THE COURTYARDS AT PASADENA - PASADENA, TX

Complaint Deficiency

• Provide care by qualified persons according to each resident's written plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Restrictions on the use of flammable curtains
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Potential for minimal harm
  • Scope: Some
• Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide food in a way that meets a resident's needs
  • Harm: Potential for minimal harm
  • Scope: Some
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• A separate and independent backup electrical power source
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Proper medical gas storage and administration areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Proper construction of ducts through walls designed to prevent smoke passage
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Approved construction type or materials
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A fire alarm system that can be heard throughout the facility
  • Harm: Potential for minimal harm
  • Scope: Some
• Properly working alarms on sprinkler valves
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Proper medical gas storage and administration areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Weekly inspections and monthly testing of generators
  • Harm: Potential for minimal harm
  • Scope: Many
• Provide activities to meet the interests and needs of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Ensure the activities program is directed by a qualified professional
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved automatic sprinkler system connected to the fire alarm system
  • Harm: Potential for minimal harm
  • Scope: Many
• Weekly inspections and monthly testing of generators
  • Harm: Potential for minimal harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • Harm: Potential for minimal harm
  • Scope: Many
• 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that each residents' abilities in activities of daily living do not decline, unless unavoidable
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have enough nurses to care for every resident in a way that maximizes the resident's well being
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Dispose of garbage and refuse properly
  • Harm: Potential for minimal harm
  • Scope: Some
• Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly working alarms on sprinkler valves
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Portable fire extinguishers
  • Harm: Potential for minimal harm
  • Scope: Many
• Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly protected cooking facilities
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Proper medical gas storage and administration areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
  • Harm: Potential for minimal harm
  • Scope: Many
• Provide access to a telephone for resident to use in private
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that special or therapeutic diets are ordered by the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few

Staff Information

Quality Measures