Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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: Facility ID: If continuation sheet
555785 02/20/2022 Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat Resident 15 with dignity and respect by ensuring she did not have dried mucous around her lips for three days.
This deficient practice had the potential to cause psychosocial harm to Resident 15.
Findings:
During a review of Resident 15's Admission Record (AR), the Admission record indicated Resident 15 was admitted to the facility on [DATE] and last readmitted on [DATE]. According to the AR, the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
During a review of Resident 15's Minimum Data Set (MDS), a standardized comprehensive assessment and care-screening tool), dated 12/10/2021, the MDS indicated Resident 15 had severe cognitive (ability to learn, remember, understand, and make decisions) impairment.
During an observation on 2/18/2022 at 8:49 a.m., Resident 15 had dried mucous around her lips.
During an observation on 2/18/2022 at 10:37 a.m., Resident 15 had dried mucous around her lips.
During an observation on 2/18/2022 at 3:29 p.m., Resident 15 had dried mucous around her lips.
During an observation on 2/18/2022 at 4:34 p.m., Resident 15 had dried mucous around her lips.
During an observation on 2/19/2022 at 8:41 a.m., Resident 15 had dried mucous around her lips.
During an observation on 2/19/2022 at 9:22 a.m., Resident 15 had dried mucous around her lips.
During an observation on 2/19/2022 at 11:03 a.m., Resident 15 had dried mucous around her lips.
During an observation on 2/20/2022 at 10:06 a.m., Resident 15 has dried mucous around her lips. (continued on next page)
555785 15 11/08/2022
Attachment E
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0550
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Few
During an interview on 2/20 2022 at 10:22 a.m., Licensed Vocational Nurse 2 (LVN 2) stated oral care must be provided whenever it was needed and staff must be able to provide oral care even during shower days because the mucous membranes are much softer. LVN 2 acknowledged it was a dignity issue to have dried [MEDICATION(S)] around the mouth that can affect the psychosocial aspect of the resident and make one's spirit go down (sad).
During an interview on 2/20/2022 at 10:45 a.m., Certified Nursing Assistant 3 (CNA 3) acknowledged Resident 15's lips needed to be cleaned and to make sure the lips did not have any mucous around it. CNA 3 stated any resident would feel good to have a clean mouth and lips, as it enhances self-esteem and self-worth.
During the review of the facility's policy and procedure (P/P), titled Quality of Life-Dignity revised on 8/2009, the P/P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
2 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0558
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Some
Reasonably accommodate the needs and preferences of each resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the nursing staff failed to ensure call lights were within reach for three sampled residents (Residents14, 15, and 99).
This deficient practice had the potential to result in delay of care and possible injury.
Findings:
a. During a review of Resident 14's Admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
Duringa a review of Resident 14's Care Plan (CP), dated 12/13/2021, the CP indicated Resident 14 required assistance with activities of daily living (ADL's) due to medical condition and call light must be within reach and answered promptly.
A review of Resident 14's Minimum Data Set (MDS), a comprehensive assessment and care-planning tool, dated 12/28/2021, the MDS indicated Resident 14 had moderate cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impairment and required extensive assistance for bed mobility, dressing and personal hygiene.
During an observation on 2/18/2022 at 8:48 a.m., Resident 14's call light was hanging close to the floor.
Resident 14 was unable to reach the call light.
During an observation on 2/19/2022 at 9:07 a.m., Resident 14's call light was hanging close to the floor.
Resident 14 was unable to reach the call light.
During an interview on 2/19/2022 at 10:38 a.m., Licensed Vocational Nurse 2 (LVN 2) stated a resident would become irritable if they do not have the control to ask for help, and it does not accommodate their needs, especially for a resident who cannot speak for themselves, LVN 2 stated, That's just awful. LVN 2 acknowledged that it was an issue and this could affect the psychosocial aspect of the resident.
During an interview on 2/19/2022 at 12:25 p.m., the certified nursing assistant 2 (CNA 2) stated if a resident can't reach the call light and does not have the control to ask for help, this could be very frustrating and can make them feel less than a person when their needs are not being accommodated. b. During a review of Resident 15's AR, the AR indicated Resident 15 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
A review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 had severe cognitive (ability to learn, remember, understand, and make decisions) impairment. (continued on next page)
3 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0558
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Some
During an observation on 2/18/2022 at 8:41 a.m., Resident 15's call light was hooked on the wall and Resident 15 was unable to reach the call light.
During an observation on 2/18/2022 at 2:40 p.m., Resident 15's call light was hooked on the wall and Resident 15 was unable to reach the call light.
During an observation on 2/19/2022 at 8:57 a.m., Resident 15's call light was hooked on the wall and Resident 15 was unable to reach the call light.
During an interview on 2/19/2022 at 11:03 a.m., the the MDS Coordinator stated it would make a resident irritable if they do not have the control to ask for help and it does not accommodate their needs, and the resident can feel helpless. The MDS Coordinator stated it was awful and acknowledged this would affect the resident's whole being.
c. During a review of Resident 99's AR, the AR indicated Resident 99 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
A review of Resident 99's Care Plan (CP), dated, 12/13/2021, the CP indicated Resident 99 required assistance with activities of daily living (ADLs) due to medical condition and the call light must be within reach and answered promptly.
During an observation on 2/18/2022 at 8:50 a.m., Resident 99's call light was hanging close to the floor and Resident 99 was unable to reach the call light.
During an observation on 2/19/2022 at 9:01 a.m., Resident 99's call light was hanging close to the floor and Resident 99 was unable to reach the call light.
During a review of the facility's policy and procedure (P/P), titled Call light - Answering dated 1/19/2015, the P/P indicated it was the policy of the facility to leave the call light within the reach of the resident, answer calls, and respond to the resident's requests and needs as quickly as possible. 4 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0656
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for two of 12 sampled residents (Residents 30 and 42) by:
1. Failing to develop a plan of care for the use of [MEDICATION(S)] (a medication used to treat [CONDITION(S)] [[CONDITION(S)] disease ] virus infections) for Resident 30.
2. Failing to individualize the care plans addressing the left and right lower extremities [CONDITION(S)] (swelling) for Resident 42.
These deficient practices have the potential to negatively affect the delivery of care and services to Residents 30 and 42.
Findings:
a. During a review of Resident 30's Admission Record (Face Sheet), the face sheet indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
During a review of Resident 30's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/21/2022, the MDS indicated Resident 30 had severe cognitive (ability to learn, remember, understand, and make decision) impairment for daily decision making. Resident 30 needs extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and total dependence with bathing.
During a review of Resident's 30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .
During a concurrent interview and record review on 2/19/2022 at 9:08 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 30 should have a care plan for [MEDICATION(S)] to monitor side effects and adverse reaction of the medication.
b. During a review of Resident's 42's Admission record (Face Sheet), the face sheet indicated Resident 42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
During a review of Resident 42's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/27/2022, the MDS indicated Resident 42 had moderate cognitive (ability to learn, remember, understand, and make decision) impairment for daily decision making. Resident 42 required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and total dependence with bathing.
During a review of Resident 42's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (continued on next page)
5 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0656
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Some
During a concurrent observation and interview on 2/17/2021 at 9:50 a.m., in Resident 42's room. Resident 42 was observed sitting in his wheelchair with both lower extremities elevated and swollen. Resident 42 stated, My feet hurt because of the swelling.
During a concurrent interview and record review on 2/19/2022, at 9:08 a.m., with Licensed Vocational Nurse 3 (LVN 3), stated Resident 42 should have a care plan for [CONDITION(S)] of his lower extremities. LVN 3 was not able to locate a care plan to reflect the interventions for the Resident's 42 [CONDITION(S)]. LVN 3 stated a care plan was important to assess Resident 42's problems, set up a goal and provide person-centered interventions.
During an interview on 2/21/2022, at 11:50 p.m., with Director of Nursing (DON), the DON stated care plan reflects the care, goals and interventions being provided to the residents. Residents should have a care plan for each diagnosis, new antibiotic, infections, and change of condition.
During a review of the facility's policy and procedure (P/P) titled, Care Plans-Comprehensive, dated 9/2010, the P/P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to: reflect currently recognized standards of practice for problem areas and condition.
6 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0688
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Some
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of seven residents (Residents 11, 42, and 48), who had limited range of motion ([ROM] movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility, by failing to provide restorative nursing exercises.
This deficient practice placed Residents 11, 42, and 48 at risk for decline in physical functioning and development of contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff).
Findings:
a. During a review of Resident 42's Face Sheet, the Face Sheet indicated Resident 42 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
During a review of Resident 42's Minimum Data Set (MDS), a standardized assessment and care-screening tool dated 1/27/2022, the MDS indicated the resident's cognitive (though process [a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems]) level was moderately impaired. According to the MDS, Resident 42 required extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, personal hygiene, eating, walking in the room or in corridor and total assistance in bathing. The MDS indicated there was no impairment on Resident 42's both upper and lower extremities.
During a review of Resident 42's RNA's task sheet (treatment record) for the month of 2/2022 the order indicated to ambulate the resident three (3) times a week with a front wheel walker (FWW). According to the treatment record, there was one treatment documented for week of 2/5/2022 to 2/13/2022. b. During a review of Resident 11's Face sheet, the Face Sheet indicated Resident 11 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 42's cognition level was moderately impaired and required extensive assistance with bed mobility, dressing, personal hygiene, walking in the room or in corridor and total assistance in bathing. According to the MDS, Resident 11 had impairment on one side of the upper extremities and impairment on both lower extremities. c. During a review of Resident 48's Face Sheet, the Face Sheet indicated Resident 48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
A review of Resident 48's MDS dated [DATE], the MDS indicated the resident rarely/never understood and never/rarely understand others. According to the MDS, Resident 48 required extensive assistance of a two-person assist in bed mobility, and dressing. Required total assistance in personal hygiene, locomotion on and off unit, transfer, and bathing. The MDS indicated there were no impairment on the upper extremities, but impairment on both lower extremities.
(continued on next page)
7 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0688
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Some
During an interview on 2/19/2022 at 10:35 a.m., with MDS nurse, the MDS nurse stated Range of Motion exercises are important for the resident to help maintain functional mobility. When the MDS nurse was asked what if the resident miss treatment or exercises? The MDS nurse stated resident could develop contractures if exercises are not being done. The MDS nurse stated RNA charting and documentation was confusing.
During an interview on 2/19/2022 at 11a.m., with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated he provides the treatment as ordered.
During a concurrent interview and record review on 2/19/2022 at 11:46 a.m., with Registered Nurse 1 (RN 1) in the presence of the Director of Nursing (DON), RN 1 stated RNA exercises were important to help prevent decline in residents' ROM. RN 1 stated the order indicated ROM should be done 5x a week. The DON stated blank areas on the RNA treatment sheet means the ROM was not done.
During a review of Resident 48's RNA task (treatment) sheet for the month of 2/2022, there were no signatures for three (3) consecutive days from 2/1-2/7, 2022. The physician ordered RNA five (5) times a week.
During a review of the facility's policy and procedure (P/P), revised July 2017 and titled, Restorative Nursing Services the P/P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative goals and objectives are individualized and resident-centered and are outlines in the resident's plan of care.
8 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0695
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Few
Provide safe and appropriate respiratory care for a resident when needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided for two of 47 residents (Residents 2 and 15). Resident 2 was not receiving oxygen (odorless gas that is present in the air and necessary to maintain life) and for Resident 15 the staff failed to ensure the humidifier canister (humidify the air you breathe) was filled with saline.
These deficient practices had the potential to result in respiratory distress for Resident 2 and nasal discomfort and irritation of the mucous membranes for Resident 15.
Findings:
a. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care-screening tool, dated 12/10/2021, the MDS indicated Resident 2 had moderate cognitive (ability to learn, remember, understand, and make decisions) impairment and required extensive assistance for bed mobility, transfer, toilet use and personal hygiene.
A review of Resident 2 's care plan (CP), dated 8/12/2020, the CP indicated Resident 2 required oxygen administration as needed due to being at risk for respiratory distress and shortness of breath related to asthma.
During an observation on 2/18/2022 at 8:38 a.m., Resident 2 was in bed awake with a nasal canula in his nose. The oxygen was set at two (2) liters per minute. The end of the oxygen tubing was inside of a transparent plastic bag attached to the oxygen machine. The resident was not receiving the oxygen.
During an interview on 2/18/2022 at 8:39 a.m., Resident 2 stated, It is frustrating to see the oxygen on, but no oxygen is coming out. The resident stated the staff get busy in the morning, but that does not mean she should not get the oxygen when she needs it.
During an interview on 2/19/2022 at 10:25 a.m., Licensed Vocational Nurse 2 (LVN 2) stated, It feels terrible to have oxygen on besides you and you're not getting it, LVN 2 stated that it was a risk for fire and danger if there's a spark in the electric outlet that could potentially create fire. LVN 2 stated placing the oxygen tubing into a resident's nostril was primary the responsibility of the licensed nurse. LVN 2 acknowledged if oxygen was not administered when needed or required it affects the oxygen level of the resident and can cause the resident to have shortness of breath.
During an interview on 2/19/2022 at 11:14 a.m., the MDS Coordinator stated it was the licensed nurse primary responsibility to provide oxygen therapy to the resident. The MDS Coordinator stated this was a quality care issue because the resident did not receive the oxygen as ordered by the physician. (continued on next page)
9 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0695
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Few
During an interview on 2/19/2022 at 11:58 a.m., the Director of Staff Development (DSD) stated it was important to follow the doctor's order by making sure the oxygen ordered was delivered when needed. b. During a review of Resident 15's Admission Record, the Admission record indicated Resident 15 was admitted to the facility on [DATE] and last readmitted on [DATE]. According to the Admission Record, Resident 15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
A review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 had severe cognitive (ability to learn, remember, understand, and make decisions) impairment.
During an observation on 2/18/2022 at 8:41 a.m., Resident 15 was in bed with oxygen infusing at two (2) liters per minute via a nasal cannula. The humidifier bottle, dated 2/11/2022, did not have any saline solution.
During an interview on 2/19/2022 at 10:38 a.m., LVN 2 stated it was important for the humidifier to be used when administering oxygen, unless contra-indicated, to prevent nasal discomfort and irritation of the mucous membranes.
During an interview on 2/19/2022 at 11:03 a.m., the MDS Coordinator stated if any resident receives oxygen without a humidifier, it can cause the mucous membranes to become dry, irritate the throat and nostrils. The MDS Coordinator acknowledged that this was a quality-of-care issue.
During a review of facility's policy and procedure (P/P), revised on 10/2010 and titled, Oxygen Administration the P/P indicated the purpose of the procedure was to provide guidelines for safe oxygen administration. 10 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0726
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Some
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Based on interview and record review, the facility failed to ensure two of five randomly selected licensed staff (RN 1 and LVN 4) had an annual competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing specfic skill sets successfully) check done annually.
This deficient practice had the potential for the facility not to be able to assess the competency skills necessary to ensure the staff provided care to residents within the acceptable standards of practice.
Findings:
During a concurrent interview and record review on 2/19/2022 at 3:33 p.m. with the Director of Staff Development (DSD), five random selected employee files were reviewed and Registered Nurse 1 (RN) 1 and Licensed Vocational Nurse 4 (LVN 4), did not have an annual competency skill check in the employees file.
The DSD stated the last annual competency skill check for RN 1 was on 1/12/2017 and the last competency skill check for LVN 4 was 4/13/2015.
During an interview on 2/20/2022 at 11:50 a.m., with the Director of Nursing (DON), the DON stated annual competency skill check should be done yearly for all licensed staff. The DON stated it was important to have it done to make sure licensed staff can perform certain skills and provide acceptable standards of practice to all residents.
11 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0802
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Many
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Based on observation, interview, and record review, the facility's dietary staff failed to ensure the correct strength of sanitizing solution was used to sanitize food contact surfaces.
This deficient practice had the potential to cause foodborne related illnesses to the residents.
Findings:
During a concurrent observation and interview on 2/18/2022 at 8:20 a.m., the Kitchen Staff (KS) was observed filling a red bucket from a faucet connected to a container of sanitizing solution. The KS dipped a test strip into the sanitizing bucket to check the concentration of the sanitizer strength. The strips read at 100 parts per million (PPM). The KS stated the solution should measure 200 PPM and changed the container of sanitizing solution underneath the sink then refilled the bucket with the sanitizing solution and retested the solution which read 200 PPM. The KS stated she failed to check the sanitizing solution bucket that morning.
The KS stated, It is important to check strength of the sanitizing bucket to sanitized surfaces properly.
During an interview with the Dietary Supervisor (DS) on 2/18/2022 at 1 p.m., the DS stated it was important to check the sanitizer strength in the sanitizing buckets prior to it being used. The DS stated it was important to have a correct sanitizing strength to make sure work surfaces are clean, to prevent bacteria from growing, and prevent foodborne illnesses.
A review of the facility's undated policy and procedure (P/P) titled, Sanitation and Infection Control, the P/P indicated Equipment and surfaces may be sanitized using Quaternary Ammonium Sanitizer (Quat).
According to the P/P, Quat levels will be checked before it used for the red bucket or more often as needed to ensure equipment and surfaces are sanitized appropriately. 12 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0812
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms that could causes food borne illness (any illness resulting from the food spoilage of contaminated food) for 47 out of the 50 residents in the facility by not discarding frozen meat and ground meat per the facility's suggested storage guidelines and checking the freezer and refrigerator temperature twice a day per facility's policy and procedure.
These deficient practices had the potential to cause food borne illness.
Findings:
During an initial kitchen tour with Cook 1 on 2/17/2022 at 7:45 a.m., an observation of the reach-in freezer, there were plastic bags with the following meats: beef patties dated 12/5/2021, meat balls dated 8/2021, and pork patties dated 10/19/2021.
During a concurrent observation and interview the same day with Cook 1, Cook 1 stated he does not know how long food can be stored in the freezer.
During a review of the facility's freezer and refrigerator temperature logs the last recorded entry was on 2/13/2022.
During an interview with the Dietary Supervisor (DS) on 2/18/2022 at 1 p.m., the DS stated precooked food should be discarded within 14 days. The meat balls and beef patties should have been discarded after 14 days.
During a review of the facility's policy and procedure (P/P), dated 2018 and titled, Refrigerated Storage, the P/P indicated refrigerator temperatures should be recorded two times each day. According to the P/P, recommended storage time for beef (ground) with maximum storage period three-four months and pork (ground) maximum storage period of three months.
13 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0880
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Many
Provide and implement an infection prevention and control program.
Based on observation, interview, and record review, the facility failed to maintain an infection preventions and control program to prevent the spread of the coronavirus disease ([COVID19] an illness caused by a virus that can easily spread from person to person) by failing to:
1.Ensure that staff working on the green zone was wearing an N-95 (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air) and prevent infections while working in the residents' care areas.
2. Failed to maintain washing machine temperature.
These deficient practices placed 47 residents, 84 staff members, and the community at risk for the transmission of COVID-19 and the potential to contaminate linens and spread infection to residents.
Findings:
a. During initial tour of the facility on 2/18/2022 at 8:10 a.m., a housekeeper (HKP 1) was observed wearing a surgical mask while cleaning and cleaning residents' rooms.
During a concurrent observation and interview on 2/18/2022 at 9:40 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was wearing a surgical mask and when asked what personal protective equipment (PPE) should be worn. LVN 1 stated it was a surgical mask, googles or face shield. When asked are there any residents on breathing treatment or aerosol generating inhalation. LVN 1 stated there are 2 (two) residents on breathing treatment on Station 1.
During an observation and interview on 2/18/2022 at 10 a.m., with Certified Occupational Therapy Aid (COTA) 1, COTA 1 was wearing a surgical mask and stated she goes inside residents' rooms and spends more than 15 minutes providing therapy.
During a concurrent interview and record review on 2/18/2022 at 4:38 p.m., with the Infection Preventionist (IP) and the Director of Nursing (DON), the IP stated the facility just got cleared from COVID outbreak and staff who are vaccinated should wear a surgical mask and eye protection. When the IP and DON were aware of the memo sent out to all skilled nursing facilities regarding wearing N95 in the green zone. The IP and DON stated they would have all staff vaccinated or unvaccinated to wear N95 mask.
During a review of Public Health Los Angeles standard precautions dated 1/20/2022, indicated given the higher transmissibility of the Omicron variant, all staff regardless of vaccination or booster status are required to wear N95 respirators, including in the green cohort especially in facilities where they may frequently encounter residents not consistently able to wear a face mask. (continued on next page)
14 15 555785 11/08/2022
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
STREET ADDRESS, CITY, STATE, ZIP CODE
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
A. Building
B. Wing
(Each deficiency must be preceded by full regulatory or LSC identifying information) FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet
Page of
555785 02/20/2022
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0880
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Many
b. During a concurrent observation and interview on 2/19/2022 at 10:27 a.m., the laundry washers were running in the laundry room. The Laundry Staff (LS) was interviewed with the Maintenance Assistant (MA) as a Spanish interpreter, the LS stated she did not know the temperature of the washer. The LS stated Maintenance Supervisor (MS) was responsible for checking the washer temperature every day (Monday to Friday). The LS stated the washer's temperatures were not checked on the weekend. The LS stated the water temperature for the washers should be at 138.2 degrees Fahrenheit (temperature scale).
During an interview with the MS on 2/20/2022 at 9:10 a.m., the MS stated the washer temperature should be at the range above 120 degrees Fahrenheit. The MS stated the laundry staff does not know how to check the laundry water temperature. The MS stated he was responsible for checking the laundry temperature every day on Monday through Friday. The MS stated no laundry staff checked the laundry water temperature on the weekend. The MS stated it was important to make sure correct water temperature were checked prior to washing the laundry for infection control.
During a review of the facility's undated policy and procedure (P/P) titled, Washing Procedure the P/P indicated the laundry staff will record the water temperature in every load at the range above 120 degrees Fahrenheit.
15 15 555785 11/08/2022