Courtyard Care Center

Inspectors wroteBased on interviews and record review, the facility failed to ensure two of two sampled residents (Resident 2 and 8) had documented evidence that Residents 2 and 8 were assisted with their meals at least three times a day. This deficient practice had the potential to result in worsened conditions, weight loss, and higher hospitalization risks.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure sufficient staff were available to provide care To ensure one of two residents (Resident 2) had documented evidence of receiving feeding assistance for breakfast and lunch on 2/22/2026. To ensure call lights were answered in a timely manner. These deficient practices had the potential to result in worsening conditions and a delay in care and services.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure two of four sampled residents (Resident 1 and 2) medications were administered as ordered. This deficient practice had the potential to result in worsened conditions and higher hospitalization risks.

Inspectors wroteBased on interviews and record review, the facility failed to implement infection control policies when the facility failed to ensure two out of four residents sampled (Resident 3 and 4) were tested for influenza (a highly contagious infectious illness) and Covid-19 (contagious respiratory illness) as soon as respiratory symptoms (warning signs including cough, fever, sore throat, runny nose, congestion, muscle aches) manifested. The deficient practices had the potential to result in the spread of infections in the facility and cause undue harm to the residents' health and well-being. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled residents' (Resident 2) call light (device that allows residents to request assistance from nursing staff) was accessible and within reach. This deficient practice resulted in a delay in care and services.

Inspectors wroteBased on interview and record review the facility's Quality Assurance and Performance Improvement (QAPI) Committee (group responsible for identifying and responding to quality deficiencies in the facility), the facility failed to implement the action plan for the performance improvement project (structured efforts to systematically identify and resolve issues) regarding staff call light response for 56 out of 56 residents. The deficient practice placed the residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) for 56 out of 56 residents. This deficient practice had the potential to expose residents and staff to Legionella (bacteria that can cause serious lung infections) resulting in pneumonia (lung infection), hospitalization or even death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 1 administered two medications for one of two resident (Resident 15) with food as ordered by the physician. This resulted in the medication administration error rate of 7.41percent.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure the opened UTI -Stat (supplement support urinary health) bottle used for one of one resident (Resident 15) was labeled with a open date. b. Ensure the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen for one of five residents (Resident 10) was labeled with an open date and expiration date. c. Ensure an open bottle of Multivitamins with minerals (supplement) for one of two residents (Resident 24) was labeled with an open date These deficient practices had the potential to result in medication errors.

Inspectors wroteBased on observation and interview, the facility failed to food was stored in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from food spoilage or contaminated food) for 56 out of 59 residents by failing to:1. Discard unknown resident's tray that had once left the kitchen.2. Date and label frozen items, produce, and stored goods. 3. Discard expired food items in the dry storage.4. Remove wristwatch while being in the kitchen. 5. Implement safe food handling and sanitation.6. Properly perform hand hygiene and wear gloves when handling the thermometer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and recyclables properly by not completely covering two of two trash dumpsters (a large trash container designed to be emptied into a truck). This deficient practice had a potential to attract flies, insects, and other animals to the dumpster area placing 56 of 59 facility residents at risk for cross-contamination (a transfer of harmful bacteria from one place to another) and had the potential to cause nausea, vomiting and diarrhea.

Inspectors wroteBased on interview and record review the facility failed to provide documented COVID-19 (contagious disease) 2025 to 2026 vaccination (medications used to prevent diseases usually given by injection or by mouth) status, evidence of provision of education on benefits and potential side effects for all employees, including physicians. This failure had the potential to result in staff and residents contracting COVID-19 which could cause serious illness, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to inform the physician when a dialysis treatment was missed for one of two sampled residents (Resident 39). This failure had the potential to result in a delay of treatment, fluid overload and possible deterioration of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 63) received the Notice of Medicare Non-Coverage (NOMNC- a written notice that informs the resident of their last date of covered services and their right to appeal the decision) at least 48 hours prior to the last covered date. This failure had the potential for the resident to not receive the skilled treatment they may need and violate the residents' right to appeal the decision.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident's (Resident 3) Minimum data Set ([MDS] resident assessment tool), dated 11/28/2025, was coded accurately. This deficient practice resulted in an inaccurate assessment of Resident3's current health status and Resident 3's MDS erroneously indicated that Resident 3 received insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) because Resident 3 did not receive any insulin.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five employees (Licensed Vocational nurse-LVN 3) had an active basic life support certification ([BLS] essential emergency care for cardiac/breathing arrest) . This failure had the potential to result in providing ineffective cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is performed when the heart stops beating) to a resident who is in cardiac arrest.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 39) received dialysis as ordered. This failure had the potential to result in a possible deterioration, fluid overload or even death.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five employees (Certified Nurse Assistant [CNA] 2 and Restorative Nurse Assistant (RNA) 1) received a performance evaluation annually. This failure had the potential to result in employees not being at current skill level of care which could result in poor health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program (effort to measure and improve how antibiotics are prescribed by clinicians) for one of three sampled residents (Resident 39). This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification.

Inspectors wroteBased on interview and record review the facility failed to ensure two of two residents (Resident 1 and 3) neurological checks (Neuro check -series of tests performed by healthcare providers to evaluate the function of the brain) were completed as indicated in the policy. This deficient practice had the potential to result in the delay of care and services which could result in poor health outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three resident's (Resident 1) nurse progress notes for [DATE] were accurate. This deficient practice resulted in an inaccurate depiction of services and care rendered.

Inspectors wroteBased on interview and record review, the facility failed to notify two of three sampled resident ' s (Resident ' s 1 and 2) primary care doctors (MD ' s 1 and 2) when Resident ' s 1 and 2 refused to wear their Bilevel positive airway pressure ([BiPAP] a machine that delivers air to help a person breathe) mask (a special mask that that fits over the nose and mouth which is connected to the BiPAP machine) as ordered. This deficient practice had the potential for Residents ' 1 and 2 to have difficulty breathing, low blood oxygen levels and poor sleep quality.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 1, who was unable to carry out activities of daily living received care services to maintain good personal hygiene for one of three sampled residents (Resident 1) who was left with wet diaper for more than five hours. This failure resulted in Resident 1 feeling frustrated and embarrassed, due to lack of or delay in receiving sufficient services to maintain personal care and incontinent care and had the potential to lead to skin breakdown for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 1 ' s Norco as needed (controlled medications used to treat severe pain) was refilled on time. 2. Ensure licensed nurse documents in resident health records when physician was called for authorizing the refill of pain medications. 3. Ensure discontinued medication was removed out of medication cart. These deficient practices have the potential to result in an insufficient number of medications on hand in the event Resident 1 needed pain medication to treat severe pain. This deficient practice had the potential to result in a delay of necessary care and treatment and can lead to adverse health outcome for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when Certified Nursing Assistant 2 (CNA) did not perform hand hygiene for one of three sample residents (Resident 1). This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was assessed to have a cognitive (the mental process of thinking, learning, remembering, being aware of surroundings and using judgement) impairment and the inability to make medical decisions, was not allowed to leave from the facility against medical advice ([AMA] when a patient chooses to leave a hospital before the doctor recommends discharge) and they failed to ensure discharge planning was conducted for one of three sampled residents (Resident 1) when the facility was made aware that Resident 1's significant other had intentions of taking Resident 1 from the facility AMA. The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was assessed to have a cognitive (the mental process of thinking, learning, remembering, being aware of surroundings and using judgement) impairment and the inability to make medical decisions, was not taken out of the facility by a person who was listed in his clinical record as his contact and who had no contact information such as an address or telephone number listed. These deficient practices resulted in Resident 1, who was incontinent (involuntary voiding of urine and stool), non-ambulatory (inability to walk) with medical conditions/diagnoses that required medication, and whose cognition was severely impaired, being removed from the facility by an unauthorized person without the facility's knowledge or permission. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store food under sanitary conditions in one of one kitchen, by failing to: A. Ensure opened food items were labeled with date opened. B. Ensure the dry storage area was clean; and C. Ensure the residents refrigerator's freezer temperature was at or below 0 degrees Fahrenheit and the refrigerator temperature was below 40 degrees Fahrenheit. These deficient practices had the potential to result in contamination of food items that placed residents in high risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) that can lead to hospitalization and a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three of three sampled residents (Resident 1, 23, and 25) was assessed for use, received informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and had a physician order for Resident 1, 25, and 23's beds against the wall. This deficient practice resulted in a violation of resident rights to be free from restraints (any manual method, physical or mechanical device, equipment, or material that is adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, a federally mandated assessment tool) assessment for two of seven sampled residents (Resident 1 and Resident 25) by failing to a. Ensure Section GG 0115 was coded correctly to include functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of both of Resident 1's arms. b. Ensure accurate documentation of Resident 25's diagnosis of anxiety disorder (a medical condition described by feeling of fear dread, or uneasiness) in the MDS. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure availability of magnesium oxide (a dietary supplement to treat low magnesium [a mineral important to healthy body function] level), lactulose solution (a medication used to treat constipation and certain conditions of the brain) and gabapentin [a medication used to treat nerve pain and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)] in accordance with physician's orders or professional standards of practice affecting three of three sampled residents during medication administration (Residents 5, 28, and 202). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure: a) One of two sampled resident's (Resident 33's) PRN (given as needed or requested) Lorazepam (medication used to treat anxiety - feeling of fear dread, or uneasiness) had a specified duration in the order, had nonpharmacological interventions prior to the use of Lorazepam, behavior monitoring, and informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). b) One of two sampled resident's (Resident 18) Mirtazapine (medication used to treat depression - a mood disorder that causes a persistent feeling of sadness and loss of interest) had an informed consent when dose was increased, and the behavior monitoring was changed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for three of three sampled residents (Residents 5, Resident 28, and Resident 202) observed during medication administration by failing to: a. Ensure availability and administration of Resident 5's magnesium oxide (a dietary supplement to treat low magnesium level) in accordance with physician orders. b. Ensure availability and administration of Resident 28's lactulose solution (a medication used to treat constipation and certain conditions of the brain) in accordance with physician orders. c. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: a. One of one resident (Resident 25) had physician orders and documentation for Enhanced Barrier Precautions (EBP - infection control practice requires the use of gown and gloves only for high-contact resident care) implemented. b. Certified Nurse Assistant (CNA)1 donned (put on) an isolation (a type of personal protective equipment (PPE) that protects the wearer from the transfer of infections and contamination) gown while feeding and giving care to one of one resident (Resident 25) c. A Clean and sanitary environment for medications' storage in one of two inspected medication carts (Station 2 Medication Cart). These deficient practices had the potential to result in the spread of infections in the facility, contamination of medications and cause undue harm to the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to ensure one of three sampled residents (Resident 23) received feeding assistance at the same time Resident 17 was eating lunch. This deficient practice resulted in an undignified dining experience which does not promote enhancement of quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of six sampled residents (Resident 1). This deficient practice had the potential to prevent Resident 1 from receiving necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled resident's (Resident 19) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder (MD) are placed in facilities that can provide the appropriate care) screening reflected Resident 19 had a MD that qualified Resident 19 for a Level II PASARR (a comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has MD, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 19.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan addressing Resident 25's activities and Resident 1's visual impairments. These deficient practices had the potential to result in the delay of care and services for Resident 1 and 25 who may need specialized interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a person-centered care plan for one out of two sampled residents (Resident 149), who was receiving artificial nutrition (a form of nutrition that is given as liquids, including liquid foods, through a tube inserted into a vein, under the skin, or into the stomach) through a gastrostomy tube (G-tube, feeding tube placed in the stomach). This deficient practice had the potential for Resident 149 to receive the wrong feeding formula.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to prevent and/or limit a decline in range of motion (ROM, full movement potential of a joint) to one of six sampled residents (Resident 1) who was identified as having ROM limitations in both legs and a decline in ROM of both hips. This deficient practice resulted in a decline in ROM of Resident 1's both hips and had the potential to cause Resident 1 to have a further decline in ROM leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development, decreased mobility (ability to move) and a decline in activities of daily living (ADLs, basic activities such as eating, dressing, and hygiene).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure removal of an expired Folic Acid (a medication used to treat low level of folic acid or Vitamin B-9) and a discontinued Inbrija [(generic name - Levodopa inhalation powder) - a medication used to treat Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)] affecting one resident (Resident 25) from one of one inspected medication room (Medication Room). 2. Ensure Brimonidine tartrate ophthalmic solution [(a medication in form of eye drops used to treat high intraocular pressure (a term used to describe fluid pressure inside the eye)] was stored in accordance with manufacturer requirements affecting one resident (Resident 29) in one of one inspected medication room (Medication Room). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a plan of care was developed for one of four sampled residents (Resident 1) who was diagnosed with osteopenia (a condition that occurs when the body doesn ' t make new bone as quickly as it reabsorbs old bone, causing weakened) and a fracture (a break in the bone) to her left femur (thigh bone), via an x-ray, after she was observed with swelling to her left thigh with indications of pain. This deficient practice resulted in the non-existence of goals and interventions to care for a resident with osteopenia and had the potential for Resident 1 to sustain additional injuries and/or fractures.

Inspectors wroteBased on interview and record review, the facility failed to ensure records were provided within 48 hours following a request by the resident's Responsible Party (RP) for one out of two sampled residents (Resident 1). This deficient practice resulted in the inability of Resident 1 and/or Resident 1's RP to access requested records and violated Resident 1's rights to have access to their records.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure chocolate cream squares in the freezer maintained a temperature of 41 Fahrenheit ([F] unit of measurement) or below. b. Ensure the dishwashing machine was running at the proper temperature. c. Ensure the [NAME] performed hand hygiene after removal of gloves during food preparation. These deficient practices had the potential to place residents at risk for food borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures by failing to: a. Handle soiled linens in a safe and sanitary way by leaving a plastic bag with soiled linens on the floor while providing care to a resident (Resident 1). b. Ensure Laundry Aide did not reuse isolation gown (specialized clothing worn by an employee for protection against infectious materials) when sorting soiled linens in the dirty linen room. These deficient practices had the potential to result in cross contamination(physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed residents and staff at risk for infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff follows the policies and procedure (P& PP) for the application of medication patches for two out of two sampled residents (Resident 2 and Resident 32), by not putting the Licensed Vocational Nurse(LVN) initial and dating the medication patches. This deficient practice had the potential for Resident 2 and Resident 32 to have the medication patch on for the incorrect time ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician regarding insect bites for one of two residents (Resident 34). This deficient practice had the potential to result in lack of necessary care and treatment and place Resident 34 at risk for psychosocial harm.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders and provide a snack-sack (food items) for one of two sampled residents (Resident 205) who was scheduled to receive hemodialysis (HD, the removing of waste, salt and extra water to prevent build up in the body for residents who have loss of kidney function) treatment on Tuesday, Thursday and Saturday. This deficient practice had the potential to cause Resident 205 to experience hunger and exhaustion after hemodialysis treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure to assist Resident 11 that was on one to one supervision (1:1 a nurse who is assigned solely to one Resident) during lunch time for one of one sample resident. This deficient practice had the potential to put Resident 11 at risk for choking or aspiration ( have severe difficulty in breathing because of a constricted or obstructed throat or a lack of air).