Other·July 11, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incidents #CA00596620 and #CA00596707. Representing the Department of Public Health: Health Facility Evaluator Nurse, 36586 The inspection was limited to the specific facility reported incidents investigated and does not represent the findings of a full inspection of the facility.

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 07/24/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview and record review the facility failed to ensure each resident was free from sexual abuse (unwanted sexual contact, usually perpetrated by force or by taking advantage of a person not able to give consent) for two of two sampled residents (Resident 1 and Resident 2) from sexual abuse when: 1. Resident 3 was found lying naked on top of Resident 1, and 2. Resident 3 was found naked in bed touching Resident 2 inappropriately. This failure resulted in the sexual abuse of Resident 1 and Resident 2 causing psychosocial harm to vulnerable residents. Findings: Review of the undated Admission Record indicate Resident 3 was admitted to the facility in 2018 with diagnoses including hemiparesis (weakness of one entire side of the body) after a stroke, dementia (a decline in mental ability severe enough to interfere with daily life), and psychotic disorder (severe mental disorders that cause losing touch with reality with abnormal thinking and perceptions) with hallucinations (sensations that appear real but are created by your mind). Review of Resident 3's medical record documents titled Progress Notes revealed the following: - 6/29/18 at 1:15 p.m., "Continues to be monitored for increased aggressive behaviors occurring yesterday involving him hitting another resident with a closed fist in the face...He was monitored 1:1 (constant visual, arms reach observation for immediate or impulsive behavior that may be harmful to self or others) through the day shift. Per SSD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE [Social Services Director] will be transferred ...out of the memory care unit ..." - 6/30/18 at 12:11 a.m., "... [Resident 3] is visual being monitored [sic], for he has shown tendency to wander into other resident's rooms." - 6/30/18 at 4:28 a.m., "In 'C' HALL dancing and removing clothes." - 7/1/18 at 12:11 p.m., "[Resident 3] was by kitchen trying to get out doors. Ignoring all staff that attempted to talk or redirect [resident]." - 7/2/18 at 11:19 a.m., "Resident was reported to have difficulty using the toilet properly; there is ongoing concerns raised regarding BM [bowel movement] messes on the bathroom floor, around or near the toilet ... an OT [Occupational Therapy] referral for further toilet training..." 7/2/18 at 3:50 p.m., "Supervisor alerted nursing [Resident 3] was observed at station 1 standing from his w/c [wheelchair] and attempted to hit CNA [Certified Nursing Assistant] as employee was speaking to another co-worker during shift change. Resident became enraged and stated 'I'll knock you out'. Employee removed himself from area to de-escalate situation, but resident then proceeded to throw a plant onto the ground with his hand that was on the counter of the nurses' station ...He was heard mumbling 'I'll knock you out.' Again as he wheeled off...Floor supervisor talked to him 1:1 to provide reassurance ...visuals in place, continue to monitor." -7/3/18 at 6:56 a.m., "Resident up in his w/c, restless, wandering, re-oriented by nursing staff, tried to get out of w/c and get into nurse's purse and get scissors out. Was immediately stopped, scissors were confiscated safely by nursing staff." - 7/5/18 at 12:48 p.m., "[Resident 3] attempted to hit a female resident in the dining room as she was sitting in her w/c ... He stated 'Leave me alone or I'm going to start swinging.'...1:1 in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE his room ...continue to monitor." - 7/10/18 at 8:19 p.m., "Resident continuously going into other resident's rooms and making a mess in their bathrooms." - 7/14/18 at 3:19 p.m., "[Resident 3] took liberty in accessing the personal toiletries ...of his room mate [sic] and also put them on the floor. Several urine puddles were noted on various aspects of this area on and around the personal belongings. His room mates spirometer was laid in a puddle of urine. There were also clothing items that were saturated in urine..." Note further indicated Resident 3 was moved to another room. - 7/20/18 at 23:15 p.m., "...[Resident 3] continues to exhibit negative behaviors by wandering around facility, entering other [residents'] rooms, and tossing objects to the floor. Redirection to room and reminding resident where his bathroom is multiple times. Visual checks by staff at all times ...Staff encouraged to keep visual checks on [Resident 3] through the night..." -7/24/18 at 2:25 a.m., "[Resident 3] found without clothes in female resident's [Resident 1] bed. [Resident 3] removed from female resident's room, clothed, redirected. One on one supervision/ monitoring initiated." Review of the facility report faxed to the Department on 7/24/18, indicated the following: 1. Resident 3 was found naked on top of Resident 1 on 7/24/18 at 2:30 a.m., and 2. Resident 3 was found naked in bed with Resident 2 on 7/24/18 at 5:35 a.m. after being placed on 1:1 supervision. 1. Review of SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 7/24/18 and electronically signed by Licensed Nurse (LN) 1, indicated Resident 1 was the victim of sexual abuse on 7/24/18 at 2:30 a.m. by another FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident, that Resident 1 is not oriented to person, place or time and does not have the capacity to make decisions. It further indicated Resident 3 "was found lying on top of [Resident 1] with his pants down pass [sic] his buttocks, with genitals exposed. No erection observed, no body fluids observed. Resident [1] was wearing gown, brief, and covered with two blankets." Review of a summary report submitted by the facility dated 7/27/18 indicated the following: - Resident 3 "has limited mental capacity and a history of behaviors ...has exhibited baseline behaviors with periodic outbursts ...Occasional incidents noted of propelling into resident's rooms near his own. [Resident 3] has made verbalizations of a sexual nature in the past, but nothing physical in nature." - Resident 1 "has Dementia with Behavioral Disturbances ...is not alert and oriented ..." - Statement from [CNA 1] "While doing rounds, found [Resident 3] in the adjacent room lying on [Resident 1] with his pants down showing his buttock and genitals. His shirt was still on. [Resident 1] still had blankets over her. [CNA 1] told [Resident 3] to get off of [Resident 1] and when she attempted to remove him he swung at her multiple times and she ran to the nurse's station for help. [LN 1] and [LN 2] and [CNA 2] ran to the room to assist and got [Resident 3] off the bed, pulled his pants up and walked him back to his room and put him to bed." - Statement from CNA 2 "was at the nurse's station when [CNA 1] asking could we help with a resident that was in another resident's room ...When they arrived at the room [Resident 3] was at the edge of the bed with his buttocks exposed. [LN 1] and [LN 2] were able to remove [Resident 3] from the room and put him to bed." - Follow up Actions taken included Resident 3 "on 1:1 observation all shifts." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the undated Admission Record indicated Resident 1 was admitted to the facility in 2008 with diagnoses including dementia and Alzheimer's disease (a brain disease that causes a slow decline in memory, thinking and reasoning skills as well as other cognitive abilities serious enough to interfere with daily life). Review of Resident 1's Progress Notes, dated 7/24/18 at 3:00 a.m. and signed by LN 1, indicated Certified Nursing Assistant (CNA) 1 found Resident 3 "lying on top of [Resident 1] with his pants down to buttocks and genitals showing." The progress note further indicated Resident 1 was dressed and under the covers. 2. Review SBAR, dated 7/24/18 and electronically signed by LN 2, indicated Resident 2 was the victim of sexual abuse on 7/24/18 at 5:35 a.m. by another resident, that Resident 2 is oriented to person and place. It further indicated Resident 3 "was found naked lying beside [Resident 2]. [Resident 2] states that [Resident 3] rubbed her chest down to her private area. Resident stated he 'touched me all over.'" Review of a summary report submitted by the facility dated 7/27/18 indicated the following: - Resident 2 "is an alert and oriented resident whose significant other visits daily ...Initial statement regarding the incident by [Resident 2] to [CNA 2] was that [Resident 3] got into bed with her naked and that he touched her, rubbing her body from the neck down." - Resident 3 "has limited mental capacity and a history of behaviors ...has exhibited baseline behaviors with periodic outbursts ...Occasional incidents noted of propelling into resident's rooms near his own. [Resident 3] has made verbalizations of a sexual nature in the past, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE but nothing physical in nature." -Statement from CNA 2 "was instructed by [LN 2] to check on [Resident 3] every 10 minutes following the first incident that occurred earlier in the morning. Last time she saw [Resident 3] he was in his own room lying in bed. Performed rounds and when she returned [Resident 3] was not in his room and found him sitting on the edge of [Resident 2's] bed, naked wrapped in a blanket ...took him back to his room while nursing staff stayed with [Resident 2]. [Resident 2] stated [Resident 3] got in bed with her naked and touched her rubbing her body from the neck down." -Statement from LN 1, "[CNA 2] came to nurse's station... [Resident 3] had already been removed from the room and LN 2 stayed with [Resident 2] to calm her..." - Follow up Actions Taken included "1:1 with [Resident 3] all shifts and Facility staff inserviced [sic] on 1:1 supervision vs. monitoring residents." During a concurrent observation and interview on 7/25/18 at 8:50 a.m., Resident 3 was lying in bed, clothed. Resident 3 stated he could be better because he "was looking for his head" and he would "be better when Mike is here." Does not remember changing rooms yesterday and stated he does not have family that visits him. During an interview on 7/27/18 at 8:45, CNA 4 stated she was assigned to 1:1 observe Resident 3 since 6:30 this am. Stated resident reported to not sleep much and he "takes off his pajamas at night to be nude and pees on the floor." During a telephone interview on 7/27/18 at 4:40 p.m., CNA 3 confirmed the incident with Resident 1 and added there was urine on Resident 3's floor so she went to help CNA 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE clean up the floor. She stated she went back to the nurse's station to chart. At 3:45 a.m. she stated she covered CNA 2 for lunch on the hall where Resident 3 resided. CNA 3 stated, the "LN asked me to sit by his door ...didn't tell me he was a 1:1, we were short that night, I had 30 patients myself ...I couldn't have been a sitter for him." When asked if she had any training regarding being a "sitter" or watching someone who was a "1:1", CNA 3 stated "Not here, but at other places I worked I have ...If I am being a sitter, then I am in the room by the bed ...patient is always in my view." During a telephone interview on 8/1/18 at 5:05 p.m., CNA 1 stated she was caring for the residents across the hallway from Resident 1. When she was walking by, she saw Resident 3 lying on top of Resident 1 with his pants down, tried to get him off but he tried to hit her so she went to get help. CNA 1 further stated Resident 1 cannot talk so they do not know what Resident 3 did to her. CNA 1 additionally stated "Never a 1:1 issued" to her knowledge. On 8/2/18 at 2:25 p.m., during a telephone interview, CNA 2 stated she walked in and found Resident 3 sitting on Resident 2's bed wrapped in a blanket "butt naked." CNA 2 stated she stayed with "[Resident 3] 1:1 until 7:00 a.m." She stated prior to the incident with Resident 2, Resident 3 "was being checked on every 10 to 15 minutes." During a telephone interview on 8/3/18 at 11:29 a.m., LN 1 stated she helped CNA 1 remove Resident 3 from Resident 1's bed and return him to his room, and asked CNA 1 to stay with him. She stated later in the morning about 5:30 a.m., CNA 2 called for help, Resident 3 was naked on Resident 2's bed. Resident 2 was "upset, shaking and crying." LN 1 further stated Resident 3 "should have been a 1:1 because FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that is our policy, after the first incident." During an 8/3/18 at 2:05 p.m. telephone interview, LN 2 stated she helped CNA 1 and LN 1 remove Resident 3 from Resident 1's bed. She confirmed Resident 3 was at the foot of Resident 1's bed when she came in and that his pants were down, exposing his genitals and buttocks. LN 2 stated CNA 2 returned from her break and LN 2 instructed her to sit outside his door in case he came out. She added, to prevent Resident 3 from entering Resident 1's and Resident 2's room through the adjoining bathroom, a wheelchair with the brakes on, was placed to block the door. LN 2 related at 5:50 a.m., CNA 2 called for help because Resident 3 was naked on Resident 2's bed. LN 2 stated he pushed the wheelchair out of the way to enter the room. Review of the facility provided policy titled Abuse Prevention, Intervention, Investigation & Crime Reporting Policy, last revised November 2016, indicated "The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation...The facility is responsible for assuring resident safety by prohibiting verbal, mental, sexual, or physical abuse, ...Have evidence that all alleged violations are thoroughly investigated and prevent further potential abuse ...while the investigation is in progress ...The facility will monitor the adequacy of assessment, care planning and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse, neglect, exploitation and misappropriation and mistreatment such as: Physical aggression or self-injurious behaviors, Verbally abusive behavior towards others, Socially inappropriate or disruptive behaviors, Wandering into the rooms or personal spaces of others, Those requiring heavy nursing care and/or are fully dependent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on staff ....To protect residents and employees from harm or retaliation during an investigation, the facility shall: Take prompt measures to remove any resident from harm, ...Take reasonable measures to separate residents involved in Resident-to-Resident abuse or altercations..."

F607 SS=G Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 07/24/2019

F761 07/24/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by:

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2) §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to secure medications when 2 medication carts were left unlocked and unattended. This failure had the potential to allowed residents to have access to medications that could place their health at risk. Findings: The Department entered the facility on 8/3/18 at 5:25 a.m., no staff visible upon entry. On 8/3/18 at 5:30 a.m., the medication cart on the A Hall by the computer room was observed to be unlocked. The drawers were checked and the Department was able to open medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055922 (X3) DATE SURVEY COMPLETED 07/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD HEALTH CARE CENTER 1850 E. 8th Street Davis, CA 95616 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE drawers with both legend (prescription) and nonlegend (over the counter) drugs. The medication cart located further down the A Hall was also unlocked. The Department verified drawers were open for both legend and nonlegend drugs. No facility staff were observed in the hallway. At 5:35 a.m., the Department met Licensed Nurse (LN) 3 approximately 10 feet down the B Hall, perpendicular to A Hall. During an interview on 8/3/18 at 5:40 a.m., LN 4 stated she was the night shift charge nurse. When the Department notified LN 4 both medication carts were unlocked, she stated "they are new, let me go lock them." During an interview on 8/3/18 at 7:50 a.m., the Director of Nursing (DON) confirmed the medication carts should be locked when unattended. Review of the facility policy titled General Dose Preparation and Medication Administration, last revised 1/1/13 stipulated "Facility should ensure that medication carts are always locked when out of sight or unattended." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5G3Y11 Facility ID: CA030000043 If continuation sheet 12 of 12