Courtyard Manor Nurse Care Center & Assisted Liv

Inspectors wroteBased on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: multiple spots of build up debris and a red sticky substance on the covering of the ice machine;uncovered and expired food items stored in the refrigerator; andexposed hair and facial hair. This deficient practice had the potential to affect the 75 residents who consumed food from the kitchen.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that a resident's physician was immediately notified of a change in the resident's skin condition for 1 (#17) resident out 2 (#17, #77) residents investigated for pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Pre-admission Screening and Resident Review) evaluation and determination for 1 (#33) of 3 residents investigated for PASARR. A review of Resident #33's record revealed an admission date of 08/15/2024 with diagnoses that included in part, dementia in other diseases classified elsewhere, unspecified severity, with agitation and unspecified psychosis not due to a substance or known physiological condition. Further review revealed she was diagnosed with major depressive disorder on 10/07/2024. A review of Resident #33's Level I Pre-admission Screening and Resident Review dated 07/11/2024 was conducted. Review of Section III, 1. revealed in part, an empty box next to the diagnosis of major depressive disorder. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident identified with a mental disorder had an accurately completed PASARR (Pre-admission Screening and Resident Review) on admission for 1 (Resident #57) of 3 residents investigated for PASARR.Resident #57 was admitted to the facility on [DATE] with diagnoses that included in part, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, depression, and generalized anxiety disorder. A review of Resident #57's PASARR dated 02/24/2025 was conducted. Review of Section III, 1., revealed in part, an empty box next to Other Psychotic Disorder. A review of Resident #57's document Medicaid Program, Notice of Medical Certification dated 02/28/2025 revealed in part that a Level II decision was not required. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement the comprehensive person-centered care plan and a physician order for a concave mattress for 1 (Resident #76) of 27 sampled residents. Review of Resident #76's record revealed the resident was admitted to the facility on [DATE] with diagnoses that include in part, anxiety disorder, unspecified dementia, psychotic disorder with delusions, Alzheimer's Disease, and bipolar disorder. A review of Resident #76's Order Summary Report revealed a physician order dated 10/14/2024 for Concave mattress every shift. A review of Resident #76''s Care Plan Report revealed in part: Focus: I am at risk for falls related to impaired mobility, generalized weakness and multiple medication use. Interventions: Maintain concave mattress to my bed. On 01/06/2026 at 2:12 p.m., an observation was made of Resident #76's empty bed. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that nursing staff possessed competencies and skill sets necessary to provide nursing services to meet the residents' needs safely, and attain or maintain the highest practicable physical well-being for 1(#12) of 00 sampled residents as evidenced by nursing staff failing to properly maintain and record output from a Jackson Pratt (JP) drain for Resident #12.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure reasonable accommodation of resident's needs for 1 (#12) out of 29 sampled residents as evidenced by Resident #12's easy touch call light device outside of her reach.

Inspectors wroteBased on record review and interviews, the facility failed to notify a resident's representative when a resident had a significant change in condition for 1 (#18) resident out of 29 sampled residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 1 (#12) of 29 sampled residents as evidenced by staff failing to turn Resident #12 every two hours.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#57) of 3 (#12, #47 and #57) residents reviewed for ADLs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 residents (#46) investigated for respiratory care out of a finalized sample of 29 residents by failing to label and properly store Resident #46's CPAP (continuous positive airway pressure) mask.

Inspectors wroteBased on observations and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 83.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to honor and accommodate food preferences for 2 (#17 and #23) out of 6 (#17, #23, #26, #49, #72, and #379) residents reviewed for dining. This deficient practice had the potential to affect 78 residents who consumed meals from the kitchen. Resident #17 Review of Resident #17's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Type 2 Diabetes Mellitus and Muscle Wasting and Atrophy. Review of Resident #17's most recent Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 8, indicating his cognition was moderately impaired. Review of Resident #17's meal ticket, read in part, . meal note: No [NAME] Leafy foods. On 10/29/2024 at 12:40 p.m. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system of accounting of each resident's personal funds entrusted to the facility on the resident's behalf by failing to provide quarterly statements for 1 (# 49) of 1 resident investigated for personal funds out of a finalized sample of 41 residents.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2 (#1, #18) of 4 (#1, #18, #53, #62) residents investigated for PASARR in a final sample of 41 residents. Resident #1 A review of Resident #1's record revealed an admission date of 04/24/2012. Further review revealed he was diagnosed with Schizophrenia on 06/04/2015. A review of the Resident #1's current physician's orders September 2023 revealed he had been prescribed the antipsychotic medication Seroquel 25mg (milligrams) related to the diagnosis of Schizophrenia. Further review of Resident #1's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 06/22/2010. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the resident's comprehensive plan of care was implemented for 2 (#6 and #49) residents out of 41 sampled residents as evidenced by: 1. Failing to follow the physician's standing orders to address a blood sugar reading of 44 for Resident #6 and 2. Failing to ensure Resident #49 received a renal diet.

Inspectors wroteBased on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure that dietary staff utilize the appropriate hair covering when not covering a beard with a beard restraint to prevent hair from contacting food. This deficiency had the potential to affect the entire census of 79 residents, who consumed food that was prepared in the kitchen.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure each resident's plan of care and clinical record accurately reflected their advanced directives for 1 (#65) out of 41 sampled residents. This deficient practice had the potential to affect the entire census of 79 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the nurse informed each resident's RP (Responsible Party) of a significant change in condition as evidenced by: 1. Failing to notify Resident #6's RP when the resident was transferred to the hospital and; 2. Failing to notify Resident #69's RP when the resident had an unwitnessed fall for 2 (#6, #69) out of 41 sampled residents.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#39, and #65) of 2 (#39 and #65) residents reviewed for respiratory care in a final sample of 41 residents. The facility failed to ensure: 1. Respiratory equipment was properly stored when not in use 2. Resident #65 received oxygen as ordered by the physician.

Inspectors wroteBased on observations, record review and interview, the nurse failed to perform hand hygiene after removing gloves during wound care 1 (#7) out of 1 residents investigated for pressure ulcers in a final sample of 41 residents.