Courtyard Care Center

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans to address a resident to resident altercation, for one of three sampled residents (Resident 3). This failure had the potential to result in the resident not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one out of 3 sampled residents (Resident 1), when there were multiple days for which there was no evidence of documentation of resident behavioral charting after a staff-to-resident incident. This failure had the potential to compromise the resident's health, safety, and overall well-beingFindings:Review of Resident 1's clinical record indicated Resident 1 was admitted to the facility with diagnoses including cerebral infarction (also known as a stroke, an attack in the brain caused by lack of blood flow), mood disorder, and major depressive disorder with psychotic symptoms (a mental disorder that affects mood). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for one of four sampled residents (Residents 1) when the facility failed to create a baseline fall care plan (Care plans identify the specific cares and services necessary to meet the residents' needs). Failure to develop care plans had the potential to result in the residents not receiving interventions needed to maintain their health and safety at the highest practicable level.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing of a transfer for 82 transfers/discharges. This failure had the potential of not providing 71 residents and/or their responsible party (RP, a person who is accountable for making decisions on behalf of the resident) with access to an advocate who could inform them of their rights and from being inappropriately transferred.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate pharmaceutical services when: 1. Two medications, glipizide and duloxetine, were not available for two out of seven residents (Residents 224 and 55) 2. There were discrepancies between the controlled drug (those with high potential for abuse and addiction record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for four out of four residents (Residents 224, 32, 1 and 2) These failures had the potential to affect the health of residents and resulted in the facility not having accurate accountability of controlled medications which had the potential for misuse or diversion.

Inspectors wroteBased on observation, interview and record review, the facility had a facility medication error rate of 7.7% when four errors out of 52 opportunities during the medication administration for four out of six residents (Residents 12, 224, 55 and 2). This failure resulted in medication not given in accordance with the prescriber's orders which had the potential for residents not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1. There were expired food items; 2. Cookware was not properly dried; 3. The temperature log book for the refrigerator used to store food for residents was incomplete. These deficient practices potentially exposed 65 residents, who received food from the kitchen to food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Staff did not label resident wash basins kept in shared bathrooms with the residents' identifiers; 2. Staff did not wear the proper personal protective equipment (PPE) when entering a room under enhanced droplet precautions; 3. Staff did not label oxygen tubing for one resident (Resident 21); 4. Staff did not ensure the dressing around a gastrostomy tube (GT, a thin, flexible tube inserted through the stomach to deliver nutrients or medications) was intact and correct infection precaution was followed for one resident (Resident 7); and 5. A urinary catheter (a device that drains urine) bag was found touching the floor, for one resident (Resident 38). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed of risks and benefits of treatment for four (Resident 23, Resident 34, Resident 70, and Resident 174) out of 16 sampled residents when: 1. Resident 23's psychotropic medication (drugs that affect the brain, mood, thoughts, or behavior) informed consent was not completed and verified; 2. Resident 70' psychotropic medication informed consent was not completed and verified; 3. Resident 34's responsible party was not notified in a timely manner about the results of a chest X-ray (digital image of internal composition of the body); and 4. Resident 174's psychotropic medication informed consent was not completed and verified. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney that authorizes another person to act on behalf of the resident) and completion of the Physician Order for Life-Sustaining Treatment (POLST, a document that specifies the medical treatments the residents wants to receive during serious illness) form for one out of two sampled residents (Resident 23). These failures had the potential to lead to the delivery of unnecessary or inappropriate medical services against residents' goals and wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and develop a comprehensive care plan for one of 18 residents (Resident 67), when Resident 67's dementia (a general term for a group of brain disorders that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving) diagnosis was not addressed. This failure had the potential to result in the inability to identify the residents' individualized care issues and implement person-centered care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure needed care and services were provided in accordance with the resident's goals for care for one resident (Resident 38) out of six sampled residents, when Resident 38's physician's order for interaction was not followed. This failure had the potential to put Resident 38 at risk for decline in physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident receiving dialysis (removal of waste and excess fluid from the body) treatment received consistent care with professional standards for one out of two sampled residents (Resident 32) when their dialysis communication sheets (DCS) were missing for several treatment days. This failure had the potential for Resident 32's dialysis care not being properly communicated and putting Resident 32 at risk for complications.

Inspectors wroteBased on interview and record review, the consultant pharmacist (CP) failed to identify and report irregularities during the medication regimen review (MRR) for two (Resident 25 and Resident 174) out of 23 sampled residents when: 1. Abnormal Involuntary Movement Scale (AIMS, a rating scale that measures the severity of abnormal movements) was not done for Resident 25; and 2. AIMS was not done for Resident 174. This failure had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects (undesirable effects from the medication).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 18 sampled residents (Residents 23, 25, 70 and 174) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications when Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements known as tardive dyskinesia [TD], a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment was not done. The failure resulted in lack of adequate monitoring and unnecessary medications for the residents, which had the potential for increased risks associated with the use of psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's private medical information was protected against unauthorized disclosure for 1 of 3 residents, when Resident 1 was furnished with medications labeled with medical information relevant to Resident 2 and Resident 3 upon discharge from the facility. This failure resulted in Resident 2 and Resident 3's private information being disclosed to another resident without their permission. Review of Resident 1's clinical record indicated she was admitted on [DATE]. Resident 1had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates cognitively intact). Review of Resident 1's social service progress note dated 12/19/23, indicated Resident 1 was accepted at another skilled nursing facility (SNF) and would discharge on [DATE]. [...]

Inspectors wroteDuring an observation 10/2/23 at 8:49 a.m., Residents 36, 43 and 56 were in their beds with quarter side rails up. Review for Resident 36's Bed Rails assessments lacked documented evidence that Resident 36 was assessed for bed rails safety between 4/27/21 and 10/2/23. Review for Resident 43's Bed Rails assessments lacked documented evidence that Resident 43 was assessed for bed rails safety between 4/29/21 and 10/2/23. Review for Resident 56's Bed Rails assessments lacked evidence that Resident 56 was assessed for bed rails safety. Based on observation, interview, and record review, the facility failed to assess bed rails (adjustable metal or rigid plastic bars that attach to the bed) safety for 12 of 17 residents (Residents 6, 11, 12, 21, 26, 28, 36, 43, 46, 52, 54 and 56) periodically, according to their policy. This failure placed the residents at risk for entrapment and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: 1. A dented can of applesauce was stored on a the dry storage shelf. 2. An outdated bag of pinto beans was stored on a dry storage shelf. 3. Outdated onions were stored on a dry storage shelf; and, 4. Outdated ground herbs were stored on top of the kitchen condiment shelf. These failures had the potential to cause foodborne illness for residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) B did not remove their gloves or perform hand hygiene after placing dirty laundry in a bin before taking a wheelchair into a room; and, 2. Licensed Vocational Nurse (LVN) C did not clean a blood pressure (BP) cuff after obtaining vital signs for 4 of 4 residents (Residents 2, 46, 63, and 220) during medication pass. These failures increased the potential for the spread of communicable diseases among residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly minimum data set (MDS, a resident clinical assessment tool) assessment in a timely manner for one of 17 sampled residents (Resident 61). This failure resulted in Resident 61's MDS to not be reviewed timely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good grooming and personal hygiene for one of 17 sampled residents (Resident 46) when Resident 46's fingernails were unkept. This failure left the resident incompletely groomed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of practice for one of four sampled residents (Resident 28) when oxygen was not administered per a physician's order. This failure resulted in Resident 28 receiving oxygen at a higher setting than prescribed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications from one of three emergency kits (e-kits) were locked and replaced after use. This failure had the potential to result in medications not being available during emergency situations.

Inspectors wroteBased on observation, interview, and record review, the facility had a 5.13% (percent, a specified amount of units for every hundred units) medication error rate when two medication errors out of 39 opportunities were identified during medication pass for two of ten residents (Resident 2 and Resident 220). These failures had the potential to result in ineffective drug therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy for medication self-administration for 1 of 3 residents (Resident 25) when Resident 25 had medications on her bedside table without an IDT (interdisciplinary team, composed of a group of healthcare staff from various disciplines who work together to discuss care for individual residents) evaluation allowing for it. This failure left medications accessible to a resident, who lacked an evaluation for whether such medications should be left at her bedside.

Inspectors wroteBased on interview and record review, the facility failed to administer the correct pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) for one of five sampled residents (Resident 25) per the Centers for Disease Control and Prevention (CDC)'s pneumococcal vaccine schedule guidelines. This failure resulted in Resident 25 receiving an additional unnecessary pneumococcal vaccine.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its own policy and procedure to evaluate residents' fall risk, to investigate the fall, to implement resident centered care plan, to revise the fall care plan and/or place the effective interventions to prevent four of 17 sampled residents (Residents 1, 24, 37 and 38) from multiple falls recurring when: 1. For Resident 1, the facility did not revise the fall care plan, did not implement fall care plan intervention or evaluate the resident's fall risk. Resident 1 had eight (8) unwitnessed falls from 5/21/2020 to 1/25/2022. 2. For Resident 24, the facility did not revise the fall care plan, did not implement fall care plan intervention or evaluate the resident's fall risk. Resident 24 had four (4) unwitnessed falls from 9/11/2021 to 1/8/2022. 3. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. Food service equipment was stored wet, and 2. The floor below the dish machine was not smooth and cleanable. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross-contaminate food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the 68 residents eating at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to routinely assess the arteriovenous fistula (AV fistula, a connection surgically made between an artery and a vein for dialysis access) for one of three sampled residents (Resident 22) who received dialysis (a procedure in which a machine filters wastes and fluid from the blood). This failure had the potential to result in unidentified complications with Resident 22's AV fistula.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when: 1. The facility did not reorder two out of 12 emergency medication kits (E-kits) after using them; and 2. The facility failed to ensure controlled medications (medications regulated by the government because they may be abused or cause addiction) for four out of six residents (Residents 31, 371, 20 and 66) were accounted for. Failure to reorder the E-kits had the potential to result in medications not being available to the residents when needed. Failure to account for controlled medications had the potential to result in diversion (transfer for illicit use) of the medications.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure residents were provided a well-balanced diet that met nutrition needs when serving sizes on the meal tray tickets did not match the planned and approved menu for Regular diets, Regular Puree diets (texture modified diets that do not require chewing), Carbohydrate Controlled (CCHO, therapeutic diets designed for people with diabetes to keep the carbohydrate levels in meals evenly spaced throughout the day), Mechanical Soft diets (texture modified diets that require less chewing than regular diets), and Renal 80 gram (therapeutic diet that is low in sodium, phosphorus, and protein for people with kidney disease) CCHO Mechanical Soft diets. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify all residents, their representatives, and families of a confirmed case of COVID-19 in the facility in a timely manner, when the communication was not sent for five days after a positive COVID-19 case was identified in the facility. This failure could potentially cause a spread of COVID-19 in the facility and is in violation of federal regulations to mitigate the spread of COVID-19 virus.

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, notice that transfers potential financial liability) to one of three residents (Resident 30). This failure had the potential to compromise Resident 30's right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid by Medicare). This failure also had the potential to result in Resident 30 not being informed of his payment responsibilities to the facility after Medicare Part A services ended.

Inspectors wroteBased interview and record review, the facility failed to follow its own policy and procedure to report the allegations of resident-to-resident verbal abuse of two encounters, for two (Resident 4 and Resident 44) of 17 sampled residents to the California Department of Public Health (CDPH), the ombudsman and law enforcement immediately, but not later than 2 hours when: 1. Resident 4 was involved in an altercation on 7/29/21 at 6:00 p.m., 2. Resident 44 was involved in an altercation on 7/29/21 at 6:00 p.m. and 8/21/21 at noon. This failure had the potential to result in delay of investigation and the reporting of further allegations of abuse. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of six residents (Resident 19) and/or the resident's representative regarding the facility's policy for the bed hold when they were transferred to the hospital without receiving notice. This failure has the potential to violate the resident's right to allow the resident to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 17 sampled residents (Resident 1) and one resident (Resident 68). Failure to accurately assess had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and security for one of three residents (Resident 47) when facility staff was unaware Resident 47 wandered away outside the facility for several hours. This failure compromised the resident's safety and put her at high risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to address whether one of 17 sampled residents (Resident 1) would benefit from gradual dose reduction (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) of a psychotropic medication (medication capable of affecting the mind, emotions and behavior). This failure had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects (undesirable effects from the medication).

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 17 sampled residents (Residents 43, 38 and 47) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 43, the facility did not identify and monitor target behaviors (specific behaviors intended to be reduced or eliminated by the medication), did not monitor side effects (undesirable effects from the medication), and did not identify appropriate indications for the use of psychotropic medications; 2. For Resident 38, the facility did not identify and monitor target behaviors for psychotropic medications; and 3. For Resident 47, the facility did not identify and monitor target behaviors for psychotropic medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain consents to either receive or refuse pneumonia vaccine for one of five residents (Resident 23). This failure put the resident at risk of not being informed of the risks and benefits of the pneumonia vaccines, and not giving them the ability to make an informed decision.

Inspectors wroteBased on observation, interview and record review, the failed to maintain comfortable and sanitary shared bathroom for one of three residents, when there was a black matter and long, narrow piece of black material that was sticky on one side in the bathroom tile surfaces. Also, the two tissue holder beside the toilet had no rollers. This had the potential to affect resident's psychosocial well-being.