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Deficiency Records for Courtyard at Seasons
A list of the most recent deficiencies for Courtyard at Seasons. 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 Courtyard at Seasons. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-07-12 | 2022-10-15 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-12 | 2022-10-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-12 | 2022-10-15 | 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 | 2022-07-12 | 2022-10-15 | 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 | 2022-07-12 | 2022-10-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-12 | 2022-10-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-12 | 2022-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-12 | 2022-10-15 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-14 | 2022-10-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-06 | 2022-10-15 | 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 | 2022-07-06 | 2022-10-15 | 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 | 2022-07-06 | 2022-10-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-06 | 2022-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-12 | 2022-08-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-22 | 2022-01-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-22 | 2022-01-19 | 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 | 2021-12-22 | 2022-01-19 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-22 | 2022-01-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-26 | 2022-01-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-26 | 2022-01-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-26 | 2022-01-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-26 | 2022-01-19 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-09 | 2019-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-09 | 2019-07-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-05-09 | 2019-07-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-09 | 2019-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-09 | 2019-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-09 | 2019-07-11 | 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 | 2019-05-09 | 2019-07-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-05-09 | 2019-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-09 | 2019-07-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-05-09 | 2019-07-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-05-09 | 2019-07-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-09 | 2019-06-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-04-26 | 2018-05-28 | 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 | 2018-04-26 | 2018-05-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-26 | 2018-05-28 | N |
| Post nurse staffing information every day. | Health | 2018-04-26 | 2018-05-28 | 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 | 2018-04-26 | 2018-05-28 | 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 | 2018-04-26 | 2018-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-26 | 2018-05-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-04-24 | 2018-05-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-04-24 | 2018-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-24 | 2018-05-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-04-24 | 2018-05-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-04-24 | 2018-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-24 | 2018-05-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-04-24 | 2018-05-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-24 | 2018-05-28 | N |
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