Health 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 Page 1 of 2 055922 055922 08/26/2025 Courtyard Health Care Center 1850 East 8th Street Davis, CA 95616

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review of Resident 1's progress notes dated 8/14/25 at 19:21 (7:21 p.m.), indicated, .low grade fever at 99.7. elevated pulse at 108, and low oxygen level 92% on 3L [liters, unit of measurement] of Oxygen [normal oxygen saturation at room air, 95% to 100%]. MD [physician] ordered to recheck pulse and temperature and to notify oncall doctor if symptoms worsen. 30mins after initial exam, this nurse went back to reassess resident and noted that resident pulse lowered to 75bpm [beats per minute] while resting, ordered updated.During a review of Resident 1's progress notes dated 8/15/25 at 07:00 (7 a.m.), indicated, .The resident's wound is now weeping. The resident is tachypneic [rapid breathing] and tachycardic [fast heart rate]. Oxygen saturation is below baseline; resident on 3L [liter, unit measurement] 02 [oxygen] via NC [nasal cannula, tubing to the nose that supplies oxygen]. The resident will be sent out via AMR [ambulance] .During a review of Resident 1's SBAR (report to provider) dated 8/15/25 at 0800 (8 a.m.), indicated, .Nursing observations, evaluation, and recommendations are: Resident was observed to be short of breath using his accessory muscles to breath and even to answer short quick questions. Resident was diaphoretic [sweating] and tachycardia [fast heart rate] with a heart rate fluctuating between 115-120. Resident was observed to be on 3 liters via nc sating at 91 %. Resident had a bp [blood pressure] of 100/54, 97.9 temp [temperature] and a heart rate of 115-120. Residents lie [left lower extremity] appeared to be swollen and red and was warm to touch. Primary Care Provider Feedback. transfer out.During a review of Resident 1's progress notes dated 8/15/25 at 08:51 (8:51 a.m.), indicated, .Open area was weeping and appeared to have a yellow drainage. Resident also had a thin yellow discharge that had accumulated in the corners of his eyes with some dry mucus. Resident was irritable and even became emotional when asked how he felt stating something is wrong with me. AMR was called and given report. Resident was transferred to Sutter [NAME] [hospital].During a review of Resident 1's hospital admission record titled Inter-Facility Transfer Report, dated 8/15/25, indicated, Resident 1 was admitted with .Severe sepsis with septic shock.During an interview on 8/26/25 at 12:27 p.m., with Licensed Nurse (LN) 1, LN1 stated, vital signs are taken every shift and documented in the CIC notes. LN 1 further stated, the licensed nurse will assess the resident every shift and if antibiotics are ordered, it must be initiated within 4 hours.During an interview on 8/26/25 at 1:03 p.m., with LN 2 at the Nurses' station, LN2 stated, vital signs should be taken every shift when there is a CIC, the resident is on antibiotics, and if there is a wound infection. LN 2 further stated, antibiotics must be started as soon as they are approved by Pharmacy and should be available from their E-kit. LN 2 also stated, if not available, the pharmacy delivers late at night.During an interview on 8/26/25 at 1:49 p.m. with the Director of Nursing (DON), DON stated his expectations were to have all the orders carried out by the Licensed Nurses. DON further stated, when there is a CIC, his expectations were (accurate) vital signs must be taken and documented every shift, and antibiotics must be initiated and given as soon as possible.On 8/29/25 at 9:15 a.m., the Director of Nursing (DON) was contacted via text message asking for the contact information of LN 3, LN 4, LN 5, and LN 6 to verify the VS and the MAR information. DON did not provide contact numbers for LN 3, LN 4 and LN 6, and there were no return calls received from the LNs throughout the day.During a review of the facility's policy and procedure titled, Change in Condition, revised 8/2025, indicated. It is the policy of this facility to ensure each resident receives quality of care.licensed nurse should be.following. change in vital signs, to include temperature, pulse, blood pressure. resident will be placed on.Nursing will provide no less than 3 days of observation, documentation and response to interventions. A review of the facility's policy and procedure titled, Medication Administration, undated, indicated, Medications are administered by licensed nurses.as ordered by the physician an in accordance with professional standards. obtain and record vital signs. 055922 Page 2 of 2