Deficiency Records for Tudor Oaks Health Center

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Updated as of March 01, 2024

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 2024-01-10 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
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-09-22 2021-10-11 Y
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2021-09-22 2021-10-11 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2020-02-26 2020-03-06 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-02-26 2020-03-06 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2020-02-26 2020-03-06 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-02-26 2020-03-06 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 2020-02-26 2020-03-06 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-02-26 2020-03-06 N
Provide properly protected cooking facilities. Fire Safety 2020-02-27 2020-02-28 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-02-27 2020-02-28 N