Health inspection·May 6, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the rights to be free from abuse for 1 of 4 sampled residents (Resident 1) when staff witnessed Resident 2 hitting Resident 1 ' s hand. This failure resulted in Resident 1 experiencing abuse including physical pain and emotional distress. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility in March 2016 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the right side. During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/5/25, the MDS indicated Resident 1 had no memory impairment. During a review of Resident 1 ' s SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) Form, dated 4/25/25, the SBAR indicated Resident 1 had been involved in a resident-to-resident altercation. The form indicated Resident 1 was crying and fearful. During a review of Resident 1 ' s progress note dated 4/25/25 and written by Licensed Nurse 1 (LN 1), the progress note indicated Resident 1 had been involved in an altercation with another resident and was in pain. During a review of Resident 2 ' s admission record, the admission record indicated Resident 2 was admitted to the facility in May 2021 with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 had severe memory impairment. During a review of Resident 2 ' s progress note, dated 4/25/25 and written by Social Services Assistant (SSA), the progress note indicated Resident 2 was in an altercation with another resident and struck the other resident 4 times in the face and the hand. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055922 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Health Care Center 1850 East 8th Street Davis, CA 95616 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)