Inspection·July 31, 2025

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055922 If continuation sheet Page 2 of 3 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 07/31/2025 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)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 055922 If continuation sheet Page 3 of 3