Att D - DHHS Evaluations — Signal Hill City Council, January 9, 2024

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

Page 1 ends

555785 02/01/2023 Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44958 Based on observation, interview, and record review, the facility failed to ensure the accurate dispensing and administering of drugs in accordance with the facility policy and procedure (P& P) titled Administering Medication , for 4 of 5 residents. The facility failed to:
a. to ensure medications were not left on the bedside table for Residents 1 and Resident 3 and documented accurately.
b. administer Gabapentin (medication that works in the brain to prevent seizures [unusual electrical activity in the brain that can cause changes in behavior, movement, or feelings] and relieve pain) and Hydralazine Hydrochloride (HCL- medication used to treat high blood pressure) as ordered by the physician for Residents 2 and Resident 4.

These deficient practices had the potential for medication overdose or underdosage which can cause pain, seizures, hypertension (blood pressure that is higher than normal) injury, and death.

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] and readmitted to the facility on [DATE] with diagnoses including diverticulitis (small pouches that bulge outward through the colon, or large intestine), asthma (a long-term condition that affects the airways in the lungs) and diabetes mellitus (long-lasting health condition that affects how your body turns food into energy).

During a review of Resident 1's History and Physical (H&P), dated 11/7/2021, the H&P indicated Resident 1 had the capacity to understand and make decisions.

During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 11/11/2022, the MDS indicated Resident 1 could be understood and be understood by others.

The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provided weight bearing [support weight of resident's body] support) from staff for activities of daily living ([ADLs] task such as bathing, dressing, grooming and toileting).
(continued on next page)
555785 5
12/15/2023
Attachment D
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.

During an observation on 1/5/2023, at 11:37 a.m., in Resident 1's room. Licensed Vocational Nurse (LVN) 2 was observed to place medication in a medication cup in at Resident 1's bedside table. LVN 2 was observed telling Resident 1, to take Resident 1's Tylenol when you're ready. Observed LVN 2 left Resident 1's room after leaving the medication cup on the bedside table.

During a concurrent observation and interview on 1/5/2023 at 11:40 a.m., with Resident 1, in Resident 1's room, Resident 1 was observed to be sitting up in bed with a medicine cup containing a two white pills on the bedside table Resident 1 stated, her nurse left the Tylenol at her bedside to take.

During an interview on 1/5/2023, at 12:05 p.m., with LVN 2, LVN 2 stated she left two tablets of Tylenol 325 mg in a medicine cup at Resident 1's bedside on 1/5/2023, at 11:38 a.m. LVN 2 stated she did not stay with Resident 1 to ensure she took the medication and confirm she swallowed the pills. LVN 2 stated she left Resident 1's medication in a medicine cup on Resident 1's bedside table because Resident 1 wasvery particular with medication and likes to take it at her desk. LVN 2 stated it was important to stay with Resident 1 to ensure she took the medication.

During a review of Resident 1's Medication Administration (MAR), the MAR indicated acetaminophen 325 mg, 2 tablets were given by mouth at 1/5/2023, at 11:38 a.m. by LVN 2.

During an interview on 1/5/2023, at 2:00 p.m., with LVN 2, LVN 2 stated she left the Tylenol on the bedside table for Resident 1 to take and documented that she had administered the medication to Resident 1 without visually confirming that Resident 1 took the medication. LVN 2 stated she should have stayed with Resident 1 until she took the medication and document administration in MAR. LVN 1 stated she put Resident 1 at risk of medication overdose or underdosage.

During a review of Resident 3's face sheet, the face sheet indicated Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes mellitus, hemiplegia (unable to move or feel on one side of the body) and hemiparesis (weakness of one entire side of the body) and post-traumatic stress disorder (mental health disorder that some people develop after they experience or see a traumatic event).

During a review of Resident 3's H&P, dated 7/12/2022, the H&P indicated Resident 1 has the capacity to understand and make decisions.

During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 39 could be understood and be understood by others. The MDS indicated Resident 1 required supervision to limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs) from staff for ADLs.

During a review of Resident 3's Physician Order Summary Report, the report indicated acetaminophen tablet 325 mg, give two tablets by mouth every four hours as needed for temperature 100 F. (continued on next page)
2 5 555785 12/15/2023
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.

During an observation on 1/5/2023, at 12:10 p.m., in Resident 3's room, the Director of Nursing (DON) was observed to walk into Resident 3's room and ask Resident 3 if he needed anything. The DON was observed to pick up the medicine cup with two white pills and ask the Resident 3 if he was going to take his medication. Resident 3 stated he would and proceeded to swallow the medication.

During a subsequent interview on 1/5/2023, at 12:20 p.m., with the DON, the DON stated LVN 1 should have stayed with Resident 3 until he swallowed his medication to ensure that he ingested the entire ordered dose.

The DON stated it was the role of the licensed nurse and facility's policy and procedure to ensure residents were given medication safely. The DON stated it was important for licensed staff to stay with Resident 3 to ensure medications were taken to prevent underdosing and overdosing of mediation.

During an interview on 1/5/2023, at 2:50 p.m., with LVN 1, LVN 1 stated she left two tablets of Tylenol on the bedside table for Resident 3. LVN 1 stated it was important to stay until he ingested the medication and document administration to MAR. LVN 1 stated she cannot ensure Resident 3 took his medication and had the potential to place Resident 3 at risk of medication overdose or underdosage.

During an interview on 1/5/2023, at 3:00 p.m., with the DON, the DON stated the licensed nurse must document the medication immediately after it was given and not before. The DON stated by documenting that a medication was given prior to administration, had the potential risk for overdose or underdosage causing harm and pain to the resident. DON stated if medication was not documented in the MAR, it was assumed it was not be given.

During a review of the facility's policy and procedure, (P/P) titled, Documentation of Medication Administration, revised April 2007, the P/P indicated, The facility shall maintain a medication administration record to document all medication administered, a nurse shall document all medications administered to each resident on the resident's MAR, the administration of the medication must be documented immediately after, never before it is given.

During a review of the facility's policy and procedure, (P/P) titled, Administering Oral Medications, revised October 2010 , the P/P indicated. The purpose of this procedure is to provide guidelines for the safe administration of oral medication and to remain with the resident until all medications have been taken. b. During a review of Resident 2's face sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- group of diseases that cause airflow blockage and breathing-related problems), rheumatoid arthritis (disease that mostly affects joints [part of the body where two or more bones meet to allow movement]) , and chronic kidney disease (CKD- condition in which the kidneys [organ in the body that remove waste and extra water from the blood] are damaged and cannot filter blood as well as they should). (continued on next page)
3 5 555785 12/15/2023
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.

During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment (couldn't always understand and be understood by others). According to the MDS, Resident 2 required limited to total assistance (full staff performance during activity) from staff for ADLS.

During a review of Resident 2's Physician Order Summary Report printed 1/18/2023, the summary indicated to administer gabapentin tablet 600 mg, give one tablet by mouth four times a day for pain management.

During a review of Resident 2's MAR, dated 1/5/2023, the MAR indicated Gabapentin tablet 600 mg tablet, was due on 1/5/2023, at 10:00 a.m. and administered on 1/5/2023, at 11:23 a.m., by LVN 2.

During a review of Resident 4's face sheet, the face sheet indicated Resident 4 was admitted to the facility on [DATE] diagnoses including multiple sclerosis (disease that impacts the brain, spinal cord and optic nerves [relay messages from your eyes to your brain]), hypertension (high or raised blood pressure) and chronic pain syndrome (pain that carries on for longer than 12 weeks despite medication or treatment).

During a review of Resident 4's H&P, dated 1/5/2022, the H&P indicated Resident 4 has the capacity to understand and make decisions.

During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 could be understood and be understood by others. According to the MDS, Resident 4 required limited assistance to extensive assistance from staff for ADLs.

During a review of Resident 4's Physician Order Summary Report printed 1/18/2023, the summary indicated to administer Gabapentin Tablet 100 mg, give one tablet by mouth three times a day related neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) and Hydralazine Hydrochloride (HCL- medication used to treat high blood pressure) oral ( by mouth) tablet 50 mg, give one table by mouth two times per day related to primary hypertension.

During an observation on 1/5/2023 at 11:20 a.m., with LVN 1, in Resident 4's room, LVN 1 was observed to handing Resident 4 several pills in a medication cup. Resident 4 was observed to ingest all the pills in the medication cup while LVN 1 stood at her bedside.

During a review of Resident 4's MAR, dated 1/5/2023, the MAR indicated the following: Gabapentin tablet 100 mg tablet, was due on 1/5/2023, at 9:00 a.m. and administered on 1/5/2023, at 11:29 a.m. by LVN 1, Gabapentin 100 mg tablet, was due on 1/5/2023 at 1:00 p.m., and administered at 1:00 p.m. by LVN 1, Hydralazine HCL tablet 50 mg was due on 1/5/2023 at 09:00 a.m., and administered at 11:29 a.m., by LVN 1. (continued on next page)
4 5 555785 12/15/2023
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.

During a subsequent interview on 1/5/2023, at 2:46 p.m., with RX, RX stated that hydralazine HCL if not taken within the hour of the physician's ordered dose, had the potential risk for increased blood pressure.

During an interview on 1/5/2023, at 2:50 p.m., with LVN 1, LVN 1 stated she had fallen almost two hours behind on giving Resident 4 her medications. LVN 1 stated she should have asked for help but did not ask.

LVN 1 stated, there are nurses available to help, but she did not think to ask for help in passing her medications.

During an interview on 1/5/2023, at 3:00 p.m., the DON stated she was not aware Resident 2 and Resident 4 were receiving their medications late. The DON stated, per facility's policy, medications must be given within the hour of the scheduled dose. The DON stated if the medications were given late, the residents are at risk for medication underdosage and or overdosage. The DON stated the residents are not receiving their required services.

During a review of the facility's policy and procedure, (P/P) titled, Administering Medications, revised December 2012, the P/P indicated Medications shall be administered in a safe and timely manner, and as prescribed, the DON will supervise and direct all nursing personnel who administer medications and have related functions, medications must be administered in accordance with the orders, including any required time frame, medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meals).
5 5 555785 12/15/2023
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

FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID: Facility ID: If continuation sheet

Page 1 ends

555785 03/23/2023 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** 47092 Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), received care that promotes dignity and respect by not providing incontinence care within a reasonable time when Resident 1 repeatedly requested assistance.

This failure resulted in Resident 1 experiencing psychosocial harm by verbal expression of repeatedly asking staff for help, and by crying in front of other residents and staff.

Findings:

During a review of Resident 1's Admission Record (A/R) dated 3/21/2023, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that included heart failure (a chronic condition in which the heart does not pump blood adequately causing fatigue) and muscle weakness.

During a review of Resident 1 ' s Minimum Data Set (MDS), an assessment and care-screening tool, dated 3/16/2023, indicated, Resident 1 required extensive assistance (staff provide weight-bearing support to stand or walk), and Resident 1 had occasional to frequent incontinence of bowel and bladder.

During a review of Resident 1 ' s care plan titled, Resident is Incontinent of Bowel and Bladder, dated 3/10/2023, indicated, to assist resident to the bathroom and/or offer urinal/bedpan accordingly, and to provide good peri care after each incontinence.

During a review of Resident 1 ' s care plan titled, Requires Assistance with ADLs due to Medical Condition, dated 3/10/2023, indicated, for staff to meet and anticipate Resident 1 ' s needs by assisting in maintaining good personal hygiene as needed.

During a review of Resident 1 ' s Discharge Summary, dated 3/16/2023, indicated, Resident 1 was being discharged from facility per request.
(continued on next page)
555785 6
12/15/2023
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 03/23/2023
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 observations and interviews on 3/21/2023, at 10:35 a.m., with Resident 2 (R2), R2 stated, she is afraid staff will hear what she tells me. R2 stated that she witnessed Resident 1 (R1) not get changed out of her soiled diaper for 3 hours one evening but does not recall the date. R2 stated the call light was pushed 4 times, 3 times by R1, and 1 time by R2. R2 stated that 4 different staff members came to respond to the call light but none of them assisted R1 with her soiled diaper. R2 stated she asked one of the female staff members, who she was not able to identify, why they are not helping R1, but her question was ignored. R2 stated 1 out of the 4 times a male nurse came in the room in response to the call light and told R1 that he will not change her right now since it is dinner time. R2 stated that R1 was crying and R2 felt bad so she pushed the call light. R2 stated a female staff member with braids came in to respond to the call light but told R1 not right now, and that R1 must wait until after dinner. R2 stated that around 8:15 p.m. someone came to assist R1 in cleaning up. R2 stated both her and R1 overheard staff complaining about R1 causing problems for them. R2 stated later that evening when a nurse came to check on R1 she refused help and told R2 not to say anything to the staff. R2 stated R1 was afraid and told R2 to please be quiet and not to say anything to the staff members anymore. R2 stated R1 called someone over the phone and then the next day R1 ' s husband and daughter in law came to take her home. R2 stated that she was afraid to bother staff about being cleaned up herself and does not want to cause trouble.

During an interview on 3/21/2023, at 11:51 a.m., with Certified Nursing Assistant 1 (CNA1), CNA1 stated, the maximum time it should take to change a knowingly soiled resident is 30 minutes if she is busy, but usually 5-10 minutes otherwise. CNA1 stated that it could hurt their skin if they stay soiled longer than 30 minutes.

During an interview on 3/21/2023, at 12:04 p.m., with Director of Staff Development (DSD), DSD stated, the maximum time it should take to change a knowingly soiled resident is as soon as possible, because residents could have irritation to the skin. DSD stated beyond 30 minutes is unreasonable for residents to remain soiled. DSD stated if care staff are busy other care staff are expected to help in keeping residents clean.

During an interview on 3/21/2023, at 12:10 p.m., with Daughter in Law (DTR), DTR stated, on 3/14/2023 she received a call late at night from her mom (R1) who wanted to come home because R1 had a bowel movement and was not changed for 2-3 hours. DTR stated before she removed R1 from the facility she visited the facility late at night on 3/15/2023 and saw R1 ' s hands were shaking and thought R1 was having a nervous breakdown, so the next day she insisted a discharge home for R1.

During an interview on 3/21/2023, at 1:30 p.m., with the Administrator (ADM), ADM stated, certified nursing assistants (CNA) are expected to change soiled residents right away unless there is an emergency, or they are assisting other residents. ADM stated the maximum time a resident should wait when they are knowingly soiled is 15 minutes, and if the nurse is busy, they are expected to ask another care staff member to help otherwise a residents ' skin can breakdown.

During an interview on 3/21/2023, at 3:00 p.m., with Licensed Vocational Nurse 1 (LVN1), LVN 1 stated, on 3/14/2023 at 8:45 p.m. he noticed R1 ' s call light was on and responded to see what she needed. LVN1 stated he saw that R1 had been crying and told him that she had been waiting for a while to be changed.

LVN1 stated that he assisted her in changing her diaper. LVN 1 stated that soiled residents should be changed right away, and it is every nurses 'duty to change them otherwise their skin can breakdown. (continued on next page)
2 6 555785 12/15/2023
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.

During an interview on 3/23/2023, at 7:17 a.m., with Certified Nursing Assistant 2 (CNA2), CNA2 stated, on 3/14/2023 at 5:15 p.m. R1 requested to be changed but it was dinner time and he had 3 other residents to assist in feeding. CNA2 stated he went back to R2 between 6:35-6:40 p.m. to change her. CNA2 stated it was at least an hour before changing her and that it was too long of a time for R1 to stay soiled in feces.

CNA2 stated he usually responds within 10-15 minutes, but he was busy. CNA2 stated he only documented 1 bowel movement for that shift because he was busy.

During a review of Resident 1 ' s record titled, Bowel Record, dated 3/14/2023, indicated, Resident 1 only had one bowel movement documented for the 3:00-11:00 p.m. shift, signed by CNA2.

During a review of the facility ' s policy and procedure (P&P) titled, Perineal Care, dated 10/2010, indicated, cleanliness and comfort are to be provided to the resident to prevent infections and skin irritation.

During a review of the facility ' s policy and procedure (P&P) titled, Quality of Life - Dignity, dated 9/2009, indicated, staff shall promote dignity and assist residents as needed promptly responding to the resident ' s request for toileting assistance.

During a review of CNA job description, undated, indicated, duties include respecting residents ' rights by treating residents fairly with dignity and respect.
3 6 555785 12/15/2023
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.

This failure resulted in Resident 1 experiencing psychosocial harm by verbal expression of repeatedly asking staff for help, and by crying in front of other residents and staff.

Findings:

During a review of Resident 1 ' s Admission Record (A/R) dated 3/21/2023, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that included heart failure (a chronic condition in which the heart does not pump blood adequately causing fatigue) and muscle weakness.

During a review of Resident 1 ' s Discharge Summary, dated 3/16/2023, indicated, Resident 1 was being discharged from facility per request.
(continued on next page)
4 6 555785 12/15/2023
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 03/23/2023
Courtyard Care Center 1880 Dawson Avenue
Signal Hill, CA 90806
F 0675
Level of Harm - Minimal harm or
potential for actual harm
Residents Affected - Few
During an observation and interview on 3/21/2023, at 10:35 a.m., with Resident 2 (R2), R2 stated, she is afraid staff will hear what she tells me. R2 stated that she witnessed Resident 1 (R1) not get changed out of her soiled diaper for 3 hours one evening but does not recall the date. R2 stated the call light was pushed 4 times, 3 times by R1, and 1 time by R2. R2 stated that 4 different staff members came to respond to the call light but none of them assisted R1 with her soiled diaper. R2 stated she asked one of the female staff members, who she was not able to identify, why they are not helping R1, but her question was ignored. R2 stated 1 out of the 4 times a male nurse came in the room in response to the call light and told R1 that he will not change her right now since it is dinner time. R2 stated that R1 was crying and R2 felt bad so she pushed the call light. R2 stated a female staff member with braids came in to respond to the call light but told R1 not right now, and that R1 must wait until after dinner. R2 stated that around 8:15 p.m. someone came to assist R1 in cleaning up. R2 stated both her and R1 overheard staff complaining about R1 causing problems for them. R2 stated later that evening when a nurse came to check on R1 she refused help and told R2 not to say anything to the staff. R2 stated R1 was afraid and told R2 to please be quiet and not to say anything to the staff members anymore. R2 stated R1 called someone over the phone and then the next day R1 ' s husband and daughter in law came to take her home. R2 stated that she was afraid to bother staff about being cleaned up herself and does not want to cause trouble.

During an interview on 3/21/2023, at 12:10 p.m., with a family member, family stated, on 3/14/2023 she received a call late at night from her mom (R1) who wanted to come home because R1 had a bowel movement and was not changed for 2-3 hours. DTR stated before she removed R1 from the facility she visited the facility late at night on 3/15/2023 and saw R1 ' s hands were shaking and thought R1 was having a nervous breakdown, so the next day she insisted a discharge home for R1.

LVN1 stated that he assisted her in changing her diaper. LVN 1 stated that soiled residents should be changed right away, and it is every nurses ' duty to change them otherwise their skin can breakdown. (continued on next page)
5 6 555785 12/15/2023
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.

CNA2 stated he usually responds within 10-15 minutes, but he was busy. CNA2 stated he only documented 1 bowel movement for that shift because he was busy.

During a review of Resident 1 ' s record titled, Bowel Record, dated 3/14/2023, indicated, Resident 1 only had one bowel movement documented for the 3:00-11:00 p.m. shift, signed by CNA2.

During a review of CNA job description, undated, indicated, duties include personal nursing care functions such as keeping incontinent residents clean and dry.
6 6 555785 12/15/2023

Signal Hill City CouncilJanuary 9, 2024

Signal Hill City Council
January 9, 2024