Courtyard Health And Rehabilitation

Penalty

Inspection fine: $22,325

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from abuse, neglect, and intimidation by admitting and retaining a resident with known aggressive and violent behaviors without implementing adequate supervision, behavioral interventions, or protective measures for other residents. The resident in question had diagnoses including Schizoaffective Disorder, Bipolar Type, Schizophrenia, and Suicidal Ideation, and was assessed as having severe cognitive impairment. Despite repeated incidents of aggression, threats, and physical intimidation towards both staff and other residents, the facility did not provide necessary psychiatric intervention or relocate vulnerable roommates to ensure their safety. Multiple residents were directly affected by the aggressive behaviors. One resident, who shared an adjoining room, reported being repeatedly threatened and verbally abused at night, leading to fear and inability to sleep. Another roommate experienced threats and was once barricaded in the room by the aggressive resident, preventing access to medication and staff intervention. A third resident, located across the hall, expressed fear and avoided leaving her room when the aggressive resident was present and yelling in the halls. Staff interviews confirmed that these behaviors were ongoing and that no formal interventions, such as increased supervision or room changes, were implemented to protect the affected residents. Progress notes and staff interviews documented a pattern of escalating behaviors, including refusal of medication, threats to kill staff and residents, inappropriate sexual comments, physical aggression, and property damage. The aggressive resident repeatedly barricaded doors, threatened others, and required police and emergency medical intervention on multiple occasions. Despite these incidents, the facility did not implement effective interventions or provide adequate supervision, resulting in an unsafe environment and placing multiple residents at risk for serious injury, harm, impairment, or death.

Removal Plan

• Resident #1 was transported to the local emergency department and subsequently to an inpatient behavioral health facility; Resident #1 remains in inpatient behavioral health facility.
• Once Resident #1 exited the facility, the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk.
• The Executive Director interviewed the resident that was barricaded in the room with Resident #1 to assess for fear or trauma.
• The facility issued an emergency notification of discharge to Resident #1's family and began searching for alternative placement; Resident #1 will not return until cleared and appropriate safeguards are in place.
• Education was initiated with all facility staff by the Director of Nursing on Abuse and Neglect Policy, with emphasis on resident psychosocial harm, de-escalation of behavioral episodes, and investigation of psychosocial harm. Staff will be educated prior to accepting assignment.
• Education was conducted with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of residents.
• Interviews with current residents with a BIMS of 10 or greater were conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing to assess for any psychosocial harm or incident of trauma.
• Residents #2, #3, and #4's care plans were updated to include trauma-centered care.
• The Quality Assurance Performance Improvement (QAPI) Committee met to review the incident and policies.
• Abuse Neglect Policy, Behavioral Health Policy, and Accidents and Supervision Policy were reviewed.
• The Director of Nursing started an all-staff in-service on Abuse/Neglect policy with emphasis on resident psychosocial harm, abuse de-escalation of behavioral episodes, and investigation of psychosocial harm.
• Affected residents' care plans were updated to reflect trauma-informed care by the Care Plan team.
• The Regional Director in-serviced the Administrator and the Director of Nursing regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations, and Accidents and Hazards.
• An Emergency Quality Assurance Committee was held with key facility staff in attendance.

Penalty

Inspection fine: $22,325

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents involving a resident with known aggressive behaviors. Upon admission, the resident had documented diagnoses of Schizoaffective Disorder, Bipolar Type, Schizophrenia, and Suicidal Ideation, and exhibited severe cognitive impairment. Despite these known risks, the facility did not implement appropriate psychiatric care, enhanced supervision, or reassign vulnerable roommates. The resident repeatedly refused medications, threatened staff, and engaged in escalating aggressive and combative behaviors, including chasing and cornering staff, barricading rooms, and making death threats. Multiple staff interviews revealed that the resident's behaviors were not consistently managed or reported. Nurses and LPNs observed the resident threatening to harm others, barricading himself and others in rooms, and requiring police intervention on more than one occasion. Staff acknowledged that affected roommates and nearby residents were not relocated or provided with additional protection, and interventions were limited to verbal reassurance. Residents reported feeling unsafe, unable to sleep, and fearful of being harmed, with one resident avoiding their room and another being trapped and crying due to fear. Record reviews documented a pattern of aggressive incidents, including threats to kill staff and residents, inappropriate sexual comments, attempts to scald others, and physical altercations requiring emergency services. The facility did not remove environmental risks, such as unsecured fire extinguishers and movable beds, which the resident used to barricade doors. The lack of adequate supervision, failure to implement effective interventions, and insufficient response to escalating behaviors resulted in Immediate Jeopardy and Substandard Quality of Care, directly affecting multiple residents.

Removal Plan

• The Director of Nursing started an all-staff in-service on Abuse/Neglect policy with emphasis on resident psychosocial harm and abuse de-escalation of behavioral episodes and an investigation of psychosocial harm.
• Affected residents care plans were updated to reflect trauma informed care by the Care Plan team.
• The Regional Director in-serviced the Administrator and the Director of Nursing regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations and Accidents and Hazards.
• An Emergency Quality Assurance Committee was held with the following staff in attendance: Regional Director, Executive Director, Director of Nursing, MDS Nurse, Business Development Services, Social Services Director, Assistant Director of Nursing, Environmental Services, Maintenance Director and Infection Prevention Nurse.
• Residents #2, #3 and #4's Care Plans were updated to include Trauma Centered care.
• Education was initiated with all facility staff by the Director of Nursing on Abuse and Neglect Policy with emphasis on Resident's psychosocial harm, de-escalation of behavioral episodes and investigation of psychosocial harm. Staff will be educated prior to accepting assignment.
• Education was conducted with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of Residents.
• Interview with current Residents with a Brief Interview Mental Status (BIMS) or 10 or greater was conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing to assess for any psychosocial harm or Incident of trauma.
• Quality Assurance Performance Improvement (QAPI) Committee met. Abuse Neglect Policy, Behavioral Health Policy and Accidents and Supervision Policy was reviewed with no changes made.
• Once Resident #1 exited facility the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk.
• Resident #1 will not return to the facility until cleared and appropriate safeguards are in place.

Penalty

Inspection fine: $12,428

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to securely safeguard hazardous chemicals in two unlocked janitor's closets during a four-day survey. Observations revealed that the janitor closets on the 200 hall and the Intermediate Care Hall were unlocked and contained hazardous chemicals such as 3M Concentrated Glass Cleaner and 3M Quat Disinfectant. These chemicals pose a potential safety hazard, especially for cognitively impaired residents. The facility's policy, revised in June 2016, mandates that janitor closet doors must be locked when chemicals are stored inside. Interviews with staff, including the Housekeeping Supervisor, Maintenance Staff, Director of Nursing, and the Administrator, confirmed the oversight. The Housekeeping Supervisor acknowledged the unlocked closets and admitted not having keys to lock them, while the Maintenance Staff was unaware of the issue until informed during the survey. The Director of Nursing and the Administrator both recognized the safety risk posed by the unlocked closets, particularly for residents identified as wanderers. Safety Data Sheets for the chemicals indicated serious eye damage/irritation and other hazards, emphasizing the importance of keeping these chemicals out of reach.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that dietary staff supported and respected a resident's right to make choices about meal preferences. This deficiency was identified for one of the twenty-six sampled residents, who was a diabetic and expressed dissatisfaction with the lack of meal options. The resident reported that alternate meals were never posted or available for selection, which caused distress as she felt compelled to eat what was provided to avoid health issues related to her diabetes. The facility's policy required menus to be periodically reviewed and to include primary, alternate, and always available meal options. However, observations revealed that the menus in the dining areas did not include alternate options. The Dietary Manager confirmed that the menus were outdated and did not accommodate individual preferences due to the limitations of their computerized system. The system was designed to formulate menus based on residents' allergies and preferences identified at admission, but it did not allow for alternate or individual meal choices. The Dietary District Manager acknowledged that residents should have the option of an alternate meal, at least through an always available menu.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide palatable and appropriately temperature-controlled foods for one of the sampled residents. The facility's policy, revised in February 2023, mandates that food should be prepared to conserve nutritive value, flavor, and appearance, and served at a safe and appetizing temperature. However, during an interview, a resident complained that the food served was usually cold. An observation and interview with the Dietary Manager revealed that the meal tray provided to the resident had food temperatures of 122°F for white rice and spinach, and 109°F for egg noodles with gravy, which were deemed unacceptable. The Dietary Manager acknowledged that these temperatures were not palatable and might deter residents from eating. The resident involved was admitted to the facility in December 2016 and had a diagnosis of Type 2 Diabetes Mellitus, with a BIMS score indicating cognitive intactness.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to proper infection prevention and control practices, as evidenced by improper hand hygiene and wound care during direct care observations. Certified Nursing Assistants (CNAs) #1 and #2 did not perform hand hygiene before providing perineal care to a resident, and CNA #1 retrieved additional wipes with unclean gloves, causing potential cross-contamination. Both CNAs acknowledged their failure to follow hand hygiene protocols, which was confirmed by the Director of Nursing (DON) as an infection control issue. Registered Nurse (RN) #2 was observed providing wound care to two residents without following proper infection control procedures. For one resident, RN #2 did not change gloves after removing a soiled dressing and used the same gauze in a circular motion, alternating between clean and dirty areas. She acknowledged that her actions could increase the risk of infection. For another resident, RN #2 did not perform hand hygiene before donning gloves and used the same gloves to handle multiple wounds, further risking cross-contamination. She also opened a door with soiled gloves, which could spread infection throughout the facility. The residents involved had significant medical conditions, including pressure ulcers and cognitive impairments, which made them vulnerable to infections. The DON confirmed that the actions of the CNAs and RN #2 were not in line with the facility's infection control policies and emphasized the importance of hand hygiene and proper wound care procedures to prevent the spread of infections.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to uphold the dignity and respect of a resident during mealtime. An observation on January 6, 2025, revealed that a Certified Nursing Assistant (CNA) was standing while assisting a resident with lunch, which is against the facility's protocol for maintaining resident dignity. The CNA admitted to being unaware of the requirement to sit while feeding residents. Further interviews with the Charge Nurse and the Director of Nursing (DON) confirmed that staff should sit at eye level with residents during meals to prevent feelings of intimidation and to facilitate eye contact, which is crucial for resident comfort and dignity. The resident involved was admitted with diagnoses including Primary Generalized Osteo Arthritis and Cognitive Communication Deficit and was assessed as severely cognitively impaired, requiring substantial maximum assistance with eating.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement care plan interventions related to wound care for a resident with a Stage 4 pressure ulcer on the sacral region. The comprehensive care plan for the resident specified that the wound should be cleansed with wound cleanser and 4 x 4 gauze, and then patted dry with 4 x 4 gauze. However, during an observation, a registered nurse did not pat the wound dry as required by the care plan. The nurse admitted to not following the care plan during an interview. The Minimum Data Set (MDS) nurse emphasized the importance of adhering to care plans to inform staff of residents' care needs. The resident's admission record indicated diagnoses of a Stage 2 pressure ulcer on the right heel and a Stage 4 pressure ulcer on the sacral region.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the comprehensive care plan was implemented, specifically in providing oral care during Activities of Daily Living (ADLs) for two residents. Resident #3, who is totally dependent on staff for personal hygiene and oral care due to morbid obesity and muscle weakness, reported that staff have never assisted him in cleaning his teeth. Despite being cognitively intact with a BIMS score of 15, Resident #3 stated that staff promised to bring him a toothbrush and toothpaste, but this has not happened yet. This was confirmed during interviews on two separate occasions, and the resident reiterated his desire to brush his teeth daily. Similarly, Resident #6, who requires setup or clean-up assistance for oral care due to cerebrovascular disease with hemiplegia/hemiparesis on the right side, reported not receiving oral care since arriving at the facility. Despite being cognitively intact with a BIMS score of 15, Resident #6 stated that staff promised him a toothbrush and toothpaste, but it has yet to arrive. The MDS coordinator emphasized that the care plan serves as a guide for meeting residents' needs, and failure to follow it results in unmet needs. The facility administrator also confirmed that staff are expected to adhere to the care plans.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that dependent residents received adequate assistance with activities of daily living (ADL), specifically oral hygiene, for two sampled residents. Resident #3, who has diagnoses of morbid obesity and muscle weakness, reported that staff did not assist him in retrieving his toothbrush and toothpaste from his nightstand, which he could not reach. Despite being cognitively intact and able to brush his own teeth if given the supplies, Resident #3 expressed frustration over the lack of assistance, which he had not communicated to the staff. Similarly, Resident #6, who has diagnoses including lack of coordination, stiffness of joints, and hemiplegia, reported not receiving any oral care since his admission to the facility. He stated that staff had promised him a toothbrush and toothpaste but had not provided them, and he had never declined such care. Interviews with staff, including the Interim Director of Nurses and a CNA, confirmed that residents should be assisted with oral hygiene daily and that it is the responsibility of CNAs to provide necessary supplies and assistance. The Administrator also emphasized that CNAs are expected to provide comprehensive care, including oral hygiene. Despite these expectations, the facility's failure to ensure that these residents received the necessary assistance with oral hygiene was evident, as both residents expressed a desire for daily oral care that was not being met.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility staff failed to provide appropriate treatment and services to promote the healing and prevent complications of a pressure ulcer for one of the sampled residents. Specifically, Resident #5, who has Alzheimer's Disease, Type 1 Diabetes Mellitus, and Atherosclerotic Heart Disease, did not receive the prescribed wound care. The facility's policy requires weekly skin evaluations and documentation of skin impairments, as well as reporting changes in skin integrity to the physician and resident representatives. However, due to the absence of a wound care nurse for two weeks, the facility relied on a Nurse Practitioner who visits weekly and uploads assessments by the following Monday. During this period, the Interim Director of Nursing (IDON) expected staff to perform wound care and document it in the resident's chart. An observation of wound care for Resident #5 revealed that LPN #1 did not apply the Dakins moist dressing to the wound bed as per the physician's orders before covering it with foam border gauze. The order, dated 2/9/24, specified cleaning the unstageable pressure wound to the sacrum with full-strength Dakins, placing Dakins moist gauze to the wound bed, and covering it with foam border gauze every day shift. LPN #1 confirmed the deviation from the physician's orders, acknowledging that the orders are essential for wound healing. The IDON also confirmed that not following the physician's orders could potentially worsen the wound condition.