Courtyard Gardens Nursing and Rehab CTR

In the surveyor’s words

From the most serious findings on record at Courtyard Gardens Nursing and Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 27, 2026

  Based 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).Findings include:Review of Resident 1's clinical record revealed diagnoses that included chronic atrial fibrillation (a long-lasting, irregular heartbeat) and diabetes (when the body doesn't produce enough insulin).Review of Resident 1's care plan revealed a focus area related to the Resident's activities of daily living (ADL) self-care deficit related to impaired cognition, muscle weakness, and decreased mobility. […]

• Actual harm, isolatedF697Jan 27, 2026

  Based 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. Findings include:Review of Resident 1's clinical record revealed diagnoses that included chronic atrial fibrillation (a long-lasting, irregular heartbeat) and diabetes (when the body doesn't produce enough insulin).Review of Resident 1's clinical record revealed a Health Status Note written on March 31, 2025, at 4:18 AM, that the Resident was alert, and able to make her needs… […]

• No harm, potential for more than minimal, widespreadF880Nov 7, 2023

  Based 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). Findings include: During an interview with the Nursing Home Administrator (NHA) on November 7, 2023, at 11:00 AM, the NHA was unable to provide a policy that addressed water management or a list of water management team members. […]

• No harm, potential for more than minimal, patternF684Jan 27, 2026

  Based 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).Findings include:Review of Resident 2's clinical record revealed diagnoses that included respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) and hypertension (high blood pressure).Review of Resident 2's clinical record revealed the Resident was admitted to the facility on [DATE], with an abdominal fistula (an abnormal opening between the intestines or stomach and another organ or the skin, causing leakage of digestive fluids) which is covered with a colostomy bag (a discreet,… […]

• No harm, potential for more than minimal, patternF726Jan 27, 2026

  Based 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).Findings include:Review of Resident 2's clinical record revealed diagnoses that included respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) and hypertension (high blood pressure).Review of Resident 2's clinical record revealed the Resident was admitted to the facility on [DATE], with an abdominal fistula, which is covered with a colostomy bag.Review of Resident 2's current physician orders revealed an active… […]