Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Courtyard Care Center during CMS and state inspections, most recent first.
A resident with multiple medical and cognitive conditions was involved in an altercation with another resident, but the facility did not update or revise the care plan to address the incident or implement new interventions, as required by policy. The DON confirmed that no care plan entry was made following the event.
A resident with a history of stroke and mental health disorders was involved in a physical altercation with a CNA, leading to involvement from APS and police. Despite facility policy requiring 72-hour monitoring and documentation after such incidents, only one entry was made in the resident's record during this period, as confirmed by the DON. This failure resulted in inadequate monitoring and documentation of the resident's condition following the incident.
A resident with multiple chronic conditions and a high fall risk score was admitted without a baseline fall care plan in place. Despite experiencing several falls, the resident's care plan did not address fall risk, and this omission was confirmed by the ADON during record review.
The facility failed to notify the Long Term Care Ombudsman of 82 transfers/discharges, affecting 71 residents. The Social Services Director confirmed that no notifications were sent since May 2024 due to the absence of an Ombudsman, despite facility policy requiring such notifications.
The facility failed to provide appropriate pharmaceutical services by not having glipizide and duloxetine available for two residents, leading to missed doses. Additionally, discrepancies were found between the controlled drug records and medication administration records for four residents, involving oxycodone. These issues were confirmed by the interim DON, highlighting a failure to adhere to the facility's policies on medication availability and record accuracy.
A facility was found to have a medication error rate of 7.7%, exceeding the acceptable threshold. Errors included improper insulin administration, unavailability of glipizide and duloxetine, and incorrect application of Ketotifen eye drops. These incidents involved multiple residents and highlighted failures to follow physician orders and facility protocols.
The facility failed to maintain safe food storage and handling practices, with expired food items found in storage, improperly dried cookware, and incomplete temperature logs for a refrigerator. These deficiencies potentially exposed 65 residents to food-borne illnesses.
The facility failed to implement proper infection control practices, including unlabeled wash basins, improper PPE use, unlabeled oxygen tubing, and inadequate GT dressing care. A urinary catheter bag was also found touching the floor. These deficiencies had the potential to compromise residents' health and safety.
The facility failed to ensure informed consent for psychotropic medications for several residents. A resident with schizoaffective disorder had incomplete consent for Risperidone, lacking details on risks and benefits. Another resident's responsible party was not informed of chest X-ray results. A third resident on multiple psychotropic medications had incomplete consent forms, missing details on side effects and lacking signatures. The Interim Director of Nursing acknowledged these deficiencies.
The facility did not follow its policy for documenting an advance directive and completing the POLST form for a resident. The POLST form was marked for an advance directive, but the healthcare agent field was empty, and no signed advance directive was found in the resident's record. The social services director confirmed the absence of this documentation, which should have been placed on the chart and communicated to staff upon admission.
A facility failed to develop a comprehensive care plan for a resident with dementia. The resident's electronic health record lacked a dementia care plan, which was confirmed by the facility's nurse consultant. The facility's policy requires individualized care plan interventions for dementia, but this was not implemented for the resident.
A facility failed to follow a physician's order for a resident to be placed in a wheelchair for interaction on specific days, as observed during multiple interviews and record reviews. The resident, diagnosed with major depressive disorder, mood disorder, and muscle weakness, was consistently found lying in bed instead of being in a wheelchair, contrary to the care plan. This non-compliance with the physician's orders had the potential to impact the resident's physical, mental, and psychosocial well-being.
A resident with end-stage renal disease did not receive consistent dialysis care due to missing dialysis communication sheets (DCS) for several treatment days. The facility's policy requires communication of critical dialysis information, but the DCS forms were absent from the resident's records, as confirmed by the Interim Director of Nursing.
The consultant pharmacist failed to conduct the Abnormal Involuntary Movement Scale (AIMS) for two residents on psychotropic medications, Seroquel and Risperidone, as required by facility policy. The pharmacist acknowledged the absence of AIMS assessments, which are necessary for monitoring the effects of these medications. Despite the facility's claim of using a different system, the pharmacist was unaware of any alternative monitoring method.
The facility failed to conduct Abnormal Involuntary Movement Scale (AIMS) assessments for residents on psychotropic medications, leading to potential unnecessary medication use. A resident with schizoaffective disorder was on Seroquel without AIMS monitoring, and another with paranoid schizophrenia had not been assessed since 2021. Two other residents on antipsychotics also lacked AIMS documentation. The facility did not have a replacement system for AIMS, as confirmed by the Consultant Pharmacist and Interim Director of Nursing.
A facility failed to protect residents' private medical information when a resident was discharged with medications labeled with the names and prescriptions of two other residents. The incident was confirmed by the DON and RN, indicating a breach of the facility's policy on safeguarding resident information.
Failure to Update Care Plan After Resident Altercation
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan following a resident-to-resident altercation involving a resident with significant medical and cognitive conditions. The resident, who had diagnoses including anoxic brain damage, alcohol dependence, anxiety disorder, and type II diabetes mellitus, was observed in the hallway yelling and grabbing another resident's arm. Despite this incident, there was no care plan entry created to address the altercation or to outline interventions to prevent recurrence or address the resident's needs. Record review and interview with the DON confirmed that the interdisciplinary team typically updates care plans after incidents, but in this case, no such update was made. Facility policies require that care plans be reviewed and revised upon a resident's status change, and that the interdisciplinary team collaborates on intervention options. However, these procedures were not followed, resulting in the absence of documented interventions or updates to the resident's care plan after the altercation.
Failure to Document and Monitor Resident After Staff Altercation
Penalty
Summary
A deficiency occurred when the facility failed to provide care and services in accordance with professional standards of practice for a resident with a history of cerebral infarction, mood disorder, and major depressive disorder with psychotic symptoms. After an altercation between the resident and a CNA, in which both parties admitted to physical contact, the resident's daughter contacted adult protective services and the police were involved. The resident was observed in bed with no visible injuries following the incident. Despite facility policy requiring increased supervision and documentation for at least 72 hours following such incidents, there was only one documented entry in the resident's clinical record during the required monitoring period. The DON confirmed that nursing staff should have documented the resident's status for 72 hours post-incident, but this was not done, with only a single entry recorded. This lack of documentation failed to ensure the resident's health, safety, and well-being were adequately monitored after the incident.
Failure to Develop Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a baseline fall care plan for a resident who was admitted with multiple diagnoses, including type 2 diabetes mellitus, end stage renal disease, muscle weakness, and osteoarthritis. Upon admission, the resident was assessed as high risk for falls, as indicated by a fall risk assessment score of 15. Despite this high risk status and the resident experiencing several falls while in the facility, there was no care plan in place to address fall risk in the resident's clinical record. During an interview, the Assistant Director of Nursing (ADON) confirmed that there was no care plan to address the resident's fall risk and acknowledged that a separate care plan for falls should have been present. The facility's own policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes to meet each resident's identified needs, including those related to fall risk.
Failure to Notify Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman in writing of transfers or discharges for 82 instances, affecting 71 residents and their responsible parties. This deficiency was identified through interviews and record reviews, which revealed that transfer notification forms were missing from the electronic health records of residents transferred to acute care hospitals. The Social Services Director (SSD) confirmed that the facility had not notified the Ombudsman of any transfers or discharges since May 2024, due to the absence of an Ombudsman. A review of the facility's records indicated that from May 2024 to January 2025, there were 98 transfers or discharges, but only seven notifications were sent to the Ombudsman in January 2025. The facility's policy requires that transfer/discharge notices be provided to the resident, their representative, and the Ombudsman, with evidence maintained of such notifications. However, the SSD admitted that neither the Ombudsman nor the residents or their representatives received the required notices, except for those in January 2025.
Pharmaceutical Services and Record Discrepancies
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services by not having two medications, glipizide and duloxetine, available for two residents. During a medication pass observation, it was noted that glipizide was not available for a resident with Type 2 Diabetes Mellitus, and duloxetine was not available for another resident with schizoaffective disorder. The facility's policy requires medications to be available on the day they are ordered, but this was not adhered to, leading to missed doses for these residents. Additionally, there were discrepancies between the controlled drug records (CDR) and the medication administration records (MAR) for four residents. Instances were found where oxycodone, a controlled medication, was recorded in the CDR but not documented as given in the MAR. This discrepancy was confirmed by the interim Director of Nursing, who noted that the times recorded in the CDR and MAR should match, as per the facility's policy on controlled substance administration and accountability. The failure to maintain accurate records of controlled medications and ensure their availability as per physician orders had the potential to affect the health of the residents. The facility's policies on pharmaceutical services and controlled substance accountability were not followed, leading to these deficiencies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 7.7%, exceeding the acceptable threshold of 5%. This was identified during medication administration observations involving four residents. One incident involved a Licensed Vocational Nurse (LVN) administering insulin aspart to a resident without priming the pen injector needle with the required two units, contrary to the recommended procedure. Another incident involved an LVN not having glipizide on hand for a resident, necessitating a call to the physician and pharmacy for a refill, which delayed the administration of the medication. Further observations revealed that duloxetine was not available for another resident, requiring the LVN to contact the pharmacy to restock the medication. Additionally, an LVN administered Ketotifen eye drops to both eyes of a resident, despite the physician's order specifying administration to only the right eye. These errors indicate a failure to adhere to physician orders and facility protocols, potentially impacting the therapeutic effectiveness of the medications for the residents involved.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage, preparation, and distribution, as observed during a survey. Expired food items were found in various storage areas, including gelatin, ground beef, buns, and a pie crust, all past their expiration dates. These items were stored in different refrigerators and a freezer, indicating a lack of proper inventory management and oversight in the kitchen. Additionally, cookware was not properly dried before storage, as seven large metal sheet pans were found stacked wet on a storage rack, contrary to the facility's procedure that requires air drying of dishes and utensils. Furthermore, the temperature log book for a refrigerator used to store food brought in by visitors was incomplete, with missing temperature records for several days. This lapse was acknowledged by the director of staff development, who confirmed that the temperatures should have been recorded. These deficiencies in food storage and handling practices potentially exposed 65 residents to food-borne illnesses, as they received food from the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. Staff did not label resident wash basins with identifiers in shared bathrooms, as observed in resident rooms AA and BB. This was confirmed by a Certified Nursing Assistant and the Interim Director of Nursing, who acknowledged that resident items should be labeled with the resident's name and room number. Additionally, staff did not wear the appropriate personal protective equipment (PPE) when entering a room under enhanced droplet precautions. The Interim Director of Nursing and a Licensed Vocational Nurse entered a room without wearing a faceshield, despite the requirement being clearly indicated on the door sign. The Maintenance Supervisor also failed to wear the correct PPE, wearing a regular face mask instead of an N-95 mask and faceshield. Another deficiency was noted when staff did not label oxygen tubing for a resident, as observed with Resident 21, whose nasal cannula device lacked a label with a date or initials. A Licensed Vocational Nurse confirmed that oxygen tubing should be labeled with the date of change. Furthermore, the facility did not ensure the dressing around a gastrostomy tube (GT) was intact for Resident 7. The GT dressing was loose, and the tape was not adhering properly. A Certified Nursing Assistant was observed not wearing a gown while providing close contact care, contrary to the facility's policy for enhanced barrier precautions. Lastly, a urinary catheter bag was found touching the floor for Resident 38, which was verified by a Certified Nursing Assistant. The Infection Preventionist stated that urine bags must not touch the floor, aligning with the facility's policy to prevent complications such as urinary tract infections. These failures in infection control practices had the potential to compromise residents' health and safety and lead to the spread of communicable illnesses.
Failure to Ensure Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed about the risks and benefits of their treatments, specifically regarding psychotropic medications. Resident 23, who was diagnosed with cerebral vascular accident and schizoaffective disorder, had an informed consent form for Risperidone that was incomplete, lacking details about the risks, benefits, and side effects. Similarly, Resident 70, with diagnoses of deconditioning and schizoaffective disorder, had an informed consent form for Olanzapine that also did not include necessary information about the medication's risks, benefits, and side effects. Resident 34, who suffered from a hypoxic brain injury, had a chest X-ray performed, but there was no documentation indicating that the responsible party was informed of the results, which showed clear lungs. This lack of communication was contrary to the facility's policy requiring notification of significant changes or new treatments to the resident's responsible party. The Interim Director of Nursing (IDON) acknowledged the absence of documentation regarding the communication of the X-ray results. Resident 174, diagnosed with anxiety disorder, major depressive disorder, and paranoid schizophrenia, was on multiple psychotropic medications, including Risperidone, Buspirone, and Sertraline. The informed consent forms for these medications were incomplete, lacking specific details about frequency, indications, possible side effects, and adverse reactions. Additionally, there was no signature from the resident or a representative, and the forms did not indicate whether consent was verbal. The IDON confirmed these deficiencies and noted that the facility had changed its consent forms since a new company took over.
Failure to Document Advance Directive and POLST Form
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives and the completion of the Physician Order for Life-Sustaining Treatment (POLST) form for a resident. Specifically, the POLST form for a resident, admitted on an unspecified date, was marked for an advance directive, but the field for a healthcare agent was left empty. Additionally, there was no documented copy of an advance directive signed by the resident or their responsible party in the clinical record. During an interview and record review, the social services director confirmed the absence of the advance directive documentation, which was contrary to the facility's policy that requires copies of advance directives to be placed on the resident's chart and communicated to the staff upon admission.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with dementia. During a review of the resident's electronic health record, it was found that there was no care plan addressing the resident's dementia. This oversight was confirmed during an interview with the facility's nurse consultant, who acknowledged that the resident should have had a specific cognitive care plan. The facility's policy on dementia care, revised in December 2022, requires care plan interventions to be related to each resident's individual symptoms and rate of dementia progression, aiming for improvement or maintenance of the expected stable rate of decline associated with dementia. However, this policy was not followed for the resident in question.
Failure to Follow Physician's Orders for Resident Interaction
Penalty
Summary
The facility failed to provide necessary care and services in accordance with the resident's goals for care, specifically for one resident, referred to as Resident 38. The deficiency was identified when the physician's order for Resident 38 to be up in a wheelchair for interaction every Monday, Wednesday, and Friday was not followed. During multiple observations and interviews, it was noted that Resident 38 was consistently found lying in bed and not placed in a wheelchair as per the physician's orders. Licensed Vocational Nurse (LVN) A confirmed that Resident 38 was not in a wheelchair during the observed times and had not seen the resident in a wheelchair even when stationed elsewhere. Resident 38's medical records indicated diagnoses of major depressive disorder, mood disorder, and muscle weakness, which necessitated the need for interaction as part of their care plan. The facility's policy and procedure on the provision of physician-ordered services required nursing and support staff to ensure compliance with activity restrictions prescribed by the physician. The failure to adhere to these orders had the potential to put Resident 38 at risk for decline in physical, mental, and psychosocial well-being.
Missing Dialysis Communication Sheets for a Resident
Penalty
Summary
The facility failed to provide consistent dialysis care for a resident, identified as Resident 32, who required dialysis treatment. Resident 32 was admitted with a diagnosis of cerebrovascular accident and end-stage renal disease, necessitating dialysis on Tuesday, Thursday, and Saturday. However, the dialysis communication sheets (DCS) for several treatment days, specifically from January 16 to January 28, were missing from the resident's clinical record. This absence of documentation meant that critical information regarding the resident's dialysis care was not properly communicated, potentially putting the resident at risk for complications. During an interview and record review with the Interim Director of Nursing (IDON), it was confirmed that the DCS forms were not present in the resident's chart or the white binder that accompanies the resident to and from the dialysis center. The facility's policy on hemodialysis, last revised in June 2023, mandates that licensed nurses communicate with the dialysis facility using a DCS or other written format to include medication administration, physician orders, laboratory values, vital signs, dialysis treatment provided, and any adverse reactions. The failure to adhere to this policy resulted in a deficiency in the standard of care provided to Resident 32.
Consultant Pharmacist Fails to Conduct AIMS for Residents on Psychotropic Medications
Penalty
Summary
The consultant pharmacist (CP) failed to identify and report irregularities during the medication regimen review (MRR) for two residents. For Resident 25, who has a diagnosis of Schizoaffective Disorder and is prescribed Seroquel, the CP verified that the Abnormal Involuntary Movement Scale (AIMS) was not conducted. The CP acknowledged that the facility should have performed the AIMS initially and every six months, but since 2022, the facility reportedly does not use AIMS, and the CP did not recommend it. The facility's policy requires ongoing evaluation of the effects of psychotropic medications during the pharmacist's monthly review, but this was not adhered to. Similarly, for Resident 174, diagnosed with paranoid schizophrenia and prescribed Risperidone, the AIMS was last conducted in September 2021. The CP confirmed that the AIMS was last recommended in December 2022, but the facility claimed to use a different system, which the CP was unaware of. The facility's policy mandates that a resident's drug regimen must be free of unnecessary drugs, which includes adequate monitoring, but this was not followed. The lack of AIMS assessments for both residents indicates a failure to monitor the effects of psychotropic medications adequately.
Lack of AIMS Assessments for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that four residents were free from unnecessary psychotropic medications due to the lack of Abnormal Involuntary Movement Scale (AIMS) assessments. These assessments are crucial for monitoring involuntary movements that can develop as side effects of long-term antipsychotic medication use. Resident 25, diagnosed with schizoaffective disorder, was prescribed Seroquel, an antipsychotic medication known to cause extrapyramidal symptoms, including tardive dyskinesia. However, the facility did not conduct AIMS assessments for this resident, as confirmed by the Consultant Pharmacist (CP), who noted that the facility had not used AIMS since 2022 and did not have a replacement system in place. Similarly, Resident 174, diagnosed with paranoid schizophrenia and prescribed Risperidone, had not undergone an AIMS assessment since 2021. The CP verified this lapse and mentioned that the facility claimed to use a different system, though no specifics were provided. Additionally, Residents 23 and 70, both on antipsychotic medications for schizoaffective disorder, also lacked documented AIMS assessments in their medical records. The Interim Director of Nursing (IDON) confirmed the absence of a specific form or assessment to monitor abnormal involuntary movements, indicating a systemic issue in the facility's monitoring practices for residents on psychotropic medications.
Unauthorized Disclosure of Residents' Medical Information
Penalty
Summary
The facility failed to ensure the protection of residents' private medical information when Resident 1 was discharged with medications labeled with medical information relevant to Resident 2 and Resident 3. This incident occurred when Resident 1, who was cognitively intact with a BIMS score of 15, was discharged to another skilled nursing facility. Upon discharge, Resident 1 was given medications that did not belong to her but were labeled with the names, prescriptions, and drug indications of Resident 2 and Resident 3. Resident 1's friend returned these medications to the facility, highlighting the breach of confidentiality. Interviews with the Director of Nursing (DON) and Registered Nurse A (RN A) confirmed that the medications belonging to Resident 2 and Resident 3 were mistakenly given to Resident 1. The facility's policy on safeguarding resident identifiable information was not followed, resulting in the unauthorized disclosure of Resident 2 and Resident 3's private medical information. The DON acknowledged that the facility did not have authorization to disclose this information, and the incident violated the residents' rights to have their medical information protected against unauthorized release.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Win Post-acute | 1.4 mi | ★★★★★ | 1 | 0 |
| Creekside Post-acute | 1.5 mi | ★★★★★ | 2 | 0 |
| Skyline Healthcare Center - San Jose | 1.7 mi | ★★★★★ | 1 | 0 |
| O'connor Hospital D/p Snf | 1.7 mi | ★★★★★ | 8 | 0 |
| A Grace Sub Acute & Skilled Care | 1.7 mi | ★★★★★ | 3 | 0 |
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