Other·August 14, 2019

F000 INITIAL COMMENTS

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 incident #CA00624919. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 38669 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F566 SS=D Right to Perform Facility Services or Refuse CFR(s): 483.10(f)(9)(i)-(iv)

F566 §483.10(f)(9) The resident has a right to choose or refuse to perform services for the facility and the facility must not require a resident to perform services for the facility. The resident may perform services for the facility, if he or she chooses, when(i) The facility has documented the resident's need or desire for work in the plan of care; (ii) The plan specifies the nature of the services performed and whether the services are voluntary or paid; (iii) Compensation for paid services is at or above prevailing rates; and (iv) The resident agrees to the work arrangement described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on interviews and review of facility documents and records, the facility failed to allow 1 of 3 sampled residents (Resident 1) to 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: 5M7O11 Facility ID: CA030000043 If continuation sheet 1 of 8 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 08/08/2019 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 refuse to perform services for the facility at his/her discretion when staff insisted Resident 1 sew the staff member's personal items brought in from home. This failure denied Resident 1 the right to decline to participate in an activity. Findings: Resident 1 was admitted to the facility mid 2017 with diagnoses including anxiety disorder and major depressive disorder. Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/30/19, indicated, Resident 1 had a BIMS score of 15 meaning Resident 1 had no cognitive impairment. During an interview with Resident 1 on 2/27/19 at 1:30 p.m., Resident 1 recalled that on 2/18/19 at approximately 3 p.m., the Activities Assistant (AA) had given her a bag of clothes from home to mend and was asking when they'd be ready. Resident 1 told the AA she would do it later. The AA poked Resident 1 in the chest with her finger and repeatedly kissed Resident 1 about the neck causing Resident 1 to cry. The Certified Nurse Assistant (CNA) attempted to help Resident 1 and got into a verbal altercation with the AA. Resident 1 stated, "I really don't like all the kissing on my neck. This isn't the first time. I tried to get away from her but she wouldn't let me pass. It made me uncomfortable. She was so aggressive." Review of a facility document titled 'Interview/Investigative Record' indicated the AA was interviewed on 2/18/19 and provided a statement, "[Resident 1] was in the hallway and we were having a conversation about one of the activities projects. She has sewing projects that she is working on...This is between [Resident 1] and me only." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M7O11 Facility ID: CA030000043 If continuation sheet 2 of 8 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 08/08/2019 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 February 2019 facility 'Activities Calendar' indicated no sewing or mending activities scheduled for the month. During an interview with the Activities Manager (AM) on 2/27/19 at 2:41 p.m., the AM confirmed the AA works under her direction and stated she had asked the AA many times in the past to be less pushy. The AM confirmed sewing was not on the facility calendar of activities and stated, "The activities we provide for the residents come from our calendar. It is not acceptable to bring clothes from home to have a private activity with the resident." All Care Plans for Resident 1 were reviewed. There was no evidence of a Care Plan describing Resident 1's need or desire to work for the facility. During an interview with the Director of Nursing (DON) on 2/27/19 at 3:43 p.m., the DON confirmed there was no Care Plan specific for sewing staff clothing and stated, "It is not acceptable for staff to bring anything into the facility to ask residents to do as a favor." Review of a 2015 facility policy titled 'Residents' Rights to Refuse Activities' indicated, "Advocate the implementation of all of the residents' rights, including the right to refuse activities...Acknowledge and respect a Resident's right to...participate in activities...No resident shall be forced to participate in activities."

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

F600 §483.12 Freedom from Abuse, Neglect, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M7O11 Facility ID: CA030000043 If continuation sheet 3 of 8 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 08/08/2019 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 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: Based on interviews and record review, the facility failed to provide a safe environment and ensure 1 of 3 sampled residents (Resident 1) was free from physical and mental abuse when staff poked her in the chest and repeatedly kissed her, making Resident 1 feel uncomfortable. This failure caused Resident 1 to become emotionally upset, exhibited by crying, and resulted in Resident 1 being medicated with an anti-anxiety medication in order to calm down. Findings: Resident 1 was admitted to the facility mid 2017 with diagnoses including anxiety disorder and major depressive disorder. Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/30/19, indicated, Resident 1 had a BIMS score of 15 meaning Resident 1 had no memory problems. Review of the clinical chart for Resident 1 indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M7O11 Facility ID: CA030000043 If continuation sheet 4 of 8 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 08/08/2019 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 -An assessment tool for Resident 1, dated 1/30/19, noted Resident 1 had no cognitive deficits; -A Nurses Note, written immediately following the incident on 2/18/19, noted Resident 1 "was crying, visibly upset, and distraught" and requested both medication and to see her psychiatrist to calm down; and -A Nurses Note written the next day on 2/19/19 noted Resident 1 felt like she "was falling back into her depression." The facility called the Department to report an incident regarding an 'Employee to Resident Abuse' complaint on 2/19/19. During an interview with Resident 1 on 2/27/19 at 1:30 p.m., Resident 1 recalled that on 2/18/19 at approximately 3 p.m., the Activities Assistant (AA) had given her a bag of clothes from her (AA's) home to mend and was asking when they'd be ready. Resident 1 told the AA she would do it later. The AA poked Resident 1 in the chest with her finger and repeatedly kissed Resident 1 about the neck causing Resident 1 to cry. The Certified Nurse Assistant (CNA) attempted to help Resident 1 and got into a verbal altercation with the AA. Resident 1 stated, "I really don't like all the kissing on my neck. This isn't the first time. I tried to get away from her but she wouldn't let me pass. It made me uncomfortable. She was so aggressive." During an interview with the Licensed Nurse (LN 1) on 2/27/19 at 2:06 p.m., the LN 1 stated, she heard yelling in the hall between the AA and the CNA. The CNA informed the LN 1 that Resident 1 was crying and upset. The LN 1 got an order from the Nurse Practitioner for Diazepam (a medication to calm anxiety). The LN 1 stated, "It was a one time dose because [Resident 1] was really upset." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M7O11 Facility ID: CA030000043 If continuation sheet 5 of 8 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 08/08/2019 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 During an interview with the LN 2 on 2/27/19 at 2:18 p.m., the LN 2 confirmed she witnessed the exchange between the AA and the CNA which occurred on 2/18/19 around 3 p.m. The LN 2 stated, she heard the CNA arguing with the AA to allow Resident 1 to go to her room because she was in tears. The LN 2 stated, "It got loud...[AA's] personality was in your face and overwhelming." During an interview with the CNA on 2/27/19 at 2:30 p.m., the CNA recalled, coming down the hall and seeing Resident 1 upset and the AA crouching over Resident 1 talking about mending some clothing. The CNA intervened and told the AA Resident 1 "was upset and needed her space." Review of a facility document titled 'Interview/Investigative Record' indicated the AA was interviewed on 2/18/19 and provided a statement, "[Resident 1] was in the hallway and we were having a conversation about one of the activities projects. She has sewing projects that she is working on...This is between [Resident 1] and me only." An undated facility document titled 'Injury of Unknown Source Investigation' indicated, "Type of Injury-Other injury: Mental abuse" and Resident 1 "was being harassed by activities staff [AA] asking if she had mended her clothes and smothering patient with hugs and kisses to the face--[Resident 1] felt uncomfortable. Contributing Risk Factor: lack of boundaries on staff." Review of the February 2019 facility 'Activities Calendar' indicated no sewing or mending activities scheduled for the month. During an interview with the Activities Manager (AM) on 2/27/19 at 2:41 p.m., the AM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M7O11 Facility ID: CA030000043 If continuation sheet 6 of 8 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 08/08/2019 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 confirmed the AA works under her direction and stated she had asked the AA many times to be less pushy in the past. The AM confirmed sewing was not on the facility calendar of activities and stated, "The activities we provide for the residents come from our calendar. It is not acceptable to bring clothes from home to have a private activity with the resident." During an interview with the Social Services Director on 2/27/19 at 3:33p.m., the SSD stated, "[The AA] was talked to before about being too touchy. We had to give her a verbal warning to back off." During an interview with the Director of Nursing (DON) on 2/27/19 at 3:43 p.m., the DON confirmed there had been a prior incident involving [AA] and another Resident. Since that time, she was no longer allowed to work with Residents directly and was to be supervised by another staff member when she had any contact with Residents. The DON stated, "There was no physical injury to [Resident 1]; mental, yes." Review of a 2015 facility policy titled 'Residents' Rights to Refuse Activities' indicated, "Advocate the implementation of all of the residents' rights, including the right to refuse activities...Acknowledge and respect a Resident's right to...participate in activities...no resident shall be forced to participate in activities." Review of a facility policy titled 'Abuse Prevention, Intervention, Investigation & Crime Reporting Policy' and revised August 2016 indicated, "Every resident has the right to be free from...mental abuse...Any form of mistreatment of residents...is strictly prohibited." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5M7O11 Facility ID: CA030000043 If continuation sheet 7 of 8 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 08/08/2019 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 5M7O11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000043 (X5) COMPLETE DATE If continuation sheet 8 of 8