Health inspection·February 19, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify two of three sampled resident ' s (Resident ' s 1 and 2) primary care doctors (MD ' s 1 and 2) when Resident ' s 1 and 2 refused to wear their Bilevel positive airway pressure ([BiPAP] a machine that delivers air to help a person breathe) mask (a special mask that that fits over the nose and mouth which is connected to the BiPAP machine) as ordered. This deficient practice had the potential for Residents ' 1 and 2 to have difficulty breathing, low blood oxygen levels and poor sleep quality. Findings: a. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 1/10/2025, the MDS indicated Resident 1 ' s cognition was intact and was dependent on facility staff to complete activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1 ' s Physician Orders dated 1/6/2025, the Physician Orders indicated MD 1 ordered Resident 1 was to wear the BiPAP at bedtime every night for obstructive sleep apnea, ordered on 1/6/2025. During a review of Resident 1 ' s Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/2025, the MAR indicated Resident 1 refused to wear the BiPAP on 1/7/2025, 1/14/2025, 1/15/2025, and on 1/16/2025. b. During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognition was moderately impaired and required substantial/maximal assistance (helper does more than half the effort) from staff to complete ADLs. During a review of Resident 2 ' s Physician Order dated 2/11/2025, the Physician Order indicated Page 1 of 2 555785 555785 02/19/2025 Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806

F 0580 Level of Harm - Minimal harm or potential for actual harm Resident 2 was to wear the BiPAP machine at bedtime, to monitor hours of use, and adjust straps to resident ' s comfort every evening and night shift. During a review of Resident 2 ' s MAR dated 2/2025, the MAR indicated Resident 2 did not wear the BiPAP mask on 2/11/2025, and from 2/13/2025 through 2/18/2025. Residents Affected - Some During a review of Resident 2 ' s Nursing Progress Note dated 2/11/2025, the note indicated Resident 2 refused to wear the BiPAP mask and stated that it was not the same as the one at home. The note indicated the facility documented they explained the risk and benefits to Resident 2 and respected Resident 2 ' s wishes. During a review of Resident 2 ' s Nursing Progress Note dated 2/13/2025, the note indicated Resident 2 refused to wear the BiPAP mask and stated she was not able to breath with the mask. During an interview on 2/19/2025 at 12:16 p.m., Resident 2 stated she has not used the BiPAP mask and machine since she was admitted to the facility on [DATE]. Resident 2 stated the BiPAP mask does not fit like the one she uses at home because the air was shooting out of the mask and into her eyes. Resident 2 stated the facility staff have struggled to get the mask to fit. During an interview on 2/19/2025 at 1:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 would not wear the BiPAP mask consistently. LVN 1 stated some days Resident 1 would refuse and some days he would wear the BiPAP mask. LVN 1 stated on 1/7/2025, Resident 1 refused to wear the BiPAP mask and there was no documentation indicating the licensed nurses notified Resident 1 ' s MD 1 of the refusal. LVN 1 stated Resident 1 refused to wear the mask on 1/14/2025 through 1/16/2025 (three days), and there was no documentation indicating Resident 1 ' s MD 1 was notified or the reason why Resident 1 was refusing to wear the mask. LVN 1 stated if a resident refuses to wear the BiPAP mask, the physician should be notified, and the notification should be documented. LVN 1 stated without the documentation of the notification of the physician, there is no evidence the physician was aware of the residents ' refusal. During an interview on 2/19/2025 at 3:26 p.m., LVN 2 stated Resident 2 refused to wear the BiPAP mask since the day she was admitted to the facility. LVN 2 stated Resident 2 did not like how the BiPAP mask fit, and Resident 2 said it did not fit like the mask she used at home. LVN 2 stated she did notify MD 2 when Resident 2 refused to wear the mask. LVN 2 stated resident ' s refusal to wear the BiPAP mask should have been reported to the physician because the resident could have respiratory issues, or their sleep could be affected. During an interview on 2/19/2025 at 3:50 p.m., the Director of Nursing (DON) stated prior to the resident ' s admission, the rental company for the BiPAP machine will send the equipment prior to the resident ' s admission. The DON stated the rental company would send three different sizes of BiPAP masks and then charge nurse would fit test the resident to ensure there are no air leaks and to ensure the mask fits according to the resident ' s comfort. The DON stated if the resident refuses to wear the BiPAP mask, the refusal should be documented, and the physician notified. During a review of the facility ' s policy and procedure (P&P) titled CPAP/BiPAP Support, dated 3/2024, the P&P indicated the facility staff should notify the physician if the resident refuses the procedure. 555785 Page 2 of 2