A list of the most recent deficiencies for Courtyard Care 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-10-09 | 2023-11-10 | 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 | 2023-10-09 | 2023-11-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-09 | 2023-11-10 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-10-06 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-06 | 2023-11-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-06 | 2023-11-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-10-06 | 2023-11-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-06 | 2023-11-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-06 | 2023-11-03 | 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 | 2023-10-06 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-06 | 2023-11-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-06 | 2023-11-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-06 | 2023-11-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-11 | 2023-01-20 | Y |
| 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 | 2023-01-11 | 2023-01-20 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-01-11 | 2023-01-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-06 | 2022-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-05-27 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-31 | 2022-03-01 | N |
| 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 | 2022-01-31 | 2022-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-31 | 2022-03-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-31 | 2022-03-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-31 | 2022-03-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-31 | 2022-03-01 | 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 | 2022-01-31 | 2022-03-01 | 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 | 2022-01-31 | 2022-03-01 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-01-31 | 2022-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-31 | 2022-03-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-31 | 2022-03-01 | N |
| Report COVID19 data to residents and families. | Health | 2022-01-31 | 2022-03-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-31 | 2022-03-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-31 | 2022-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-31 | 2022-03-01 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-29 | 2022-01-07 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-20 | 2019-12-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-03 | 2019-10-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-03 | 2019-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-03 | 2019-10-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-03 | 2019-10-28 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-10-03 | 2019-10-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-03 | 2019-10-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-03 | 2019-10-28 | 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 | 2019-10-03 | 2019-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-03 | 2019-10-28 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-10-03 | 2019-10-28 | N |
