Courtyard Health Care: Sepsis Death Delay - CA
The resident showed clear warning signs on the evening of August 14. His temperature climbed to 99.7 degrees, his pulse jumped to 108 beats per minute, and his oxygen levels dropped to 92 percent while receiving three liters of supplemental oxygen through nasal tubing. Normal oxygen saturation ranges from 95 to 100 percent.
A physician ordered staff to recheck the resident's pulse and temperature and notify the on-call doctor if symptoms worsened. Thirty minutes later, a nurse returned and found the pulse had dropped to 75 beats per minute while the resident was resting.
But the situation deteriorated rapidly overnight.
By 7 a.m. the next morning, nursing notes described a resident in distress. His wound was weeping, he was breathing rapidly with an elevated heart rate, and his oxygen saturation had fallen below his baseline despite continued oxygen support.
An hour later, nurses documented even more alarming symptoms in their report to the physician. The resident was short of breath and using accessory muscles to breathe, even when answering brief questions. He was sweating and his heart rate fluctuated between 115 and 120 beats per minute. His blood pressure had dropped to 100/54, his temperature was 97.9 degrees, and his oxygen saturation was 91 percent despite three liters of supplemental oxygen.
His left leg appeared swollen, red, and warm to the touch.
At 8:51 a.m., nurses noted that an open area on the resident was weeping with yellow drainage. He also had thin yellow discharge in the corners of his eyes with dried mucus. The resident had become irritable and emotional, telling staff "something is wrong with me."
An ambulance was called. The resident was transferred to Sutter hospital, where he was diagnosed with severe sepsis and septic shock.
Federal inspectors interviewed multiple licensed nurses about the facility's monitoring protocols. Licensed Nurse 1 told inspectors that vital signs should be taken every shift and documented, and that antibiotics must be started within four hours when ordered.
Licensed Nurse 2 confirmed that vital signs should be taken every shift when there is a change in condition, when the resident is on antibiotics, and if there is a wound infection. She said antibiotics must be started as soon as they are approved by pharmacy and should be available from the facility's emergency medication kit. If not available, she said, the pharmacy delivers late at night.
The Director of Nursing told inspectors his expectations were clear: all physician orders must be carried out by licensed nurses. When there is a change in condition, he said, accurate vital signs must be taken and documented every shift, and antibiotics must be initiated and given as soon as possible.
But when inspectors tried to verify information about vital signs monitoring and medication administration records, the Director of Nursing failed to provide contact information for several nurses. No return calls were received from those staff members throughout the day.
The facility's own policies supported the Director of Nursing's stated expectations. The Change in Condition policy, revised in August 2025, required licensed nurses to monitor changes in vital signs including temperature, pulse, and blood pressure. It mandated at least three days of observation, documentation, and response to interventions.
The Medication Administration policy stated that medications must be administered by licensed nurses as ordered by physicians and in accordance with professional standards, including obtaining and recording vital signs.
The inspection found that some residents were affected by the facility's failure to ensure adequate monitoring and treatment protocols were followed during changes in condition.
The resident's rapid decline from a low-grade fever to life-threatening septic shock illustrated the critical importance of consistent monitoring and prompt response to clinical changes. Sepsis can progress quickly in elderly residents, making early detection and treatment essential for preventing serious complications or death.
Federal inspectors cited the facility for failing to ensure residents received necessary care and services to maintain their highest level of well-being, finding minimal harm or potential for actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Courtyard Health Care Center from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COURTYARD HEALTH CARE CENTER in DAVIS, CA was cited for immediate jeopardy violations during a health inspection on August 26, 2025.
The resident showed clear warning signs on the evening of August 14.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.