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 (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 3 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 06/26/2025 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)