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Deficiency Records for Tudor Oaks Health Center
A list of the most recent deficiencies for Tudor Oaks Health Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Tudor Oaks Health Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-05 | 2024-06-10 | Y |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2024-03-05 | 2024-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-05 | 2024-04-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-05 | 2024-04-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-10 | 2024-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-26 | 2023-09-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-26 | 2023-09-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-26 | 2023-09-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-28 | 2023-05-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-05 | 2023-03-03 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-05 | 2023-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-05 | 2023-02-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-05 | 2023-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-05 | 2023-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-05 | 2023-02-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-05 | 2023-02-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-05 | 2023-02-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-05 | 2023-02-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-05 | 2023-02-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-05 | 2023-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-05 | 2023-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-05 | 2023-02-21 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-01-04 | 2023-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-04 | 2023-01-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-04 | 2023-01-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-04 | 2023-01-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-04 | 2023-01-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-04 | 2023-01-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-01-04 | 2023-01-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-04 | 2023-01-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-01-04 | 2023-01-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-11-03 | 2021-11-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-03 | 2021-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-11-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-11-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-03 | 2021-11-24 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-02 | 2021-11-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-02 | 2021-11-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-02 | 2021-11-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-02 | 2021-11-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-03 | 2021-11-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-03 | 2021-11-04 | N |
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