Health inspection·January 30, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to ensure a plan of care was developed for one of four sampled residents (Resident 1) who was diagnosed with osteopenia (a condition that occurs when the body doesn ' t make new bone as quickly as it reabsorbs old bone, causing weakened) and a fracture (a break in the bone) to her left femur (thigh bone), via an x-ray, after she was observed with swelling to her left thigh with indications of pain. This deficient practice resulted in the non-existence of goals and interventions to care for a resident with osteopenia and had the potential for Resident 1 to sustain additional injuries and/or fractures. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (a brain condition that causes repeated seizures [uncontrolled movement]), diabetes mellitus ([DM] a disorder in which the amount of sugar in the blood is elevated), functional quadriplegia (the condition of being unable to move and feel from the neck down) and disorders of bone density (strength of the bone). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool, dated 4/24/2023, the MDS indicated Resident 1 ' s cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff requiring a one-person physical assist to complete her activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting, bed mobility and transfers. During a review of Resident 1 ' s SBAR (Situation, Background, Assessment and Recommendation) Communication Form and Progress Note dated 1/11/2024 and timed at 7:33 p.m., the SBAR and Progress Note indicated Resident 1 was observed with swelling to her left thigh and was grimaced when her left thigh was touched. The SBAR and Progress Note indicated Resident 1 ' s primary doctor ordered a stat (immediate) x-ray of Resident 1 ' s left thigh and femur. During a review of Resident 1 ' s Radiology Interpretation Report (x-ray results), the x-ray results indicated an acute (immediate and can be severe) complete moderately displaced (the pieces of the bone has moved creating a space and/or abnormal position) and angulated fracture (the two ends of the broken bone have shifted out of alignment) of the proximal shaft of femur (involving the head and neck of the thigh bone) and mild osteopenia. Page 1 of 2 555785 555785 01/30/2024 Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s Clinical records, the Clinical records indicated there was no comprehensive care plan developed by the facility to address Resident 1 ' s diagnosis of osteopenia. During an interview on 1/23/2024 at 1:52 p.m., Certified Nursing Assistant 1 (CNA 1) stated she was not aware of any special precautions needed when caring for and assisting Resident 1 when providing ADLs care. During an interview on 1/23/2024 at 2:45 p.m., Licensed Vocational Nurse 2 (LVN 2) stated there should have been a Care Plan developed with specific interventions to prevent Resident 1 from repeated injuries. During an interview on 1/23/2024 at 3:36 p.m., Registered Nurse Supervisor 1 (RNS 1) stated there was no plan of care that addressed Resident 1 ' s osteopenia and one should have been developed to address Resident 1 ' s fragility (easily broken or damaged) to prevent complications in the future. During an interview on 1/123/2024 at 4:16 p.m., the Director of Nursing (DON) stated the purpose of developing care plan is to address the residents ' individual needs and to ensure their safety, to prevent illness and other complications. During a review of the facility ' s Policy and Procedure (P/P) titled Care Plans-Comprehensive revised 9/2023, the P/P indicated the facility will formulate an individualized comprehensive care plan for each resident that will include objectives and timetables to meet their medical, nursing, mental and psychological needs. During a review of the facility ' s P/P, titled, Osteoporosis- Clinical Protocol revised 4/ 2013, the P/P indicated the physician will identify individuals with osteopenia and/or osteoporosis (brittle bones) and together with the staff will identify basic measures to address modifiable risk factors and provide pertinent medical interventions for individuals with osteoporosis or those significant risk for osteoporosis. 555785 Page 2 of 2