Leisure Court Nursing: Medication Errors & Food Safety - CA
LVN 2 acknowledged to inspectors that she had committed a medication error by signing the medication administration record for Resident 20's Zyprexa without actually giving him the drug on January 21. The nurse said she "supposed to make sure medications were given as ordered."
The Zyprexa had been ordered by a physician on January 17 for the resident's schizoaffective disorder. But pharmacy records showed the medication wasn't delivered until January 22 at 11:15 p.m. — five days after it was ordered and one day after the nurse falsely documented giving it.
"It was unacceptable for the charge nurses to document in the MAR to show the medications were administered when the residents' medications were not available or on hand," the Director of Nursing told inspectors.
The medication violations were among widespread pharmaceutical service failures documented during the January 27 inspection. Federal regulators found the facility failed to ensure proper medication administration for multiple residents and left narcotic inventory sheets unsigned during shift changes on dozens of occasions.
Another nurse, LVN 1, routinely documented medications on administration records before actually giving them to residents — a practice the Director of Nursing said violated facility policy. The proper sequence, according to policy, was to "pour, pass, and sign the MAR."
During one observed medication pass, LVN 1 refused to give Resident 20 a prescribed stool softener, saying she needed to "clarify the order with the physician." But physician records showed the docusate sodium had been properly ordered on December 31. When asked the next day if she had given the medication after clarifying the order, LVN 1 said no.
The facility also failed to maintain accurate controlled substance records. Narcotic check sheets for Medication Cart B showed missing nurse signatures during shift changes on more than 30 occasions between June 2024 and January 2025. Federal regulations require two licensed nurses to conduct physical inventories of controlled medications at each shift change.
Blood pressure medications were repeatedly given to residents when their blood pressure readings fell below the parameters specified by physicians. Resident 37 received metoprolol when his systolic blood pressure was 109, 104, and 101 mmHg, despite physician orders to hold the medication if systolic pressure dropped below 110. The resident also received clonidine when his blood pressure was 99/55, below the 110 systolic threshold.
Resident 53 received metoprolol four times when blood pressure readings were below the physician's hold parameter of 120 systolic. According to medical references, hypotension is among the most common adverse effects of these blood pressure medications.
Kitchen safety violations compounded the facility's problems. Cook 1 was observed using a red cutting board to prepare raw chicken, when facility guidelines required yellow cutting boards for poultry. The cook didn't respond when asked if using the wrong color board was acceptable.
Two dietary aides couldn't properly test sanitizing solutions used to clean food preparation surfaces. One aide held test strips in sanitizing solution for only two seconds instead of the required ten seconds, then confirmed the 150 parts per million reading was inadequate. Facility policy required sanitizing solutions to maintain at least 200 ppm.
Kitchen equipment showed evidence of poor sanitation practices. Inspectors found a blender with brown residue inside the pitcher, a microwave with food buildup on the turntable and door, and a toaster with thick, greasy deposits. Steam table pans were stacked and stored while still wet, violating food safety requirements for air-drying equipment.
The facility served inadequate protein portions to vegetarian residents. When the regular menu provided 28 grams of protein from meatloaf, residents with vegetarian diet orders received grilled cheese sandwiches containing only nine grams of protein. Resident 70, diagnosed with severe protein-calorie malnutrition, was among those receiving the nutritionally insufficient meals.
Psychotropic medication consent forms went unrenewed for months beyond the required six-month intervals. Seven residents had expired informed consent documents for antidepressants, mood stabilizers, and antipsychotic drugs. Resident 53's consent forms for Risperdal, Depakene, and Remeron hadn't been renewed since May 2024.
Monitoring of psychotropic drug side effects proved inconsistent. Blood pressure checks for orthostatic hypotension showed identical readings in lying and sitting positions for Resident 53 — an impossibility that indicated nurses weren't actually changing the resident's position between measurements.
One medication cart was left unlocked and unattended in a hallway where staff and residents regularly passed. LVN 1 admitted she had removed narcotic medications from the cart and "forgot to lock it."
Hospice care coordination failures left Resident 49 without required visits. Physician orders called for certified home health aide visits three times weekly and skilled nurse visits one to three times weekly. But hospice records showed weeks with no visits at all, and many weeks with only one aide visit instead of three. The facility had no designated hospice coordinator to ensure proper service delivery.
Personal belongings contaminated the laundry room's clean folding area, where inspectors found purses, cell phone chargers, bottled water, and residents' eyeglasses mixed among clean linens. Two pairs of reading glasses had come from soiled linens collected from resident rooms but hadn't been sanitized.
Bed safety assessments remained incomplete for residents using side rails. Entrapment risk evaluations failed to document measurements for Zone 2 — the area under rails between supports where residents could become trapped. The facility's own policy required assessing all seven potential entrapment zones before installing bed rails.
Resident 13, who had been using bilateral side rails for an extended period, never received a proper entrapment assessment before installation. The licensed nurse acknowledged that risk assessments "should be completed prior to installation of side rails" but verified none had been done.
Equipment maintenance problems included ice machines cleaned with incorrect chemical concentrations, medication refrigerators with ice buildup, and a microwave with charred interior that was being used to heat food brought by visitors.
The facility's 94 residents who received meals from the kitchen faced potential foodborne illness risks from the multiple sanitation failures. Maintenance tools were stored improperly on kitchen floors instead of designated areas away from food preparation zones.
The Director of Nursing and Administrator acknowledged the inspection findings when presented with the violations on January 27.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Leisure Court Nursing Center from 2025-01-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LEISURE COURT NURSING CENTER in ANAHEIM, CA was cited for violations during a health inspection on January 27, 2025.
But pharmacy records showed the medication wasn't delivered until January 22 at 11:15 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.