Other·January 10, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of The Department of Public Health during the investigation of a Facility Reported Incident (FRI). FRI Number: CA00657559 Representing the Department of Public Health: Surveyor ID: 38550 RN, HFEN The inspection was limited to the specific FRI investigated and does not represent a full inspection of the facility. One deficiency was issued for FRI Number: CA00657559

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 12/24/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1EIV11 Facility ID: CA940000098 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555785 (X3) DATE SURVEY COMPLETED 12/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD CARE CENTER 1880 Dawson Ave Signal Hill, CA 90755 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report within five working days, the results of an allegation of sexual abuse for one out of three sampled residents (Resident 1) to the Department of Public Health (DPH), the ombudsman and law enforcement as indicted in the facility's policy and procedure. Resident 1, who had a history of anxiety (excessive worry or fear), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and dementia (loss of memory and other mental abilities severe enough to interfere with daily life) reported having her vagina touched inappropriately and without gloves by Certified Nursing Assistant 1 (CNA 1). The results of the investigation were not reported to the DPH, the ombudsman or law enforcement. This deficient practice had the potential to jeopardize the safety of Resident 1. Findings: A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on July 8, 2019. Resident 1's diagnoses included anxiety and generalized muscle FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1EIV11 Facility ID: CA940000098 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555785 (X3) DATE SURVEY COMPLETED 12/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD CARE CENTER 1880 Dawson Ave Signal Hill, CA 90755 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE weakness. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated July 15, 2019, indicated Resident 1 did not have problems with memory and cognition (thought process). The MDS indicated Resident 1 required extensive assistance and physical assistance from one staff with dressing, toileting, bed mobility and personal hygiene. A review of the facilities Verification of Investigation Report indicated on October 3, 2019, the Administrator (ADMIN) was notified by Resident 1's Assisted Living Facility ([ALF] type of housing and limited care that is designed for senior citizens who need some assistance with daily activities but do not require care in a nursing home ), that Resident 1 reported having her vagina touched by Certified Nursing Assistant 1 (CNA) 1 on or around September 10, 2019. According to the report, the ADMIN interviewed Resident 1 and CNA 1 regarding the incident on September 12, 2019 and on October 3, 2019. On October 15, 2019 at 10:30 a.m., during a telephone interview, the Administrator (ADMIN) stated she completed the investigation of Resident 1's allegations on either October 8, 2019 or October 9, 2019. On October 17, 2019 at 10:50 a.m., during a concurrent interview and record review, the ADMIN denied providing the results of the outcome of Resident 1's investigation to the DPH, the ombudsman or local Law enforcement. The ADMIN stated she was unaware that the results had to be sent to the agencies. The ADMIN stated the facilities' policy indicated a written report would be provided to the DPH, the Ombudsman and law FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1EIV11 Facility ID: CA940000098 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555785 (X3) DATE SURVEY COMPLETED 12/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD CARE CENTER 1880 Dawson Ave Signal Hill, CA 90755 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE enforcement within five working days. A review of the facility's policy and procedure, titled "Abuse Investigations," with a revision date of April 2010, indicated the facility would report the results of all abuse investigations to the DPH, the ombudsman and local law enforcement within five working days of the reported incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1EIV11 Facility ID: CA940000098 If continuation sheet 4 of 4