Courtyard Care Center

In the surveyor’s words

From the most serious findings on record at Courtyard Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 6, 2022

  Based on interview and record review, the facility failed to provide services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Complete Resident 1's post fall neurological assessment after unwitnessed fall incidents per facility's protocol 2. Accurately assess Resident 1 upon admission, and develop an individualized resident-centered care plan to address Resident 1's communication concerns. 3. Follow Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Get a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Provide Resident 1's pain management as indicated. […]

• Actual harm, isolatedF689Jan 31, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF623Jan 31, 2025

  Based 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. Findings: During a review of Residents 11 and 58's electronic health records regarding their transfers to an acute care hospital, on several occasions, a transfer notification form, that is to be sent to the Ombudsman, was not located. […]

• No harm, potential for more than minimal, widespreadF812Jan 31, 2022

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, patternF755Jan 31, 2025

  Based 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. Findings: 1. […]