Health inspection·April 4, 2024

F 0583 Keep residents' personal and medical records private and confidential. 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 ensure a resident's private medical information was protected against unauthorized disclosure for 1 of 3 residents, when Resident 1 was furnished with medications labeled with medical information relevant to Resident 2 and Resident 3 upon discharge from the facility. This failure resulted in Resident 2 and Resident 3's private information being disclosed to another resident without their permission. Residents Affected - Few Review of Resident 1's clinical record indicated she was admitted on [DATE]. Resident 1had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates cognitively intact). Review of Resident 1's social service progress note dated 12/19/23, indicated Resident 1 was accepted at another skilled nursing facility (SNF) and would discharge on [DATE]. Review of social service progress notes dated, 1/7/24, indicated Resident 1's friend (R1F) came to the facility to return medications given to Resident 1 upon her discharge that did not belong to Resident 1. Per R1F, the medications were not labeled with Resident 1's name and belonged to two residents currently residing at the facility from where Resident 1 had been discharged on 12/20/23. During interview on 1/10/24 at 4:15 p.m. with R1F, she stated she accompanied Resident 1 to her home upon discharge from the second SNF. R1F stated Resident 1 noticed, among Resident 1's medication cards, there were 2 medication cards, not labeled with Resident 1's name. R1F stated Resident 1 took pictures of the medication cards and asked R1F if she would return the medications to the facility. During a concurrent record review with R1F, she referred to photos taken by Resident 1, on 1/7/24, which contained pictures of the medications and medication cards of Resident 2 and Resident 3 that Resident 1 had in her possession. Resident 2's medication card contained 42 yellow round pills, and the label of which indicated: [Resident 2's name] . 12/11/23 [facility name SNF], CARBIDOPA-LEVO 25-100MG . GIVE 2 TABLETS BY MOUTH THREE TIMES A DAY FOR PARKINSONS DISEASE. Resident 3's medication card contained 21 white oval pills, and the label of which indicated: [Resident 3's name] . 12/11/23 [facility name SNF], METOPROLOL SUCC ER 25MG . GIVE 1 TABLET BY MOUTH ONE TIME A DAY RELATED TO ESSENTIAL HYPERTENSION . During an interview on 1/11/24 at 10:30 a.m. with the director of nursing (DON), she stated that medications belonging to Resident 2 and Resident 3 were given to resident 1 upon her discharged on 12/20/23. The DON confirmed that Resident 2 and Resident 3 were current residents at the facility. The DON stated the facility did not have authorization to disclose Resident 2 and Resident 3's personal health information to Resident 1. The DON further stated Resident 2 and 3's right to have their (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: 555635 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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)