Health inspection·June 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure two of two residents (Resident 1 and 3) neurological checks (Neuro check -series of tests performed by healthcare providers to evaluate the function of the brain) were completed as indicated in the policy. Residents Affected - Few This deficient practice had the potential to result in the delay of care and services which could result in poor health outcomes. Findings: A. During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 originally on 3/14/2025 with a diagnosis including acute respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 4/12/2025, the MDS indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 needed set up assistance when eating, substantial assistance (helper does more than half the effort) with personal hygiene, and was dependent (helper does all the effort to complete the task) on staff with bathing, showering, and toileting hygiene. During a review of Resident 1's COC/Interact Assessment Form (SBAR), dated 4/25/2025 at 2:21 a.m., the SBAR (Situation Background Assessment Request - a communication tool used by healthcare workers when there is a change of condition among the residents) indicated Resident 1 had an unwitnessed fall at 2:20 a.m. During a review of Resident 1's Care plan report (untitled) a care plan for Resident actual all was initiated on 4/25/2025. The care plan interventions were to complete neuro checks as ordered. B. During a review of Resident 3's admission record, the admission Record indicated the facility admitted Resident 3 originally on 3/26/2025 with a diagnosis including Pneumonia (an infection/ inflammation of the lungs), meningitis (infection and inflammation of the brain and spinal cord), and abnormalities of gait and mobility. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognition. The MDS indicated Resident 3 substantial assistance with eating and oral hygiene, and Page 1 of 3 555785 555785 06/26/2025 Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806

F 0684 was dependent on staff with bathing, showering, toileting hygiene, personal hygiene, and dressing. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's COC/Interact Assessment Form (SBAR), dated 4/19/2025 at 6:02 p.m., the SBAR indicated Resident 3 had an unwitnessed fall at 3:20 p.m. Residents Affected - Few During an interview and record review on 6/27/2025 at 1:43 p.m., with the Director of Nursing (DON), Resident 1 and 3's Neurological assessment Checklist were reviewed. The instructions on the form indicated, for the first 24 hours, complete the assessments every 30 minutes times (x) 2, then every hour x2, then every 2 hours x3, and then every 4 hours x4. The DON stated Resident 1's neuro checks for the first 24 hours were checked every 30 minutes x2, every hour x2, then every three hours x3. The DON stated Resident 3's neuro checks were completed every 30 minutes x2, then every 2 hours x2, then every 3 hours x2, every 4 hours x4. The DON stated the neuro checks were not completed at correct frequencies for both residents. The DON stated that neuro checks need to be completed as instructed. During a review of the facility's policy and procedure (P&P) titled, Neurological Assessment, revised 2/2025, the P&P indicated Neurological assessment will be completed following an unwitnessed fall. The P&P indicated neurological assessment will be performed with the frequency as per falls protocol. 555785 Page 2 of 3 555785 06/26/2025 Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three resident's (Resident 1) nurse progress notes for [DATE] were accurate. This deficient practice resulted in an inaccurate depiction of services and care rendered. Findings: During a review of Resident 1's admission record, the admission Record indicated the facility admitted Resident 1 on [DATE] with a diagnosis including acute respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had severely impaired cognition. During a review of Resident 1's Order Entry, dated [DATE] at 3:53 p.m., the order indicated Resident was to be sent to the General Acute Care Hospital (GACH). During a review of Resident 1's GACH Discharge Summary [DATE] at 1:43 p.m., the summary indicated Resident 1 expired on [DATE]. During a concurrent interview and record review on [DATE] at 12:55 p.m., with Registered Nurse (RN)1, Resident 1's daily nurses notes were reviewed. The nurses' notes indicated an entry made on [DATE] at 1:29 p.m. and again at 1:30 p.m. RN 1 stated the entries made on [DATE] were late entries for the date of [DATE]. RN 1 stated she forgot to indicate they were late entries and the actual date and time the entries occurred. During an interview and record review on [DATE] at 3 p.m., with the Director of Nursing (DON), the DON stated documentation needs to be complete and accurate. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 12/2024, the P&P indicated all services provided to the resident, or any changes in the resident's medical condition shall be documented in the resident's medical record. Documentation will be objective, complete, and accurate. 555785 Page 3 of 3