F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to develop and implement comprehensive person-centered
care plans to address a resident to resident altercation, for one of three sampled residents (Resident 3).
This failure had the potential to result in the resident not receiving the interventions necessary to maintain
their highest level of well-being.Findings:Review of Resident 3's clinical record indicated Resident 3 was
admitted to the facility on [DATE] with diagnoses including anoxic brain damage (brain damage caused by
lack of oxygen), alcohol dependence, anxiety disorder (a disorder that causes people to feel panicked for
long periods of time), and type II diabetes mellitus (a disorder that causes elevated blood sugar
levels).Review of Resident 3's minimum data set (MDS, a required assessment for all skilled nursing facility
residents to get reimbursed by Medicare) Section C-Cognitive Patterns indicated Resident 3 had a brief
interview for mental status (BIMS, a score to evaluate cognitive status of residents) score of four.Review of
Resident 3's chart indicated on 8/29/25, Resident 3 was seen in the hallway of the facility yelling and
grabbing another resident's arm. Resident 3 and the other resident were separated after the altercation. On
9/4/25, Resident 3 was discharged to another facility.During a concurrent interview and record review with
the director of nursing (DON) on 9/12/25 at 12:37 p.m., the DON said the interdisciplinary team, which
consists of herself and other department such as social services and rehabilitation, typically updates a
resident's care plan after any incident takes place. The DON also confirmed there was no care plan entry
for Resident 3.Review of facility policy titled Comprehensive Care Plans, revised 12/19/22, indicated .The
comprehensive care plan will describe at a minimum, the following.The services that are to be furnished to
attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of
facility policy titled Care Plan Revisions Upon Status Change, revised 12/19/22, indicated .The
comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status
change.The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and
collaborate on intervention options.The care plan will be updated with the new or modified interventions
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
09/12/2025
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)
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
Based on interview and record review, the facility failed to ensure care and services were provided in
accordance with professional standards of practice for one out of 3 sampled residents (Resident 1), when
there were multiple days for which there was no evidence of documentation of resident behavioral charting
after a staff-to-resident incident. This failure had the potential to compromise the resident's health, safety,
and overall well-beingFindings:Review of Resident 1's clinical record indicated Resident 1 was admitted to
the facility with diagnoses including cerebral infarction (also known as a stroke, an attack in the brain
caused by lack of blood flow), mood disorder, and major depressive disorder with psychotic symptoms (a
mental disorder that affects mood).Review of Resident 1's clinical record indicated on 8/29/25, Resident 1
had an altercation with a certified nurse assistant (CNA). Resident 1 had called his daughter after a CNA
had cared for him, and said the CNA had push him. Resident 1's daughter called adult protective services
(APS), and the police were called. Resident 1 told the police that he pushed the CNA first, and the CNA
pushed back.During a concurrent observation and interview with Resident 1 on 8/29/25 at 1:54 p.m.,
Resident 1 was seen in his room, lying in bed, with no visible injuries. Resident 1 said he grabbed the CNA
and the CNA pushed him off. Resident 1 also said he had yelled at the CNA.During a concurrent interview
and record review with the director of nursing (DON) on 9/12/25 at 12:33 p.m., the DON said the nursing
staff should be documenting on residents who have an incident with a staff member or other resident for 72
hours. The DON confirmed that there was only one documented entry for Resident 1 in the 72 hour period
after the incident on 8/29/25, on 8/31/25.Review of facility policy titled Abuse, Neglect and Exploitation,
revised 12/19/22, indicated .The facility will make efforts to ensure all residents are protected from physical
and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include
but are not limited to.Increased supervision of the alleged victim and residents.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555635
If continuation sheet
Page 2 of 2
