Courtyard Health Care Center

In the surveyor’s words

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

• Actual harm, isolatedF676May 24, 2024

  Based on observation, interview, and record review the facility failed to ensure one of 30 sampled residents (Resident 43) received services to maintain mobility when Restorative Nursing Aide services (RNA, provides residents with exercises to improve or maintain mobility and independence) were not provided to Resident 43 as recommended by a Physical Therapist (PT, a healthcare professional who specializes in helping residents improve their physical functioning). This failure resulted in Resident 43 not receiving services to maintain her highest practicable physical level of functioning and psychosocial well-being. […]

• Actual harm, isolatedF689Jan 7, 2022

  Based on interview and record review the facility failed to ensure an environment was free of accident hazards for one resident (Resident 1) when Resident 1 fell off a wheelchair, for a census of 86. This failure led to Resident 1's death. Findings: A review of the facility's document titled Admission Record, dated [DATE], indicated Resident 1 was admitted in [DATE] with diagnoses including acquired absence of left leg above knee and right leg above knee. A review of a Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated Resident 1 had no memory problems, normally used a wheelchair to move around, and had no history of falls. […]

• No harm, potential for more than minimal, widespreadF812Jul 10, 2026

  Based on observation, interview, and record review the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards of food service for a census of 104 Residents when:1.Two ovens were observed with blackened, burnt debris on the bottom and doors;2.Food items in Freezer #1 were opened and undated;3.Food items in the dry storage area were placed in bowls unlabeled and undated; and,4. Meal trays were observed being delivered to residents with uncovered food. These failures had the potential to cause food borne illness among a vulnerable resident population. […]

• No harm, potential for more than minimal, patternF605Jul 10, 2026

  Based on interview and record review, the facility failed to ensure five residents (Residents 1, 3, 4, 12, and 91) out of 26 sampled residents were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors), when they received psychotropic medications while nursing staff did not implement nonpharmacological (non-drug, behavioral interventions). This failure had the potential to result in the unnecessary use of psychotropic medications and to not utilize the lowest effective dose of medication.1. […]

• No harm, potential for more than minimal, patternF658Jul 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure professional standards were followed for four residents (Residents 1, 3, 4, and 12) out of 26 sampled residents when: 1. Resident 3 did not receive appropriate pain management services during wound care treatment;2. Resident 12's physician's order to discontinue medication was not carried out;3. Resident 4's opioid (a potent medication to treat pain) medication was not administered by nursing staff according to the physician's order; and,4. Nursing staff did not routinely check Resident 1's blood sugar (BS) prior to administration of (brand name for semaglutide)(a medication to treat type 2 diabetes). […]