Courtyard Gardens Nursing and Rehab Ctr

Inspectors wroteBased on clinical record review, review of select facility documentation, and staff interview, it was determined that the facility failed to implement interventions to ensure resident safety during transport, which resulted in actual harm as evidenced by an ankle fracture for one of four residents reviewed (Resident 1).

Inspectors wroteBased on review of the clinical record, electronic hospital record review, and staff interview, it was determined that the facility failed to ensure pain management was provided in accordance with professional standards of practice for one of four residents reviewed (Resident 1), which resulted in actual harm to the Resident as evidenced by uncontrolled pain and subsequent hospitalization for pain management.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide the highest practical well-being by not following physician orders as well as involve the physician in treatment changes for one of two residents reviewed (Resident 2).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one of one resident reviewed (Resident 2).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for one of 19 residents reviewed (Resident 36). Findings Include: Review of Resident 36's clinical record revealed diagnoses that included diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), psychosis (a mental disorder when a person has trouble telling the difference between what's real and what's not), and muscle weakness. [...]

Inspectors wroteBased on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 18, 69, and 81).

Inspectors wroteBased on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one of four residents reviewed for pressure ulcers (Resident 69).

Inspectors wroteBased on document review and staff interviews, it was determined the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia).

Inspectors wroteBased on facility policy review, observations, product label review, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and four of four nourishment areas.

Inspectors wroteBased on document review and staff interviews, it was determined that the facility failed to ensure each resident is informed of the items and services for which the resident may be charged and the amount of charges for those services at the conclusion of the Medicare A skilled services stay by issuing the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (SNF ABN) for two of three residents reviewed at the conclusion of the Medicare A covered stay (Residents 37 and 64). Findings Include: Review of Resident 37's SNF Beneficiary Protection Notification Review form revealed the Resident's last covered day of Medicare Part A services to be September 22, 2023. [...]

Inspectors wroteBased on state regulations, surveyor observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 24 residents reviewed (Resident 27). Findings Include: Review of the Pennsylvania Nursing Practice Act, Chapter 21.145. Functions of the LPN (Licensed Practical Nurse), revealed The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: The LPN may accept a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility to issue orders for medical and therapeutic measures. Review facility policy, titled Medication Administration General Guidelines, dated 2006, revealed in section B. Administration, Step 2. [...]

Inspectors wroteBased on observations, record review, and staff interviews, it was determined that the facility failed to follow physician orders for two of 20 residents reviewed (Residents 38 and 53). Findings Include: Review of Resident 38's clinical record revealed diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and muscle weakness. Review of Resident 38's physician orders revealed an order for Geri Sleeves BUE (bilateral upper extremities) every shift for skin protection, may remove for care and soilage, with a start date of August 3, 2023. [...]

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post daily current staffing and census for the following dates: October 31, 2023; November 1, 2, 4, and 5, 2023.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission for one of 26 residents reviewed (Resident 50). Findings Include: Review of Resident 50's clinical record revealed an admission date of September 19, 2022, and diagnoses that included osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily). Review of Resident 50's admission Fall Risk assessment dated [DATE], revealed that the Resident had experienced three or more falls in the last three months prior to admission, and that their fall risk score was 24. [...]

Inspectors wroteBased on policy reviews, observations, and resident and staff interviews, it was determined that the facility failed to provide respiratory services consistent with professional standards of practice for two of 21 residents reviewed (Resident 32 and 89).