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.
(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 2
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
01/30/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555785
If continuation sheet
Page 2 of 2
