MEDFORD, MA - Federal inspectors cited Courtyard Nursing Care Center for multiple violations during a March 2025 inspection, including the improper use of physical restraints on residents with cognitive impairments.
Improper Physical Restraint Use Documented
Inspectors observed staff using pillows and bed positioning as unauthorized physical restraints on a resident with Alzheimer's disease. The violations occurred despite facility policies requiring physician orders and proper assessments before implementing any restraint measures.
Federal surveyors documented that Resident #130, who had been at the facility since December 2020 with severe cognitive impairment, was subjected to restraint practices that violated federal regulations. Staff placed pillows under the bed's fitted sheet and positioned the bed close to the wall to prevent the resident from moving freely.
During interviews, nursing staff revealed the unauthorized nature of these interventions. "Resident #130 wiggles around in bed a lot and the nursing assistants put the pillow on the edge of the bed to prevent the Resident from rolling around and rolling out of bed," stated Nurse #1 during the inspection.
The facility's own restraint policy clearly defines physical restraints as "any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts the freedom of movement." The policy mandates that restraints require written physician orders and proper consent procedures.
Assessment and Documentation Failures
Beyond restraint violations, inspectors identified significant failures in resident assessments and care documentation. The facility incorrectly coded Minimum Data Set (MDS) assessments for multiple residents, failing to document critical health conditions and safety incidents.
Assessment inaccuracies included: - Failure to document bilateral extremity contractures in a long-term resident - Omission of a documented fall from quarterly assessment reports - Inadequate tracking of required daily medical monitoring
The Director of Rehabilitation confirmed that one resident had bilateral upper and lower extremity contractures for over a year, yet these conditions were not reflected in official assessments. Such omissions can impact care planning and federal reimbursement calculations.
Care Standard Violations
Inspectors documented multiple instances where the facility failed to meet accepted clinical practice standards. These violations affected residents requiring specialized medical monitoring and therapeutic equipment.
For residents with congestive heart failure, federal regulations require strict adherence to physician orders for daily weight monitoring. Inspectors found that Resident #143, who had a physician's order for daily weights due to heart failure, was not weighed on multiple days despite the medical necessity of this monitoring.
Weight fluctuations in heart failure patients can indicate fluid retention and worsening cardiac function. The facility's medication records showed the resident either refused weighing or was sleeping during scheduled times, but nursing staff failed to notify the attending physician as required by medical protocols.
Therapeutic Equipment Without Proper Authorization
The inspection revealed that specialized medical equipment was being used without appropriate physician oversight. Resident #117, who had a stage 3 pressure ulcer and mobility limitations, was found on an air mattress without any corresponding physician's order in the medical record.
Air mattresses serve as pressure redistribution devices for residents at risk of developing or worsening pressure ulcers. These therapeutic devices require physician orders to ensure appropriate settings based on the resident's weight, mobility status, and medical condition.
Both the Unit Manager and Director of Nursing confirmed during interviews that residents using air mattresses should have physician orders to monitor appropriate settings and ensure proper medical supervision.
Activities of Daily Living Support Failures
Perhaps most concerning was the facility's failure to address a resident's significant decline in self-feeding abilities following hospitalization. Resident #138, who could feed independently with setup assistance before a hospital stay, returned completely dependent on staff for feeding.
The resident's healthcare proxy reported having to advocate for any rehabilitation services. "The facility did not want to provide any therapy services and she had to fight for physical therapy, but they never addressed his/her ability to self-feed," the proxy told inspectors.
Medical records confirmed the resident's functional decline from self-feeding to total dependence occurred after hospitalization for a serious intestinal infection. Despite this documented change, the facility failed to provide occupational therapy evaluation or intervention to restore feeding abilities.
Federal regulations require nursing homes to help residents maintain their highest level of functioning. When residents experience functional declines, facilities must assess the causes and provide appropriate rehabilitation services unless medically contraindicated.
Regulatory Framework and Standards
The violations identified at Courtyard Nursing Care Center represent failures across multiple federal quality standards. Physical restraint regulations protect residents' rights to freedom of movement and dignity. Accurate assessments ensure appropriate care planning and resource allocation.
Clinical care standards require nursing homes to follow physician orders consistently and obtain proper authorization for therapeutic interventions. When residents experience functional declines, federal regulations mandate prompt assessment and appropriate therapeutic intervention.
The Centers for Medicare & Medicaid Services classifies these violations as causing "minimal harm or potential for actual harm" with "few" residents affected. However, the cumulative impact of these systemic failures raises concerns about the facility's overall compliance with federal quality standards.
These violations highlight the importance of proper staff training on restraint alternatives, accurate documentation practices, and proactive rehabilitation services. Federal oversight ensures nursing homes maintain standards that protect resident safety, dignity, and quality of life.
The facility has been required to submit corrective action plans addressing each identified violation to prevent recurrence and ensure resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Courtyard Nursing Care Center from 2025-03-11 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.