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Deficiency Records for Regalcare at Courtyard-Medford
A list of the most recent deficiencies for Regalcare at Courtyard-Medford. 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 Regalcare at Courtyard-Medford. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-09 | 2024-08-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-09 | 2024-08-09 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-29 | 2024-04-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-21 | 2024-04-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-03-21 | 2024-04-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-21 | 2024-04-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-21 | 2024-04-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-21 | 2024-04-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-21 | 2024-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-21 | 2024-04-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-21 | 2024-04-24 | 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 | 2024-03-21 | 2024-04-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-21 | 2024-04-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-21 | 2024-04-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-21 | 2024-04-24 | 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 | 2024-03-21 | 2024-04-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-21 | 2024-04-24 | 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 | 2024-03-21 | 2024-04-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-21 | 2024-04-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-21 | 2024-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-21 | 2024-04-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-21 | 2024-03-21 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-03-21 | 2024-03-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-25 | 2023-02-24 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-01-09 | 2023-02-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-09 | 2023-02-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-09 | 2023-02-18 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-09 | 2023-02-18 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-01-09 | 2023-02-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-09 | 2023-02-18 | 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 | 2023-01-09 | 2023-02-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-09 | 2023-02-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-09 | 2023-02-18 | 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 | 2023-01-09 | 2023-02-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-09 | 2023-02-18 | 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 | 2023-01-09 | 2023-02-18 | N |
| Provide or obtain dental services for each resident. | Health | 2023-01-09 | 2023-02-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-01-09 | 2023-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-09 | 2023-02-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-25 | 2023-02-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-25 | 2023-02-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-25 | 2023-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-25 | 2023-02-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-21 | 2023-02-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-25 | 2023-02-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-25 | 2023-01-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-10 | 2021-10-15 | 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 | 2021-08-10 | 2021-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-10 | 2021-10-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-10 | 2021-10-15 | 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 | 2021-08-10 | 2021-10-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-10 | 2021-10-15 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-08-10 | 2021-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-10 | 2021-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-10 | 2021-10-15 | N |
| Keep all essential equipment working safely. | Health | 2021-08-10 | 2021-10-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-08-19 | 2021-10-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-19 | 2021-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-19 | 2021-10-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-08-19 | 2021-10-06 | 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 | 2021-08-19 | 2021-10-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-19 | 2021-10-06 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-10 | 2021-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-10 | 2021-09-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-10 | 2021-09-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-10 | 2021-09-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-10 | 2021-09-22 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-08-10 | 2021-09-22 | 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 | 2021-08-10 | 2021-09-22 | 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 | 2021-08-10 | 2021-09-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-08-10 | 2021-09-22 | N |
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