Health inspection·July 31, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) discharged appropriately when:1. Final discharge instructions were not reviewed with the Durable Power of Attorney (DPOA-a legal document that gives one person the authority to make medical decisions for another person),2. Resident 1 was discharged without needed supplies (tube feeding formula and a glucometer),3. Discharge orders were to discharge home with home health; however, Resident 1 was discharged to a board and care, and4. No clinical evaluation was completed for Resident 1 to determine discharge needs and/or discharge potential.These failures placed Resident 1 at risk for potential harm due to inadequate discharge planning, lack of continuity of care and an increased risk of deterioration in the resident's health status resulting from absence of appropriate clinical oversight. Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain function disruption due to chemicals in the body), severe protein-calorie malnutrition, and cognitive communication deficit (difficulties in communication that arise from impairments in thinking, learning, and remembering). Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 10 out of 15 which indicated Resident 1 was moderately impaired in cognition. Resident 1 was discharged from the facility on 7/29/25 to a board and care, a non-medical residential setting that provides room, board, supervision and assistant with activities of daily living, not licensed to provide skilled nursing care.During a telephone interview on 7/30/25 at 2:08 p.m. with DPOA of Resident 1, the DPOA/RP ( also a Responsible Party) voiced that Resident 1 had been discharged unsafely from the facility. The DPOA/RP stated Resident 1 lacked capacity for healthcare decisions and the facility did not review discharge instructions with him, Resident 1's DPOA and RP, prior to Resident 1's discharge. The DPOA stated the facility had not provided needed tube feeding formula for Resident 1 at the time of discharge and expressed his concerns that Resident 1 could be re-hospitalized for high blood sugars because Resident 1 did not have access to a glucometer. During an interview on 7/31/25 at 2:36 p.m. with Assistant Director of Nursing (ADON) 1, ADON 1 stated she discharged Resident 1 from the facility to a board and care on 7/29/25. ADON 1 stated she was aware Resident 1 was not her own RP and it was expected to review discharge instructions with the RP. When ADON 1 was asked if it was appropriate to go over discharge instructions with a resident who lacked capacity, ADON 1 answered, No. ADON 1 further stated she reviewed Resident 1's Recapitulation of Stay (ROS) dated 7/29/25, with Resident 1 and acquired Resident 1's signature. ADON 1 further stated she discharged Resident 1 from the facility without tube feeding formula, although she was aware Resident 1 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube for supplemental feedings. ADON 1 further stated Resident 1 required blood sugar Page 1 of 3 055922 055922 07/31/2025 Courtyard Health Care Center 1850 East 8th Street Davis, CA 95616

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few checks and was discharged from the facility without a glucometer. ADON 1 stated when she spoke with the DPOA after she had discharged Resident 1, the DPOA was frustrated that she had not gone over discharge instructions with him prior to Resident 1's discharge.During a concurrent interview and record review on 7/31/25 at 4:46 p.m. with Director of Nursing (DON), Resident 1's Medical Record (MR) was reviewed. The DON confirmed Resident 1 had been discharged to a board and care on 7/29/25. The DON stated the MD (Physician) phone order, dated 7/25/25 and signed by Nurse Practitioner (NP) 1, indicated, May discharge home with home health RN (Registered Nurse)/PT(Physical Therapy)/OT(Occupational Therapy) and DME (Durable Medical Equipment-such as glucometer, wheelchairs, oxygen equipment, etc) if needed. The DON stated the order should have been updated to reflect discharge to a board and care. The DON further stated it was the expectation for the provider to assess the resident prior to discharge. The DON stated Resident 1's Medical Record (MR) contained three provider assessments titled, MD/NP/PA (Physician Assistant) dated 6/19/25, 7/17/25, and 7/22/25, and confirmed none of the assessments indicated Resident 1 was ready for discharge or addressed the resident's discharge potential. When the DON was asked to provide any clinician assessments or progress notes indicating Resident 1 was safe to discharge, the DON was not able to provide one. During a phone interview on 8/4/25 at 1:26 p.m. with NP 1, NP 1 verified she had given the phone order for Resident 1, dated 7/25/25, which indicated, May discharge home with home health RN/PT/OT and DME if needed. NP 1 explained that her discharge order for Resident 1 was May discharge to home . When questioned about the discrepancy between this order and the resident's actual discharge disposition to a boarding and care, the NP1 stated, Wherever she's living is considered home and indicated there was no discrepancy. Regarding NP's role in resident's discharge process, NP 1 stated, My only role is to give a discharge order. NP 1 stated the last time she assessed Resident 1 was on 7/17/25 and confirmed she did not speak with Resident 1's RP, stating, No. The patient [Resident 1] has capacity to make decisions. Review of Resident 1's MD orders, dated 6/12/25, the order indicated, MD determines that Resident does NOT have the Mental Capacity to make Healthcare decisions as per History & Physical or Transfer orders or preferred intensity of care. Review of Resident 1's MD/NP/PA Progress Note, dated 7/17/25 and signed by NP 1, indicated, Seen today at staff request for ongoing concern for weight loss despite being on tube feedings .Most Recent Weight 88.0 (pounds).Review of Resident 1's N Adv Skilled Evaluation ([NAME]), dated 7/28/25, the day prior to Resident 1's discharge, the SE indicated, Patient .does not like the food and will not eat the meals given to her. She will ask for .snacks that are elevating her Sugar levels . [Resident 1] still does not eat in moderation or to control her sugar levels. The [NAME] further indicated, Disorganized thinking: chronic .Will forget often like taking medications and what has been given to her already. Patient also forgets when she has been seen and may think that she has not been seen for hours although patient was just seen 10-15 minutes ago or less.Review of Resident 1's NN, dated 7/28/25, the day prior to Resident 1's discharge, the NN indicated, Ate less than 25% of 2 meals in a day.Review of Resident 1's MR, dated 7/29/25, the MR indicated, GLUCERNA [a specialized nutritional supplement for individuals with diabetes or blood sugar management needs] 1.5: Give 240 ml via G-tube (gastrostomy tube) after meals if PO (by mouth) intake less than 50%. Review of Resident 1's ROS, dated 7/29/25, the day of discharge, the ROS indicated, Most recent blood glucose (blood sugar) .324 Date 7/29/25 (the day of discharge) at 6:01 a.m. The ROS further indicated, Blood glucose range for past week: High 452 .Low 123. The ROS further indicated, Most Recent Weight .86.6 (lbs, pounds) .Resident has had weight loss. This indicated that the resident had 5.25% significant weight loss over a month period from 91.4 lbs upon admission on [DATE].Review of Resident 1's Nursing Note (NN), dated 7/29/25 and signed by ADON 1, the NN indicated, Medication and discharge 055922 Page 2 of 3 055922 07/31/2025 Courtyard Health Care Center 1850 East 8th Street Davis, CA 95616

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few instructions provided to the patient .All discharge paperwork signed by patient and provided a copy of the paperwork.Review of the facility's policy and procedure (P&P) titled, Admission, Transfer, Discharge and Bed-Holds, dated December 2016, indicated, The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: The transfer or discharge is appropriate because the resident's health has improved sufficiently. The P&P further indicated, The facility will provide sufficient preparation .in order to ensure a safe and orderly discharge from the facility.Review of the facility's P&P titled, Discharge Planning Process, dated 2025, indicated, The discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan. 055922 Page 3 of 3