Courtyard Health Care Center

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Based on observation, interview, and record review, the facility failed to follow a therapeutic diet plan to one of three sampled residents (Resident 2), when Resident 2 was served a hard to chew chicken burger at lunch. This failure had the potential to negatively impact Resident 2's nutritional status.Findings: A review of

an admission record indicated Resident 2 was admitted to the facility in October 2024 with diagnoses including moderate protein-calorie malnutrition (a condition that occurs when a person does not consume enough protein to meet their body's needs), dysphagia (a medical condition characterized by difficulty swallowing), and adult failure to thrive (a condition characterized by a significant decline in weight, muscle mass, and overall health in adults). A review of Resident 2's Minimum Data Set (MDS; an assessment tool), dated 7/23/25, indicated Brief Interview of Mental Status score was 15 out of 15 with intact cognition.

During an observation on 9/29/25 at 1:20 pm for the B-unit lunch tray pass, Resident 2's tray contained a burger bun with a large, breaded piece of chicken, tomato slice, lettuce, macaroni salad, juice, and pudding.

During an interview on 9/29/25 at 1:30 pm with Resident 2, Resident 2 stated she did not eat her lunch because she could not chew it and her upper teeth were broken, which made it hard to eat the chicken burger. Resident 2 further stated the chicken meat was not tender enough to bite for her, and the meat was hard and chewy. A review of Resident 2's therapeutic diet plan, dated 9/3/25, indicated Resident 2 was to be served a regular diet easy to chew level 7 texture. A review of Resident 2's care plan, dated 9/23/25, indicated Resident 2 had a swallowing problem and a potential nutritional risk related to underweight, protein calorie malnutrition, dysphagia, and adult failure to thrive. During an interview on 9/29/25 at 3:58 pm with the Dietary Manager (DM), DM stated if a therapeutic diet plan was not followed correctly, then there could have been a chance that Resident 2 would have not eaten enough, and not eating enough could have caused a lack of proper nutrition. DM further stated if resident 2 was not able to chew the food properly, then it could have been a possible risk of choking. A review of the facility's policy and procedure (P&P) titled, Level 7 Regular Easy to Chew for Adults, dated 1/2019, indicated, Do not use foods that are: hard, tough, chewy, fibrous, have stringy textures, pips/seeds, bones or gristle. P&P further indicated, Meat cooked until tender, if you cannot serve soft and tender, serve meat Minced and Moist.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Courtyard Health Care Center

1850 East 8th Street Davis, CA 95616

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, interview, and record review, the facility failed to store clean dishes in a sanitary manner for a census of 109 residents, when: 1. A dirty dish with half-eaten food on it was found on the shelves of clean dishes; and 2. A hot water jug stored in the clean dish area was found with dark brown residue on it. These failures decreased the facility's potential to prevent foodborne illness among vulnerable residents.Findings:1. During a concurrent observation and interview on 9/29/25 at 10:32 a.m. with the Dietary Manager (DM) in the facility's kitchen, a half-eaten food item in a dirty cup was observed on a clean dish storage shelf. The cup was placed next to clean dishes used by residents. DM confirmed the dirty cup with half-eaten food was not supposed to be left in the clean dish storage area. DM further stated cross contamination could have been an issue as well as pest control. 2. A review of an admission record indicated Resident 1 was admitted to the facility in June 2023. A review of Resident 1's Minimum Data Set (MDS; an assessment tool), dated 2/26/25, indicated Brief Interview of Mental Status score was 15 out of 15 with intact cognition. During an interview on 9/29/25 at 11:30 am with Resident 1, Resident 1 stated her fork for breakfast had a dried crusty residue on it. During a concurrent observation and interview on 9/29/25 at 10:35 a.m. with DM in the facility's kitchen, a hot water jug stored with clean dishes was observed with dark brown residue in its crevices. DM confirmed the jug should not have been stored with the clean dishes and stated he did not know what the dark brown residue was, and crevices such as where the dark brown residue was seen, could have had the potential to harbor bacteria. A review of the facility's undated policy and procedure titled, Dishwashing, indicated, All dishes will be properly sanitized through the dishwasher.

Gross food particles shall be removed by careful scraping and pre-rinsing in running water. Flatware is to be pre-soaked in a solution of water and detergent per manufacturer's instructions . Pay close attention to prevent cross-contamination of workers going from handling dirty dishes and then clean . Wash hands and change gloves whenever cross-contamination occurs. A review of the facility's undated Inservice titled, Cleaning and Sanitizing Dishes, Utensils, Pots and Pans, indicated, Cleaning and sanitizing food handling equipment, utensils, food contact surfaces, and food storage areas are vital in keeping food wholesome and safe to consume. The Inservice further indicated, Cleaning is the removal of soils, tarnishes, or stains from countertops, equipment, pots, pans, or dishes . Sanitizing is the process of reducing the number of microorganisms on a surface to safe levels so that they cannot cause disease or food spoilage . Everything

in your operation must be kept clean; however, any surface that comes in contact with food must also be cleaned and sanitized.

Event ID:

Facility ID:

If continuation sheet