Inspection Reports for
Courtyard Healthcare Center

The facility failed to follow a therapeutic diet plan for one resident by serving a hard to chew chicken burger, risking nutritional harm. Additionally, the facility failed to store clean dishes in a sanitary manner, with dirty dishes and residue found in the clean dish area, increasing the risk of foodborne illness.

The facility failed to serve food in a sanitary manner as clean utensils were found with food particles and water residuals, utensil holders had multiple small black particles, and a dietary aide did not wash hands before handling clean kitchenware, posing a potential risk for foodborne illness among residents.

The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, specifically for one sampled resident. Deficiencies included inaccurate vital sign assessments and failure to administer antibiotics timely, resulting in the resident's hospitalization for severe sepsis with septic shock.

The complaint investigation found that Resident 1 was discharged unsafely without review of discharge instructions with the DPOA, without needed supplies (tube feeding formula and glucometer), discharged to a board and care instead of home with home health as ordered, and without clinical evaluation to determine discharge readiness. The DPOA expressed concerns about the unsafe discharge and potential for re-hospitalization.

The facility failed to ensure Resident 1 was discharged appropriately, including not reviewing discharge instructions with the Durable Power of Attorney, discharging without needed supplies, discharging to a board and care instead of home with home health as ordered, and lacking clinical evaluation to determine discharge readiness. These failures placed the resident at risk for potential harm due to inadequate discharge planning and lack of clinical oversight.

The complaint investigation found that Resident 1 was inappropriately discharged to a hotel without established home health services, was found confused and non-verbal near the hotel, and was not safe for discharge given cognitive deficits. The facility also failed to prevent Resident 1's elopement and did not implement required interventions or assessments related to elopement risk.

The facility failed to ensure appropriate discharge for Resident 1, including not following physician discharge orders, giving the 30-day discharge notice at the time of discharge, failing to develop post-discharge care follow-up, lacking a physician discharge summary, and submitting an incomplete MDS discharge assessment. Additionally, the facility failed to ensure resident safety when Resident 1 eloped from the facility and did not implement required interventions per facility policy.

The facility failed to ensure food preferences were honored for three sampled residents, and failed to store food in a sanitary condition, including leaving yogurt unrefrigerated for over three hours and missing freezer temperature documentation. These deficiencies posed potential risks to residents' nutritional status and foodborne illness.

The complaint investigation found substantiated abuse where Resident 2 struck Resident 1 multiple times, causing physical pain and emotional distress. Multiple staff including CNA 1, Licensed Nurse 1, Social Services Director, and Director of Nursing acknowledged the abuse incident.

The facility failed to protect Resident 1 from physical abuse by Resident 2, who was witnessed hitting Resident 1's hand. Resident 1 experienced physical pain and emotional distress as a result of the altercation.

The facility failed to serve meals and snacks at scheduled times according to resident preferences, resulting in resident dissatisfaction and potential nutritional risks. Food safety violations included unlabeled, expired, and improperly stored food items, presence of fruit flies, and staff not wearing beard restraints. Kitchen equipment was found in poor condition with residue and leaks, posing contamination risks.

The facility had multiple deficiencies including failure to provide communication boards for non-English speaking residents, privacy breaches with unattended meal tickets, unclean environment issues, medication administration errors, inadequate pressure ulcer prevention, significant unaddressed weight loss, inadequate pain management, pharmaceutical service deficiencies, food safety violations, lack of contingency planning for EHR downtime, ineffective QAPI program, infection control lapses, and unsafe kitchen equipment.

The facility failed to administer insulin as prescribed for one of three sampled residents, which had the potential for ineffective drug therapy. Documentation gaps and medication administration errors were identified, including missed insulin doses without physician orders to hold medication.

The facility failed to maintain freezer temperatures within acceptable ranges and observed unsafe infection control practices in the kitchen, including unsanitary conditions such as mold presence and incomplete cleaning schedules. These deficiencies posed a potential risk for foodborne illness.

The facility was found deficient in ensuring the availability of routine medications, proper food storage and preparation practices, and maintenance of essential kitchen equipment. These deficiencies had the potential to cause harm or foodborne illness to residents.

The complaint investigation was substantiated as facility staff witnessed Resident 4 punch Resident 5 while Resident 5 was trying to enter Resident 4's room from the courtyard. Resident 5 was not supposed to be in the courtyard unsupervised, but gained access through sliding glass doors that were supposed to be locked.

The facility failed to protect Resident 5 from physical abuse by Resident 4 and failed to provide adequate supervision, allowing Resident 5 to access the courtyard unsupervised despite being in a locked memory care unit. This resulted in Resident 5 being punched and falling to the ground, with potential harm to other residents.

The facility had multiple deficiencies including failure to obtain informed consent for psychotropic medication, inadequate care planning, medication administration errors, improper medication disposal, food safety violations, and maintenance issues with kitchen equipment and refrigeration units.

The facility failed to ensure that occupational therapy was provided as ordered for three sampled residents, resulting in missed therapy sessions and potential failure of residents to attain their highest practicable level of physical and functional well-being. Staffing issues with the contracted therapy provider were noted as a contributing factor.

The complaint investigation found that Resident 1 slapped and punched Resident 2 multiple times, causing physical injuries. Resident 1 admitted to the assault and had a previous altercation with another resident. The incident was substantiated based on interviews, progress notes, and medical assessments.

The facility failed to ensure Resident 2 was free from abuse when Resident 1 assaulted him, resulting in physical injuries including a swollen and reddened nose and a lump on the right temple. Resident 1 admitted to the assault and had a history of prior altercations. The facility's policy prohibits all forms of abuse and is responsible for resident safety.

The complaint investigation found that Resident 1 was physically abused by Resident 2 during an altercation on 11/20/23, resulting in a bloody nose and a reddened area on the forehead. The facility did not report the investigation results to the Department within 5 working days, potentially delaying further investigation.

The facility failed to protect Resident 1 from physical abuse by Resident 2, failed to report the results of the abuse investigation to the Department within 5 working days, and failed to document the injury (bloody nose) in the nursing assessment, resulting in inaccurate assessment documentation.

The complaint investigation substantiated that Resident 2 physically abused Resident 1 by punching and pulling her hair, causing injury. The facility also failed to timely report the incident to authorities, which was confirmed through interviews and record reviews.

The facility failed to ensure Resident 1 was free from abuse when Resident 2 physically assaulted her, resulting in injury. Additionally, the facility failed to timely report the alleged abuse incident to proper authorities, potentially endangering the health and safety of all residents.

The facility failed to ensure that Initial Social Service Assessments were completed for four of seven sampled residents, potentially affecting their ability to maintain the highest practicable physical, mental, and psychosocial well-being.

The facility failed to ensure that Resident 1's surgical wound was assessed and monitored for improvement, worsening, or signs of infection upon admission and for 14 days thereafter, increasing the potential for medical complications including infection. The facility also lacked a policy and protocol for skin assessment of new residents upon admission.

The facility was found deficient in multiple areas including failure to update care plans for residents with changes in condition, improper feeding tube care, unsecured medication storage, incomplete medication regimen reviews, medication administration errors, expired and unlabeled medications, food safety violations, and inadequate infection prevention and control practices.