Deficiency Records for Courtyard Gardens Nursing and Rehab Ctr
Updated as of November 01, 2022
This is not the most recent data for Courtyard Gardens Nursing and Rehab Ctr. For the most recent information, click here.
A list of the most recent deficiencies for Courtyard Gardens Nursing and Rehab Ctr. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2021-11-15 | 2021-12-31 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-11-15 | 2021-12-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-11-15 | 2021-12-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-15 | 2021-12-31 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-15 | 2021-12-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-15 | 2021-12-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-04 | 2021-12-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-04 | 2021-12-11 | 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 | 2021-11-04 | 2021-12-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-11-04 | 2021-12-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-04 | 2021-12-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-04 | 2021-12-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-04 | 2021-12-11 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-11-04 | 2021-12-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-12 | 2020-04-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-12 | 2020-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-12 | 2020-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-12 | 2020-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-12 | 2020-04-15 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-03-07 | 2019-04-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-03-07 | 2019-04-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-07 | 2019-04-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-07 | 2019-04-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-07 | 2019-04-09 | 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 | 2019-03-07 | 2019-04-09 | 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 | 2019-03-07 | 2019-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-07 | 2019-04-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-03-07 | 2019-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-07 | 2019-04-09 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-03-07 | 2019-04-09 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-03-13 | 2019-04-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-03-13 | 2019-04-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-03-13 | 2019-04-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-13 | 2019-04-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-13 | 2019-04-09 | N |
