Inspection Reports for
Courtyard Healthcare Center

The facility failed to follow a therapeutic diet plan for one resident by serving food that was hard to chew, risking nutritional harm. Additionally, the facility failed to store clean dishes in a sanitary manner, increasing the risk of foodborne illness for residents.

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 residues, and a dietary aide did not wash hands before handling clean kitchenware, posing a risk of foodborne illness to residents.

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 for one resident, including inaccurate vital sign assessments and failure to administer antibiotics timely, resulting in the resident's hospitalization for severe sepsis with septic shock.

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 was substantiated. Resident 1 was discharged unsafely without review of discharge instructions with the Durable Power of Attorney, without needed supplies (tube feeding formula and glucometer), and without clinical evaluation to determine discharge readiness. The discharge orders were inconsistent with the actual discharge location.

The facility failed to ensure Resident 1 was discharged appropriately and safely, including failure to review discharge instructions with the Durable Power of Attorney, discharge without needed supplies, discharge to an unlicensed board and care instead of home health as ordered, and lack of 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, potentially impacting their nutritional status. Additionally, the facility failed to store food in a sanitary condition, leaving yogurt unrefrigerated for over three hours and failing to document freezer temperature, risking foodborne illness.

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 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 complaint investigation found that Resident 3 did not receive prescribed insulin doses on specific dates without physician authorization. The issue was substantiated with evidence from medication administration records and interviews with the Director of Nurses.

The facility failed to administer Novolin Insulin as prescribed for Resident 3 on multiple occasions without documented justification. The Director of Nurses confirmed missing documentation and no physician orders to hold insulin despite blood sugar levels outside parameters.

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 did not ensure proper infection control and sanitation practices in the kitchen. Mold and unsanitary conditions were observed, and cleaning schedules were incomplete or not documented.

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 failed to ensure availability of routine medications for one resident, did not store and prepare food according to professional food safety standards, and failed to maintain kitchen freezer equipment in safe operating condition. These issues had potential to harm residents through inadequate medication administration and foodborne illness risks.

The complaint investigation substantiated that Resident 4 punched Resident 5 in the courtyard while Resident 5 was unsupervised. The facility confirmed that residents from the locked memory care unit, including Resident 5, were not allowed in the courtyard without supervision, but Resident 5 gained access unsupervised 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 where the incident occurred. Both residents had extreme cognitive impairments and the facility's policies required supervision in the courtyard, which was not followed.

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

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 occupational therapy services were provided according to the plans of care for three sampled residents. Therapy sessions were missed or not provided at the ordered frequency, potentially affecting residents' physical and functional well-being.

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 involved an alleged resident-to-resident physical abuse incident on 11/20/2023 where Resident 2 struck Resident 1 in the face causing injury. The facility's investigation and reporting processes were found deficient.

The facility failed to protect Resident 1 from physical abuse by Resident 2, resulting in a bloody nose and a reddened area on Resident 1's forehead. Additionally, the facility failed to report the results of the abuse investigation within 5 working days and did not document the injury properly in the nursing assessment.

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 complaint investigation found that Resident 1's surgical wound was not assessed upon admission and treatment was delayed until 14 days later. The complaint was substantiated with findings of minimal harm or potential for actual harm.

The facility failed to meet professional standards of practice for one of six sampled residents by not assessing and monitoring Resident 1's surgical wound upon admission, delaying treatment for 14 days. This failure increased the potential for medical complications including infection.

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.