A list of the most recent deficiencies for The Courtyards at Pasadena. 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? |
|---|---|---|---|---|
| Establish policies and procedures including evacuation. | Fire Safety | 2024-02-01 | 2024-02-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-02-01 | 2024-02-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-01 | 2024-02-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-01 | 2024-02-02 | N |
| Dispose of garbage and refuse properly. | Health | 2024-02-01 | 2024-02-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-06-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-11-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-10-21 | 2022-11-30 | 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 | 2022-10-21 | 2022-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-19 | 2022-11-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-19 | 2022-11-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-03 | 2021-09-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-12 | 2021-09-03 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-08-12 | 2021-09-03 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-08-12 | 2021-09-03 | 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 | 2021-08-12 | 2021-09-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-12 | 2021-09-03 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-08-12 | 2021-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-03 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-12 | 2021-08-20 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-08-12 | 2021-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-12 | 2021-08-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-12 | 2021-08-20 | N |
