Inspection·August 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide proper care for one of five sampled residents (Resident 1) when:1.Resident 1's assessments (including vital signs) were inaccurate; and,2.The Medication Administration Record (MAR) indicated no evidence that Resident 1's antibiotic was given timely as ordered.These failures resulted in an adverse outcome wherein Resident 1 was admitted to acute care for hospitalization for severe sepsis (a life-threatening condition due to an infection) with septic shock (severe form of infection, life threatening condition, occurs when the body's immune system overreacts to an infection, leading to a drop in blood pressure and organ failure.)Findings:During a review of Resident 1 admission record (AR - official documentation that records details of a person's entry to the facility)), indicated, Resident 1 was initially admitted to the facility 9/12/20, and was re-admitted [DATE] with new diagnosis including septic shock.During a review of Resident 1's Skin assessment dated [DATE], indicated, New skin issue: Left trans metatarsal [toes] - amputation site; .Diabetic foot ulcer - present on admission.During a review of Resident 1's Change of Condition Notes (CIC - detailed records within a resident's clinical chart that document specific changes in a patient's status, symptoms, document specific and significant changes in a resident's health status, symptoms, or functioning such as vital signs, skin integrity among others), indicated mismatch dates, shifts, and times as followed:On 8/13/25 Day shift - staff documented the date of 8/10/25, for respiration of 16 breath per minuteOn 8/13/25 Night shift - staff documented the date of 8/10/25 for respiration of 16 breath per minuteOn 8/14/25 Night shift - staff documented the time of 11:02 a.m., 8/14/25 for a temperature of 98.7 FahrenheitOn 8/14/25 Night shift staff documented the time of 11:02 a.m. 8/14/25 for pulse of 91 beats per minuteOn 8/14/25 Night shift staff documented the time of 11:02 a.m., 8/14/25 blood pressure of 126/74On 8/14/25 Night shift - staff documented the time of 11:02 a.m., 8/14/25 oxygen saturation of 93%On 8/14/25 Night shift - staff documented the date of 8/13/25 pain level of 0/10On 8/15/25 Day shift - staff documented the date of 8/13/25 temperature of 98.2 FahrenheitOn 8/15/25 Day shift - staff documented the date of 8/13/25 pulse of 82 beats per minuteOn 8/15/25 Day shift - staff documented the date of 8/10/25 pulse of 16 breath per minuteOn 8/15/25 Day shift - staff documented the date of 8/13/25 blood pressure of 138/82On 8/15/25 Day shift - staff documented the date of 8/13/25 Oxygen saturation 93%8/15/25 Day shift - staff documented the date of 8/13/25 pain level of 0/10It appeared the vital signs (VS) documented indicated numbers, dates and times copied from previous shifts. There was no evidence that respiratory rate was monitored during the night of 8/14/25.During a review of Resident 1's Medication Administration Record (MAR - a legal document used by healthcare professionals to track and record all the medications given to a patient) dated August 2025, indicated, Order [start] date 8/13/25 at 1814 [6:14 p.m.], Bactrim DS [antibiotic]. Oral tablet 800-160 mg [milligram, unit dose] Give 1 tablet by mouth two times a day for cellulitis [infection] for 14 days. The MAR indicated no evidence that it was given on 8/13/25.During a Residents Affected - Some (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 08/26/2025 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)