by surveyors.
Failure to Classify Fall and Incorrect Transfer Method
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) classified an incident involving a resident found on the floor as a fall, which led to the omission of necessary post-fall protocols. The resident, who had a history of dementia, orthostatic hypotension, and repeated falls, was found on the floor by a Certified Nursing Assistant (CNA) but the LPN did not document it as a fall. Consequently, the LPN did not initiate a fall investigation, complete a post-fall evaluation, or communicate the fall to the oncoming shift, as required by the facility's policies. Additionally, the facility did not ensure that Certified Nursing Assistants (CNAs) used a Hoyer lift for transferring a resident as per the resident's care plan. The resident, who had a history of hemiplegia, morbid obesity, and vascular dementia, was transferred using an EZ stand lift instead of the required Hoyer lift. This incorrect transfer method was used despite the resident's care plan and therapy recommendations specifying the need for a Hoyer lift, leading to a near-fall incident. Interviews with staff revealed a lack of adherence to the facility's policies and procedures regarding fall management and resident transfers. The LPN involved did not recognize the incident as a fall, and the CNAs involved in the transfer incident were not fully aware of the resident's transfer requirements. The Director of Nursing (DON) and the Administrator expressed expectations that staff should follow care plans and policies, but these were not met in the incidents described.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Muskego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Muskego Health And Rehabilitation Center | 0 mi | ★★★★★ | 17 | 0 |
| Complete Care At Hales Corners | 6.1 mi | ★★★★★ | 5 | 0 |
| Lindengrove New Berlin | 7.1 mi | ★★★★★ | 5 | 1 |
| Clement Manor Health Care Center | 7.4 mi | ★★★★★ | 20 | 1 |
| Greendale Park Nursing And Rehab | 8.2 mi | ★★★★★ | 43 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.