Health inspection·January 30, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident 1, who was unable to carry out activities of daily living received care services to maintain good personal hygiene for one of three sampled residents (Resident 1) who was left with wet diaper for more than five hours. Residents Affected - Few This failure resulted in Resident 1 feeling frustrated and embarrassed, due to lack of or delay in receiving sufficient services to maintain personal care and incontinent care and had the potential to lead to skin breakdown for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1was admitted to the facility on [DATE] with diagnoses including, bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)chronic obstructive pulmonary disease (COPD-is a chronic lung disease that causes breathing difficulties.), bilateral hip osteoarthritis (wear down the cartilage in the hip joint). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/01/2024, the MDS indicated Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment. During a concurrent observation and interview on 1/29/2025 at 12:02 pm, with Resident 1, observed Residents 1 lying in bed with wet incontinent brief (diaper). Resident stated she was waiting for Certified Nursing Assistant (CNA) 1 to change her diaper. During a concurrent observation and interview on 1/29/2025 at 12:05 pm, observed CNA 1 enter Resident 1 ' s room to answer the call light. CNA 1 stated she was assigned to Resident 1.CNA 1 stated she asks Resident 1 on 1/29/2025 at 9:30 am, if she want to have her diaper change, but Resident1 refused and ask CNA 1 to come back later. CNA 1 stated it takes her 30 minutes per resident to clean up one resident, and by the time she finished with other residents, it was time for her lunch time. CNA 1 stated she went for lunch before checking on Resident 1 again. CNA 1 stated upon her return from lunch she saw Resident 1 ' s call light was on. CNA 1 stated she did not come to Resident 1 ' s room after lunch as the surveyor was in the room. During a concurrent observation and interview on 1/29/25 at 12:22 pm, with CNA 1, observed Resident 1 diaper to be soaked (extremely wet). CNA 1 stated this will have the potential to cause skin break down and Resident 1 will be uncomfortable to sit on a wet diaper. CNA 1 stated she should have informed the charge nurse of Resident 1 ' s refusal to be changed and hand off to another staff prior (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 5 Event ID: 555785 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 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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)