The Terrace at Courtenay Springs

In the surveyor’s words

From the most serious findings on record at The Terrace at Courtenay Springs, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 9, 2022

  Based on observation, interview, and record review, the facility's staff and interdisciplinary team (IDT) neglected to identify, communicate, and provide necessary care and services to ensure the safety of a resident who wandered; neglected to respond to a missing resident in a timely and efficient manner; and failed to recognize and address an unsecured area as an environmental hazard to prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 4 residents reviewed for elopement, out of a total sample of 32 residents, (#25). These failures contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. […]

• Immediate jeopardy, isolatedF689Nov 9, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring of the status and activities of a vulnerable, cognitively impaired resident to prevent unsupervised exit from the facility through an unmonitored courtyard for 1 of 4 residents reviewed for elopement, out of a total sample of 32 residents, (#25). This failure contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was a likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On [DATE] at approximately 8:30 AM, resident #25 left the West Wing dining room and walked away from the unit. […]

• Immediate jeopardy, isolatedF835Nov 9, 2022

  Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to mitigate vulnerabilities in the electronic wander monitoring system; failed to maintain a secure environment to prohibit unauthorized entry and egress through the courtyard; and failed to oversee the implementation of policies and procedures and interdisciplinary team (IDT) processes to ensure the safety of 5 of 5 physically and/or cognitively impaired residents identified to be at risk for elopement, of a total sample of 32 residents, (#11, #12, #14, #19 & #25). These failures contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. […]

• Immediate jeopardy, isolatedF600Sep 24, 2021

  Based on interview and record review, the facility neglected to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 12 residents reviewed with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:55 PM, during resident care rounds, resident #1 was found unresponsive with an abnormal color to her skin. Licensed Practical Nurse (LPN) A evaluated the resident and discovered she had a faint pulse. LPN A requested assistance from Registered Nurse (RN) B since resident #1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF658Sep 24, 2021

  Based on interview and record review, the facility failed to follow accepted professional nursing standards of clinical practice for providing basic life saving measures and initiating cardiopulmonary resuscitation (CPR) for a resident requiring emergency care and failed to announce a Code Blue medical emergency for cardiopulmonary arrest for 1 of 12 residents reviewed with physician orders for Full Code of a total sample of 25 residents, (#1). On [DATE] at 2:55 PM, during resident care rounds, resident #1 was found unresponsive with abnormal color to her skin. Licensed Practical Nurse (LPN) A evaluated the resident and discovered she had a faint pulse. […]