Coventry Court Health Center

F-F552.

50953

2. Review of the facility's P&P titled Psychotropic Drug Use dated 8/2017, showed the Licensed Nurses shall

review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse effects prior to verification of admission orders with the Attending Physician.

Medical record review for Resident 14 was initiated on 7/30/2024. Resident 14 was admitted to the facility on [DATE REDACTED], with diagnosis of anxiety, bipolar disorder and schizophrenia.

Review of Resident 14's Order Summary Report dated 7/30/24, showed the following orders dated:

- 2/20/24, quetiapine rumarate (antipsychotic) 25 mg one tablet by mouth at bedtime manifested by auditory hallucination as evidence by hearing voices not present related to other schizophrenia

- 5/10/22, clonazepam (antianxiety) 1 mg one tablet by mouth every 12 hours for anxiety disorder manifested by verbalization of feeling anxious

Review of Resident 14's comprehensive plan of care initiated on 4/1/24, showed a care plan problem initiated for schizophrenia m/b hallucinations. The interventions included to administer medications as ordered and monitor for side effects and effectiveness. However, the care plan failed to include intervention to monitor Resident 14 for signs of orthostatic hypotension related to the use of psychotropic medications.

Review of Resident 14's MAR dated 7/1-/31/24, failed to show documentation Resident 14 was monitored for signs of orthostatic hypotension.

On 8/1/2024 at 1530 hours, an interview and concurrent medical record review for Resident 14 was conducted with the DON. The DON verified the findings and stated the blood pressure should be checked for

the residents who were receiving the psychotropic medications to monitor for orthostatic hypotension.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453 Residents Affected - Few Based on observation, interview, medical record review, facility document review, and facility P&P review,

the facility failed to ensure the proper storage and disposal of medications for one of one medication storage room, three of four medication carts inspected for medication storage and labeling. In addition, the facility failed to ensure the medications were not stored at the bedside for one of 20 final sampled residents (Resident 35) and one nonsampled resident (Resident 66).

* The facility failed to ensure the oral medications were stored separate from externally used medications in

the medication room.

* The facility failed to ensure the medications in the bubble packs (type of pre-formed, plastic packaging that seal individual tablets until they are taken) were secured, sealed and free from tears or damage for two nonsampled residents (Residents 1 and 88).

* The facility failed to ensure Medication Cart C was not left unlocked and unattended.

* The facility failed to ensure the medication for one discharge nonsampled resident (Resident 83) and expired medication for one nonsampled resident (Resident 56) were removed from the medication cart.

* The facility failed to ensure an unopened insulin vial for one nonsampled resident (Resident 22) was stored

in the medication refrigerator.

* The facility failed to ensure Residents 35 and 66's medications were not kept at the bedside.

These failures had the potential to negatively impact the residents' well being.

Findings:

Review of the facility's P&P titled Medication Storage in the Facility (undated) showed the following:

- The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications;

- Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications;

- Medication rooms, medication carts, and medication supplies are locked or attended by persons with authorized access;

- Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0761 - Eye medications are kept separate from ear medications;

Level of Harm - Minimal harm or - Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label; potential for actual harm - Refrigerated medications are kept in closed and labeled containers, with internal and external medications Residents Affected - Few separated; and

- Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.

1. On [DATE REDACTED] at 0926 hours, an inspection of the facility's Medication Room and concurrent interview was conducted with RN 1.

a. The following was observed inside the medication cabinet:

- Three boxes of Glutose (oral glucose gel, used to treat low blood sugar levels was stored with Tylenol (over

the counter medication used to relieve pain and reduce fever) suppositories and Prep-H (medication used to relieve internal swelling caused by hemorrhoids) suppositories;

- A box of Salonpas lidocaine cream (medication used to provide pain relief) was stored with the ear wax removal drops, Refresh PM (medication use to relieve dry eyes) eye drops, and boxes of sodium chloride hypertonicity ophthalmic ointment (medication used to draw water out of a swollen cornea);

- A box of oral Cepacol (lozenges used to temporarily relieve pain from minor mouth problems) and three bottles of Robitussin DM (medication used to temporarily relieve cough) was stored with three bottles of saline nasal spray.

b. The following was observed inside Medication Refrigerator B:

- One Humalog (fast-acting insulin used to control high blood sugar) pen and three Basaglar (long-acting insulin used to control high blood sugar) were observed inside the freezer area;

- One bottle of oral lorazepam liquid (antianxiety medication) was stored with Rhopressa 0.02% ophthalmic solution (medication used to reduce high eye pressure in glaucoma or ocular hypertension), Lantus (long-acting insulin used to control high blood sugar) pen, Humalog pen, Novolog (rapid-acting insulin used to control high blood sugar) and Humulin (short-acting insulin used to control high blood sugar) pens.

RN 1 verified the above findings.

2. On [DATE REDACTED] at 1059 hours, an inspection of Medication Cart B and concurrent interview was conducted with LVN 1. The following was observed:

a. A bubble pack containing tamsulosin (medication used to treat symptoms of enlarged prostate gland) for Resident 83 was observed inside the cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0761 Closed medical record review for Resident 83 was initiated on [DATE REDACTED]. Resident 83 was admitted to the facility on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 83's Order Summary Report showed a physician's order dated [DATE REDACTED], for the resident may leave against medical advice. Residents Affected - Few b. A bubble pack of entecavir (antiviral medication used to treat Hepatitis B) Resident 1 was observed with a tear on one of the individual bubbles where an entecavir medication was individually stored.

c. A bubble pack of gabapentin (medication used to treat partial seizures and nerve pain) for Resident 88 was observed with a tear on two of the individual bubbles where gabapentin medications were individually stored, and a tape was used to secure the bubble pack.

LVN 1 verified the above findings.

3. On [DATE REDACTED] at 1132 hours, Medication Cart C parked in the hallway was observed unlocked and unattended. The visitors and unlicensed staff were observed passing by. The Clinical Resource verified the above findings.

On [DATE REDACTED] at 1142 hours, an interview was conducted with LVN 3. LVN 3 stated she was assigned to Medication Cart C. LVN 3 stated she went to the resident's room and did not close or push the lock button all

the way in to lock the medication cart.

4. [DATE REDACTED] at 1452 hours, an inspection of Medication Cart A and concurrent interview was conducted with RN 2. The following was observed:

a. An unopened vial of Novolog for Resident 22 was observed inside the medication cart, not refrigerated.

b. A vial of Humulin for Resident 56 was observed with an opened date of [DATE REDACTED], and expiration date of [DATE REDACTED].

RN 2 verified the above findings.

50787

5. On [DATE REDACTED] at 0847 hours, an observation of Resident 35's room was conducted. A bottle of Frankincense and Myrrh Foot Pain Relief Rubbing Oil (used for temporary relief from burning, shooting, pricking, tingling, stabbing pain and numbness of the feet) and Longevity Essential Oil Deep Penetrating Joint and Pain Relief Antibacterial Antiviral Formula (used for pain and joint relief) were observed on Resident 35's bedside dresser. Resident 35 stated the CNA applied the Frankincense and Myrrh Foot Pain Relief Rubbing Oil on her legs and the Longevity Essential Oil Deep Penetrating Joint and Pain Relief Antibacterial Antiviral Formula was used for her neuropathy (weakness, numbness, and pain from nerve damage).

Medical record review for Resident 35 was initiated on [DATE REDACTED]. Resident 35 was readmitted to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0761 Review of Resident 35's MDS dated [DATE REDACTED] showed Resident 35's BIMS score of 15 (cognitive intact).

Level of Harm - Minimal harm or Further review of Resident 35's medical record failed to show a physician's order for the Frankincense and potential for actual harm Myrrh Foot Pain Relief Rubbing Oil and Longevity Essential Oil Deep Penetrating Joint and Pain Relief Antibacterial Antiviral Formula and a care plan problem addressing the use of the above medications. Residents Affected - Few

On [DATE REDACTED] at 0919 hours, an observation and interview was conducted with the ADON/IP. The ADON/IP verified the above finding. The ADON/IP stated Resident 35 was not supposed to have the above medications at bedside. Resident 35 agreed to have the medication bottles removed and the ADON/IP stated she would have the physician called if the medications were needed.

6. On [DATE REDACTED] at 0906 hours, an observation of Resident 66's room was conducted. A box of Arthro-7 (supplement used to treat joint pain) was observed on Resident 66's bedside dresser.

Medical record review for Resident 66 was initiated on [DATE REDACTED]. Resident 66 was admitted to the facility on [DATE REDACTED].

Review of Resident 66's MDS dated [DATE REDACTED], showed Resident 66 had moderate cognitive impairment.

On [DATE REDACTED] at 0908 hours, an observation and interview was conducted with LVN 1. LVN 1 verified the above finding and stated Resident 66 was not supposed have the medication at bedside. LVN 1 stated the resident's family brought him stuff and she did not see the medication before. LVN 1 was asked who supposed to be checking the resident's bedside and LVN 1 stated she checked the residents' bedside during her shift but did not check Resident 66's bedside yet.

On [DATE REDACTED] at 1030 hours, an interview was conducted with Resident 66. Resident 66 stated his family brought the box of Arthro-7 for him but had not take the medication.

On [DATE REDACTED] at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48882

Residents Affected - Some Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure

the food safety and sanitation requirements were met in the kitchen when:

* The facility failed to ensure the kitchen utensils and equipment were clean and stored in sanitary conditions.

* The facility failed to ensure the kitchen utensils were in good condition.

* The facility failed to ensure the personnel entering the kitchen donned hair covering in the kitchen.

* The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened.

* The facility failed to ensure the fan unit inside the walk-in refrigerator was clean and free of buildup.

These failures had the potential to cause foodborne illnesses in a highly susceptible resident population of 88 facility residents who consumed food prepared in the kitchen.

Findings:

Review of the facility document titled Diet Type Report dated 7/29/24, showed 88 of 92 residents in the facility received food prepared in the kitchen.

1. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch,

the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

According to the USDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Review of the facility's P&P titled Sanitation dated 2023 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.

On 7/29/24 at 0800 hours, during an initial tour of the kitchen, the following was observed:

- a metal spoon with brown colored stain on both sides,

- a metal lemon squeezer with dried black food particles,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0812 - multiple clean kitchen utensils stored on top of a dirty baking sheet pan. The sheet pan was observed with dried food particles, multiple dried brown dust particles, and two brownish colored screws. Level of Harm - Minimal harm or potential for actual harm - the drawer holding the baking sheet pan, that contained clean cooking utensils was observed with an orange-brown discoloration on the inner bottom wall of the drawer. A white towel was used to wipe the Residents Affected - Some drawer wall and the towel was observed with a brownish color stain.

The CDM verified the above findings.

2. Review of the facility's P&P titled Sanitation dated 2023 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded.

Review of the facility's P&P titled Can Opener and Base dated 2023 showed proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade or worn-out cogwheel. The can opener must be thoroughly cleaned each work shift and when necessary, more frequently. To replace the blade on the can opener, as needed.

a. On 7/29/24 at 0800 hours, during the initial tour of the kitchen, a frayed plastic spatula was observed. The CDM verified the finding.

b. On 7/30/24 at 1415 hours, during a follow-up visit in the kitchen, an observation was conducted of the stationary table can opener. The can opener was observed with chipped stainless-steel coating, exposing

the blade. The CDM verified the finding.

3. According to the USDA Food Code 2022, Section 2-402.11 Hair Restraints, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Review of the facility's P&P titled Dress Code dated 2023, under the section Proper Dress showed hat for hair, if hair is short; hair net for hair if hair is long.

On 7/30/24 at 1120 hours, an observation and concurrent interview was conducted with the Maintenance Assistant. The Maintenance Assistant was observed in the kitchen passing the marked red line without a hair net. The Maintenance Supervisor verified the findings . When asked the Maintenance Assistant stated he should wear a hair net when entering the kitchen.

On 8/1/24 at 1257 hours, an interview was conducted with the CDM. The CDM stated he expected individuals who entered the kitchen to stay behind the red line. If they needed to pass the red line, the individual should wear a hair net and a beard mask.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0812 4. Review of the facility's P&P titled Labeling and Dating of Foods dated 2023 showed all food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either Level of Harm - Minimal harm or food safety or product rotation. The individual opening or preparing a food shall be responsible for date potential for actual harm marking at the time of processing and/or storage.

Residents Affected - Some On 7/29/24 at 0800 hours, during the initial tour of the kitchen, the following was observed to be unlabeled with an open date or use-by date:

- an opened bag of hamburger buns and

- two opened bags of hot dog buns.

The CDM verified the above findings. The CDM stated he did not know when the bags were opened, the items should have had an opened date when first opened.

5. According to the USDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Review of the facility's P&P titled Sanitation dated 2023 showed all equipment shall be maintained as necessary and kept in working order.

On 7/29/24 at 0800 hours, during the initial tour of the kitchen, the fan unit inside the walk-in refrigerator was observed with grey colored fuzz. A white towel was used to wipe the substance and the grey fuzzy substance was observed on the towel. The CDM verified this finding.

On 8/1/24 at 1405 hours, the Administrator and CDM were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 48882 potential for actual harm Based on interview, facility document review, and facility P&P review, the facility failed to ensure the Residents Affected - Few education was provided to the staff and family/visitor on safe food handling of outside food as per the facility's P&P. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.

Findings:

Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further shows the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit.

Review of the facility's P&P titled Food Brought by Family and Visitor revised 7/21/21, showed the resident and or resident representative will be informed of the policy and provided safe food handling guidance in the form of verbal and writing. This guidance will be documented and retained by nursing or in the medical

record as a progress note and/or care plan.

Review of the facility's document titled Bringing in Food for a Resident dated 2023 failed to show instructions for safe food handling of food brought into the facility.

On 8/1/24 at 1257 hours, an interview was conducted with the CDM. The CDM stated when visitors wanted to bring in food from outside, he was involved in speaking with them to ensure the therapeutic diets and textures were met. The CDM stated he did not discuss about the hand hygiene and prevention of the cross contamination with the visitors. When asked about the education provided to the staff regarding safe food handling to ensure the staff were able to provide appropriate education to the residents and visitors, the CDM stated that was the DSD's responsibility.

On 8/1/24 at 1311 hours, an interview was conducted with the DSD. The DSD provided the facility document titled Bringing in Food for a Resident and stated he reviewed the contents of the document when conducting in-services to the staff regarding safe food handling. The DSD further stated the document was reviewed with the residents and families when the visitors wanted to bring in food from outside. The DSD was asked to show if the document addressed safe food handling. The DSD reviewed the document and stated the document did not discuss the safe food handling for preparing, cooling, and storage of food, or how to prevent cross contamination.

On 8/1/24 1334 hours, an interview and concurrent review of the facility's P&P titled Food Brought by Family and Visitor and the facility document titled Bringing in Food for a Resident was conducted with the DON. The DON verified the facility documents did not provide education about the safe food handling.

On 8/1/24 at 1405 hours, the Administrator and CDM were informed and acknowledged the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Potential for 48882 minimal harm Based on observation, interview, and facility P&P, the facility failed to ensure the garbage and refuse were Residents Affected - Some properly stored in two out of three garbage dumpsters. The garbage dumpsters was observed overflowing with garbage which prevented the lids from fully closing. This failure had the potential to attract pests/rodents that carry diseases.

Findings:

According to the US Food Code 2022 5-501.113, Covering Receptacles, showed receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids.

Review of the facility's P&P titled Garbage and Rubbish Disposal revised 2/23 showed all garbage and rubbish containing food waste shall be kept in containers. All containers shall be provided with tight-fitting lids or covers, and such containers must be kept covered when stored or not in continuous use.

On 7/29/24 at 0837 hours, an observation of the facility's outside garbage dumpsters was conducted with the Maintenance Supervisor. Two garbage dumpsters were observed with the lids propped open by trash bags and cardboard boxes, preventing the lid from fully closing. The Maintenance Supervisors verified the findings and stated the dumpster lids should be completely closed and trash should not pass the maximum loading level indicated on the dumpsters.

On 8/1/24 at 1405 hours, the Administrator and CDM were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48882

Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure

the medical records for four of 20 final sampled residents (Residents 14, 17, 20, and 50) were accurate and complete.

* The facility failed to ensure Resident 50's RNA documentation was complete.

* The facility failed to ensure Resident 17's Smoking Evaluation was accurately completed.

* The facility failed to ensure Resident 50's RNA documentation was complete.

* The facility failed to ensure Resident's TARs regarding the indwelling urinary catheter securement and monitoring Resident 14's edema were completed.

* The facility failed to ensure Resident 14's medical record did not contain another resident's health information.

These failures had the potential for the residents' care needs not being met as their medical information were inaccurate.

Findings:

Review of the facility's P&P titled Charting and Documentation undated showed the purpose is to provide the following:

1. A complete account of the resident's care, treatment, response to the care, signs symptoms, etc., as well as the progress of the resident's care.

2. Guidance to the physician in prescribing appropriate medications and treatments.

3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident.

4. Nursing service personnel with a record of the physical and mental status of the resident.

5. Assistant in the development of a Plan of Care for each resident.

1. Medical record review for Resident 17 was initiated on 7/29/24. Resident 17 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 17's H&P examination dated 12/2/23, showed Resident 17 had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0842 Review of Resident 17's MDS dated [DATE REDACTED], showed Resident 17 had no impairments in her functional limitation in range of motion for her upper extremity (shoulder, elbow, wrist, and hand). Level of Harm - Minimal harm or potential for actual harm Review of Resident 17's Plan of Care showed a care plan problem dated 4/7/23, addressing Resident 17's potential for injury related to smoking and continuous use of cigarettes. The interventions showed to Residents Affected - Few complete the smoking assessment, observe Resident 17 smoking in designated areas, and report noncompliance or unsafe smoking habits to the MD and responsible party. The care plan interventions further showed Resident 17 preferred to smoke unsupervised and had stated she was able to hold cigarettes and put it out safely in the smoking receptacle.

Review of Resident 17's quarterly LN-Smoking Evaluation dated 5/22/24, showed Resident 17 smoked five times a day, did not have any dexterity problems, and was able to light her own cigarette. Under the Safety section, the evaluation showed Resident 17 was not able to safely light, hold, or dispose of safety materials, and did not need adaptive clothing, device, or assistance.

On 7/30/24 at 0730 hours, a smoking observation was conducted of Resident 17. Resident 17 was observed

on a wheelchair and wheeling herself through the facility's side door. Resident 17 was observed smoking and holding her cigarette with no observed limitations in her upper extremities.

On 7/30/24 at 1433 hours, an interview as conducted with CNA 10. CNA 10 stated Resident 17 smoked four to five times a day and did not wear an apron when smoking. CNA 10 stated Resident 17 was able to feed herself with minimal set-up assistance required and hold her own cigarettes and light her cigarettes safely.

On 7/31/24 at 1420 hours, an interview was conducted with the Activities Director. The Activities Director stated he was familiar with Resident 17 and had accompanied her to smoke on multiple occasions. The Activities Director stated Resident 17 did not have any impairment or weakness in her hands and upper extremities and that Resident 17 was able to light and hold her own cigarettes and deposit her smoking materials appropriately and safely.

On 8/1/24 at 1334 hours, an interview was conducted with the DON. The DON stated Resident 17 was able to self-ambulate in her wheelchair, open facility doors, and feed herself. The DON stated she had observed Resident 17 smoking and stated Resident 17 did not have any upper extremity impairments. Concurrent

record review for Resident 17 was conducted with the DON. The DON verified the above findings. The DON stated the smoking evaluation for Resident 17 was conducted inaccurately. When asked, the DON stated

she expected the assessments and documentation to be accurate to reflect the resident's current condition.

On 8/1/24 at 1410 hours, the DON and Administrator were informed and acknowledged the above findings.

50967

2. Medical record review for Resident 50 was initiated on 7/30/24. Resident 50 was admitted to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0842 Review of Resident 50's Order Summary Report showed a physician's order dated 6/6/24, for PRAFO application to the resident's RLE daily five times/week for up to four hours as tolerated; and to monitor skin Level of Harm - Minimal harm or integrity every shift every Monday, Tuesday, Wednesday, Thursday, and Friday. potential for actual harm

On 7/31/24 at 0853 hours, an interview was conducted with the RNA. The RNA stated Resident 50 had an Residents Affected - Few order for PRAFO application on the right lower leg for four hours a day as tolerated by the resident and applied it between 0930 to 1030 hours. The RNA also stated she would check the resident for any signs of pain, redness on his skin prior to applying the PRAFO and document on the RNA sheet.

On 7/31/24 at 0957 hours, Resident 50 was observed lying in bed asleep with no signs of pain or discomfort.

The right lower extremity PRAFO was observed present. Resident 50 was confused and nonverbal.

On 7/31/24 at 1415 hours, review of a copy of Resident 50's RNA sheet for PRAFO showed missing docuementation from 7/24 to 7/26/24.

On 7/31/24 at 1426 hours, a concurrent interview and document review was conducted with LVN 2. LVN 2 verified Resident 50's RNA sheet showed missing documentation for dates 7/24 to 7/26/24. LVN 2 stated

she would report to the RN supervisor for any missing documentation.

On 8/1/24 at 1428 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

47474

3. Medical record review for Resident 14 was initiated on 7/30/24. Resident 14 was admitted to the facility on [DATE REDACTED].

Review of Resident 14's quarterly MDS dated [DATE REDACTED], showed Resident 14 had a BIMS score of 15 which meant the resident was cognitively intact.

Review of Resident 14's Order Summary Report for July 2024 showed a physician's order dated 5/9/22, to secure the Foley catheter with catheter strap or patch to thigh every shift. Further review of the Order Summary Report showed the physician's orders dated 6/20/22, to monitor the left and right lower extremities edema every shift.

a. Review of Resident 14's TAR for July 2024 showed the entry to secure the Foley catheter; however, there were no nurses' initials on the following dates:

- Wednesday, 7/3/24

- Wednesday, 7/10/24

- Sunday, 7/14/24

- Monday, 7/15/24

- Tuesday, 7/16/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0842 - Friday, 7/19/24

Level of Harm - Minimal harm or - Monday, 7/22/24 potential for actual harm - Wednesday 7/24/24 Residents Affected - Few b. Further review of Resident 14's TAR for July 2024, showed the entries for monitoring the left lower extremity and right lower extremity edema monitoring every shift; however, there were no nurses' initials on

the following dates:

- Wednesday, 7/3/24

- Wednesday, 7/10/24

- Sunday, 7/14/24

- Monday, 7/15/24

- Tuesday, 7/16/24

- Friday, 7/19/24

- Monday, 7/22/24

- Wednesday 7/24/24

On 7/31/24 at 1010 hours, a concurrent interview and medial record review with the DSD was conducted.

The DSD verified the above findings regarding missing nurses' initials.

On 8/1/24 at 1530 hours, an interview with the Administrator and DON was conducted. The Administrator and DON verified the above findings.

46787

4. Medical record review for Resident 14 was initiated on 7/29/24. Resident 14 was admitted to the facility on [DATE REDACTED].

Further review of Resident 14's medical record showed an Integrative Psychology Progress Note dated 11/4/22, for Resident 20 was in Resident 14's medical record.

On 8/1/24 at 0954 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50787 potential for actual harm Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure Residents Affected - Some the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by:

* The facility failed to implement their infection control surveillance program for August 2023 through June 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program.

* The facility failed to accurately track and monitor for the infections for April and May 2024.

* The facility failed to ensure the staff performed hand hygiene before and after meal tray distribution.

* The facility failed to ensure the infection control practices were implemented in the facility's laundry room.

These failures posed the risk for not identifying infections and controlling the transmission of communicable disease to other residents throughout the facility.

Findings:

Review of the facility's P&P titled Infection Prevention - Surveillance of Infections and Reporting, (undated), showed the facility to maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections to ensure that measures are taken to prevent any potential outbreak.

The IP/Designee will review the log during the morning routine to ensure all potential/ actual infections/ outbreaks are being identified.

1.a. Review of the facility's monthly Prevention and Control Surveillance Log from August 2023 to June 2024 showed the following surveillance data:

- August 2023, total of 26 cases including 20 CAI and 6 HAI

- September 2023, total of 21 cases including 15 CAI and 6 HAI

- October 2023, total of 26 cases including 19 CAI and 7 HAI

- November 2023, total of 23 cases including 18 CAI and 5 HAI

- December 2023, total of 24 cases including 17 CAI and 7 HAI

- January 2024, total of 26 cases including 20 CAI 20 and 6 HAI

- February 2024, total of 30 cases including 22 CAI and 8 HAI

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0880 - March 2024, total of 26 cases including 19 CAI and 7 HAI

Level of Harm - Minimal harm or - April 2024, total of 33 cases including 25 CAI and 8 HAI potential for actual harm - May 2024, total of 30 cases including 27 CAI and 3 HAI Residents Affected - Some - June 2024, total of 28 cases including 21 CAI and 7 HAI

Review of the facility's monthly Prevention and Control Surveillance log from August 2023 through June 2024 showed documentation of the residents having an HAI or CAI and prescribed with antimicrobial medications.

Further review of the facility's monthly Prevention and Control Surveillance Log from August 2023 through June 2024 showed the facility failed to conduct surveillance for all resident infections, specific to the residents who had signs and symptoms of infection, met the McGeer's criteria (method used to retrospectively counting true infection), and were not prescribed antimicrobial medications.

On 7/31/24 at 1300 hours, an interview was conducted with the ADON/IP. When asked if she included the residents with signs and symptoms of infection, met the McGeer's criteria, and were not prescribed antimicrobial medications on the monthly Prevention and Control Surveillance Log, the ADON/IP stated she did not. The ADON/IP stated the facility monitored the residents who met the McGeer's criteria but were not prescribed antimicrobial medications on the COC log.

On 8/1/24 at 1102 hours, a follow-up interview and concurrent facility document review was conducted with

the ADON/IP. The ADON/IP verified the monthly Prevention and Control Surveillance Log from August 2023 through June 2024 did not include the residents with symptoms of infection who met the McGeer's criteria but were not prescribed with antimicrobial medications.

b. Review of the facility's monthly Prevention and Control Surveillance Log for April 2024 showed the following:

- an onset date of 4/17/24, for Resident 29's amoxicillin (antibiotic) 875-125 mg one tablet by mouth every 12 hours for 14 days, the log did not show whether the resident had CAI, HAI or did not meet the McGeer's criteria.

Review of the facility's monthly Prevention and Control Surveillance Log for May 2024 showed the following:

- an onset date of 5/13/24, for Resident 537's doxycycline (antibiotic) 100 mg one tablet by mouth two times

a day for 10 days, the log did not show whether the resident had CAI, HAI, or did not meet the McGeer's criteria.

- an onset date of 5/4/24, for Resident 26's cefdinir (antibiotic) 300 mg one capsule by mouth two times a day for seven days, the log did not show whether the resident had CAI, HAI or did not meet the McGeer's criteria.

- a total number of residents who did not meet the McGeer's criteria was two.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0880 Review of Resident 537's Surveillance Data Collection Form dated 5/14/14, showed the resident's doxycycline did not meet the McGeer's criteria. Level of Harm - Minimal harm or potential for actual harm On 7/31/24 at 1300 hours, an interview and concurrent facility document review was conducted with the ADON/IP. The ADON/IP verified the above findings and stated the surveillance log for April and May 2024 Residents Affected - Some had missing entries for the section to indicate CAI, HAI, or did not meet the McGeer's criteria. The ADON/IP stated the log for May 2024 was inaccurate because the total number of residents who did not meet the McGeer's criteria should have been three.

2.a. Review of the facility's P&P titled Hand Hygiene dated 10/2022 showed all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and or visitors. Under the Procedure section, it showed to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non- antimicrobial) and water for the following situations:

- after contact with objects in the immediate vicinity of the resident;

- after removing gloves;

- before and after eating or handling food; and

- before and after assisting a resident with meals.

On 7/29/24 at 1226 hours, a dining observation was conducted. CNA 2 was observed delivering a meal tray inside room [ROOM NUMBER]. CNA 2 then proceeded to remove the plate and cup covers. CNA 2 was then observed bringing the plate cover back to the meal cart and removing Resident 47's meal tray from the meal cart. CNA 2 then placed the meal tray on top of Resident 47's bedside table and donned gloves. CNA 2 was observed moving the resident's wheelchair and placing bib around the resident's neck. With her gloves hands, CNA 2 removed the plastic covers from Resident 47's drinks. CNA 2 then removed her gloves and left the room. CNA 2 proceeded to get another meal tray from the cart and brought it to Resident 61's room without perform hand hygiene.

On 7/29/24 at 1233 hours, an interview was conducted with CNA 2. CNA 2 verified she donned gloves to move Resident 47's wheelchair and bedside table. CNA 2 verified she did not perform hand hygiene after removing her gloves, leaving the resident's room and before serving Resident 61's meal tray. CNA 2 was asked about the facility's protocol when delivering and serving multiple resident trays and after removing gloves. CNA 2 stated she should have used hand sanitizer after removing her gloves and before serving another resident's meal tray.

b. On 7/29/24 at 1249 hours, a dining observation was conducted. CNA 3 was observed delivering a meal tray to Resident 43, proceeded to remove the plate cover and opened the milk carton then left the room. CNA 3 was then observed removing Resident 689's meal tray from the cart, delivering it to the resident, and removing the plate cover without performing hand hygiene. CNA 3 then left Resident 689's room and delivered Resident 688's meal tray to his room and removed the plate cover without performing hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0880 On 7/29/24 at 1254 hours, an interview was conducted with CNA 3. CNA 3 verified the above findings and stated she was supposed to perform hand hygiene with each time she delivered a meal tray to a different Level of Harm - Minimal harm or resident. potential for actual harm 3. Review of the facility's P&P titled Laundry dated January 2024 showed it is the policy of the facility that Residents Affected - Some careful precautionary procedures must be followed by laundry personnel to prevent spread of infectious diseases to other staff members, residents, and visitors.

On 7/29/24 at 1412 hours, an inspection of the laundry area and concurrent interview with CNA 1 and Laundry 1 was conducted. The pen holder with multiple writing materials, water bottle, and personal cell phone were observed on the laundry folding table. CNA 1 and Laundry 1 verified the findings and CNA 1 stated the water bottle and cell phone belong to her. Laundry 1 stated the laundry folding table was a clean area and should not have other things on the table.

On 8/1/24 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50787 potential for actual harm Based on interview, medical record review, facility document review, and facility P&P review, the facility Residents Affected - Some failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for

the McGeer's criteria to determine the true infection. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials.

Findings:

Review of the facility's P&P titled Antibiotic Stewardship, undated, showed it is the policy of the facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotic while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute setting, while improving treatment efficacy and resident safety, and reducing treatment - related costs. The Core Elements of stewardship are the same for both acute care setting and nursing homes, as outlined by CDC (Center for Disease Control); however, facilities may have a difference in the implementation of these elements: leadership, accountability, drug expertise, action to implement recommended policies or practices, tracking measures, reporting data, education for clinicians, nursing staff, residents, and families about antibiotic resistance and opportunities for improvement.

1.a. Review of the facility's infection control binder showed Surveillance Data Collection Form being used to assess for McGeer's criteria to determine the true infection.

Review of the facility's monthly Prevention and Control Surveillance Logs from August 2023 through June 2024 showed the following surveillance data.

- August 2023, 26 infected residents with antibiotics

- September 2023, 21 infected residents with antibiotics

- October 2023, 26 infected residents with antibiotics

- November 2023, 23 infected residents with antibiotics

- December 2023, 24 infected residents with antibiotics

- January 2024, 26 infected residents with antibiotics

- February 2024, 30 infected residents with antibiotics

- March 2024, 26 infected residents with antibiotics

- April 2024, 33 infected residents with antibiotics

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0881 - May 2024, 30 infected residents with antibiotics

Level of Harm - Minimal harm or - June 2024, 28 infected residents with antibiotics potential for actual harm However, the facility failed to show documentation the McGeer's/Surveillance Data Collection form was Residents Affected - Some completed to assess for the true infection for the residents who were admitted from the acute care hospital with antibiotics:

On 7/31/24 at 1300 hours, an interview and concurrent facility document review was conducted with the ADON/IP. The ADON/IP verified the above findings. The ADON/IP stated she did not complete the Surveillance Data Collection Form for the residents who were admitted from the acute care hospital with antibiotics. The ADON/IP stated she was trained to only complete the Surveillance Data Collection Form for

the residents who were prescribed antibiotics at the facility.

b. Medical record review for Resident 29 was initiated on 7/31/24. Resident 29 was admitted to the facility on [DATE REDACTED].

Review of Resident 29's Surveillance Data Collection Form dated 5/15/24, showed Resident 29 met the McGeer's criteria and was prescribed Augmentin (antibiotic) 875-125 mg by mouth every 12 hours. However,

the bottom portion of the form did not show if the infection was HAI, CAI, or did not meet the criteria.

c. Medical record review for Resident 75 was initiated on 7/31/24. Resident 75 was admitted to the facility on [DATE REDACTED], and readmitted [DATE REDACTED].

Review of Resident 75's Surveillance Data Collection Form dated 6/3/24, showed Resident 75 was prescribed Levaquin (antibiotic) 500 mg by mouth daily for seven days and did not meet the McGeer's criteria. The Additional Notes section showed, Patient's clinical indication does not meet McGeer's criteria. Resident's ATB (antibiotic) started from the ER. Renal calculi. However, there was no documented evidence to show the facility had notified the physician that Resident 75's antibiotic did not meet the McGeer's criteria.

d. Medical record review for Resident 537 was initiated on 7/31/24. Resident 537 was admitted to the facility

on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 537's Surveillance Data Collection Form dated 5/13/24, showed Resident 537 was prescribed doxycycline (antibiotic) 100 mg two times a day for seven days and Augmentin 875-125 mg two times a day for seven days and did not meet the McGeer's criteria. However, the bottom portion of the form did not show if the infection was HAI, CAI or did not meet the criteria; and the Additional Notes section showed, Recurrent infection. In addition, there was no documented evidence to show the physician was notified that Resident 537's antibiotic medications did not meet the McGeer's criteria.

e. Medical record review for Resident 538 was initiated on 7/31/24. Resident 538 was admitted to the facility

on [DATE REDACTED], and readmitted on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0881 Review of the facility's monthly Prevention and Control Surveillance Log for April 2024 showed Resident 538 was prescribed mupirocin (antibiotic) external ointment 2 % for right foot wound dehiscence on 3/15/24. Level of Harm - Minimal harm or However, there was no documented evidence the Surveillance Data Collection Form was completed. potential for actual harm

On 7/31/24 at 1300 hours, an interview and concurrent facility document review was conducted with the Residents Affected - Some ADON/IP. The ADON/IP verified the above findings. The ADON/IP stated the whole Surveillance Data Collection Form should be completed. The ADON/IP stated the licensed nurses initiated the McGeer's criteria tool/Surveillance Data Collection Form and she completed the bottom portion of the form to show if

the infection was HAI, CAI, or did not meet the criteria. The ADON/IP stated she documented on the bottom portion of the Surveillance Data Collection Form if the prescribed antibiotic met the McGeer's criteria or not; and if it did not meet the criteria, she then would discuss it with the physician if the antibiotic should be continued or not. The ADON/IP also stated she would document the physician's decision on the bottom portion of the form.

On 8/1/24 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50787 potential for actual harm Based on interview, medical record review, facility document review, and facility P&P review, the facility Residents Affected - Few failed to offer and provide the education for influenza and pneumococcal immunizations for two of five final sampled residents (Residents 20 and 35) reviewed for immunizations.

* The facility failed to obtain the consent and provide education on the influenza vaccine to Residents 20 and 35.

* The facility failed to ensure Resident 35's Immunization Record was accurate for receiving the pneumococcal vaccine.

These failures had the potential for the residents to be uninformed of the risks and benefits of receiving the influenza vaccine and potentially affect care provided.

Findings:

Review of the facility's P&P titled Infection Prevention- Immunizations, Influenza and Pneumococcal (Resident), undated, showed it is the policy of this facility to ensure that before entering the influenza and or pneumococcal immunization, each resident's legal representative receives education regarding the benefits and potential side effects of the immunization. Prior to vaccination, the resident and/ or resident representative will be provided information and education regarding the benefits and potential side effects of

the influenza and/or pneumococcal immunization (Influenza and Pneumonia vaccine information sheet)

1. Medical record review for Resident 20 was initiated on 7/31/24. Resident 20 was admitted to the facility on [DATE REDACTED].

Review of Resident 20's Immunization Record dated 10/26/23, showed the resident received the influenza vaccine. There was no documented evidence in Resident 20's medical record a consent for vaccination was signed by the resident or their representative.

2. Medical record review for Resident 35 was initiated on 7/31/24. Resident 35 was admitted to the facility on [DATE REDACTED].

Review of Resident 35's Immunization Record dated 10/26/23, showed the resident received the influenza vaccine. There was no documented evidence the consent for vaccination was signed by the resident or their representative. Additionally, Resident 35's pneumoccal vaccine consent form did not show the resident had previously received the pneumococcal vaccine.

On 8/1/24 at 0922 hours, an interview was conducted with the ADON/IP. The ADON/IP verified th above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0908 Keep all essential equipment working safely.

Level of Harm - Potential for 39453 minimal harm Based on observation and interview, the facility failed to ensure the equipment was maintained in a safe Residents Affected - Some operating condition.

* The facility failed to ensure there was no ice buildup in the freezers of Medication Refrigerators A and B in Medication Room A. This failure had the potential for the equipment to not function in the way it was intended.

Findings:

On 7/30/24 at 0926 hours, an inspection of Medication Room A and concurrent interview was conducted with RN 1. The freezer compartments inside Medication Refrigerators A and B were surrounded with a buildup of ice. In addition, there was no cover observed on the freezer of Medication Refrigerator B. RN 1 verified the above findings. When asked who in charge of cleaning and maintaining the medication refrigerators, RN 1 stated she was unsure if the nursing department was in charge to clean the medication refrigerators.

On 8/1/24 at 0958 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. The DON stated the ice build-up of the medication refrigerators should be reported to the Maintenance Department.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50967

Residents Affected - Few Based on observation, interview, medical record review, facility document review, and facility P&P review,

the facility failed to ensure the residents' entrapment assessments were accurate and complete for six of nine sampled residents (Residents 14, 20, 37, 50, 54, and 69) reviewed for side rails use.

* The facility failed to ensure Residents 14, 20, 37, 50, and 69's entrapment assessments were accurate.

* The facility failed to ensure Resident 14's bed entrapment assessment was complete.

* The facility failed to ensure Resident 54's bed entrapment assessment was completed for the right half side rail prior to use.

These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Findings:

According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space

in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards.

The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:

- Zone 1: within the rail;

- Zone 2: under the rail, between the rail supports or next to a single rail support;

- Zone 3: between the rail and the mattress;

- Zone 4: under the rail, at the ends of the rail;

- Zone 5: between split bed rails;

- Zone 6: between the end of the rail and the side edge of the head or foot board; and

- Zone 7: between the head or foot board and the mattress end.

Review of the facility's P&P titled Proper Use of Bed Rails revised 12/2023 showed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0909 - Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail; Level of Harm - Minimal harm or potential for actual harm - Bed rails are adjustable metal or rigid plastic bars that are attached to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eight lengths. Also, Residents Affected - Few some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, grab bars and assist bars;

- Assessment should assess resident's risk of entrapment between mattress and bed rail or in the bed rail itself; and

- The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: (a) checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. Rails should be selected and placed to discourage climbing over rails, (b) ensuring that the bed's dimensions are appropriate for the resident by confirming that the bed rails are appropriate for the size and weight of the resident using the bed, ensuring that the bed's dimensions are appropriate for the resident by, installing bed rails using the manufacturer's instructions and specifications to ensure a proper fit, inspecting and regularly checking the mattress and bed rails for areas of possible entrapment, and ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth, (c) observing ongoing precautions such as following manufacturer's equipment alerts and recalls and increasing resident supervision, especially with the use of air-filled mattresses or therapeutic air-filled beds that may present a different entrapment risk than rail entrapment, (d) conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair.

During a concurrent observation, medical record review, and facility document review for Residents 20, 37, and 50 showed the residents' bed entrapment assessments were not accurate for Zone 5. For example:

1. On 7/29/24 at 0845 hours, during the initial tour of the facility, Resident 37 was observed lying in bed with

the bilateral half padded side rails elevated. Resident 37 was confused and mumbled words; unable to verify

the use of the side rails.

Medical record review for Resident 37 was initiated on 7/29/24. Resident 37 was admitted to the facility on [DATE REDACTED].

Review of Resident 37's H&P examination dated 5/6/24, showed Resident 37 did not have the capacity to make her own medical decisions.

Review of Resident 37's Order Summary Report showed a physician's order dated 5/22/24, for bilateral half padded side rails to aid with bed mobility and minimize risk of injury in the event of seizure activity.

Review of Resident 37's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed, Pass was circled for Zones 1 through 7.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0909 On 7/30/24 at 1033 hours, an observation and concurrent interview was conducted with the ADON/IP Nurse.

The ADON/IP Nurse verified Resident 37's bilateral side rails were elevated. Level of Harm - Minimal harm or potential for actual harm On 8/1/24 at 1030 hours, a concurrent interview and document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified he documented the entrapment assessment on Resident Residents Affected - Few 37's Bed Rail 7 Zones Entrapment Assessment. When asked about the assessments of the entrapment, the Maintenance Supervisor verified the bed entrapment assessments for Zones 5 was inaccurate. The Maintenance Supervisor stated he should have marked not applicable, N/A, for Zone 5. The Maintenance Supervisor verified the above findings.

On 8/1/24 at 1428 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

2. On 7/29/24 at 0951 hours, Resident 50 was observed lying in bed awake with bilateral half side rails elevated. Resident 50 was confused and nonverbal; unable to verify the use of the side rails.

Medical record review for Resident 50 was initiated on 7/31/24. Resident 50 was admitted to the facility on [DATE REDACTED].

Review of Resident 50's H&P examination dated 2/16/24, showed Resident 50 had history of CVA or stroke and cognitive communicative deficit.

Review of Resident 50's Order Summary Report showed a physician's order dated 5/24/24, for bilateral half side rails for positioning and ease in mobility as an enabler.

Review of Resident 50's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed, Pass was circled for Zones 1 through 7.

On 7/30/24 at 1125 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 50's bilateral half side rails were elevated.

On 8/1/24 at 1030 hours, a concurrent interview and document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified he documented the entrapment assessment on Resident 50's Bed Rail 7 Zones Entrapment Assessment. When asked about the assessments of the entrapment, the Maintenance Supervisor verified the bed entrapment assessments for Zones 5 was inaccurate. The Maintenance Supervisor stated he should have marked N/A for Zone 5.

On 8/1/24 at 1428 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

50787

3. On 7/29/24 at 1045 hours, Resident 20's bed was observed with half padded bilateral upper side rails.

Medical record review for Resident 20 was initiated on 7/29/24. Resident 20 was admitted to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0909 Review of Resident 20's Order Summary Report showed a physician's order dated 6/4/24, for padded bilateral half side rail up when in bed to minimize risk for injury in the event of seizure activity with verified Level of Harm - Minimal harm or informed consent obtained by the MD from the resident/responsible party. potential for actual harm

On 7/30/24 at 1200 hours, an interview was conducted with Resident 20. Resident 20 stated she used the Residents Affected - Few side rails when she moved around in bed. When asked if the side rails helped, Resident 20 stated the side rails helped her a lot in changing positions.

On 7/31/24 at 0916 hours, a follow-up observation was conducted in Resident 20's room. Resident 20's bed was observed with wooden headboard, padded bilateral half upper side rails, and a waffle mattress.

On 8/1/24 at 0958 hours, an observation and concurrent interview was conducted with the DOR. The DOR verified Resident 20 had bilateral half side rails. When asked about the purpose of the resident's side rail use, the DOR stated he was somewhat familiar of Resident 20 and the purpose of the side rail use was for bed mobility.

Review of Resident 20's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed all the zones passed the assessment. However, Resident 20 had no lower side rails and Zone 5 indicated passed.

Review of Resident 20's Plan of Care showed a care plan problem initiated on 4/4/23, to address Resident 20's use of side rail as an enabler. The interventions/tasks included to assess the gaps between the mattress, bed fame or side rail; and the use of side rail will be reevaluated quarterly and/or as needed.

On 8/01/24 at 1032 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated he checked off Zone 5 because there was no problem. The Maintenance Director was asked why Zone 5 was assessed, the Maintenance Director did not give a response. When asked if he should have documented N/A in Zone 5, the Maintenance Director stated could be.

On 8/01/24 at 1420 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

46787

4. On 8/1/24 at 0931 hours, Resident 14 was observed lying in bed with the bilateral upper half side rails elevated.

Medical record review for Resident 14 was initiated on 7/29/24. Resident 14 was admitted to the facility on [DATE REDACTED].

Review of Resident 14's Order Summary Report showed a physician's order for bilateral half side rails for positioning and ease in mobility as an enabler.

Review of Resident 14's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed, Pass for Zone 5.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0909 Review of Resident 14's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed the following sections were blank: Level of Harm - Minimal harm or potential for actual harm - Zone 1 to 7

Residents Affected - Few - Type of Mattress

- Mattress Condition

- Length and Width of Mattress

On 8/1/24 at 1029 hours, an interview and concurrent medical record review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the above findings. The Maintenance Supervisor acknowledged Zone 5 should have been marked as N/A since Resident 14 is only using the bilateral upper side rails.

5. On 8/1/24 at 1027 hours, Resident 69 was observed lying in bed with the bilateral upper half side rails elevated.

Medical record review for Resident 69 was initiated on 7/29/24. Resident 69 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 69's Order Summary Report showed a physician's order for bilateral half side rails up in bed to aid in bed mobility.

Review of Resident 69's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed, Pass for Zone 5.

On 8/1/24 at 1029 hours, an interview and concurrent medical record review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the above findings. The Maintenance Director acknowledged that Zone 5 should have been marked as N/A since Resident 69 was only using the bilateral upper side rails.

48882

6. On 7/31/24 at 0813 hours, Resident 54 was observed in bed with the right half side rail elevated.

Medical record review for Resident 54 was initiated on 7/29/24. Resident 54 was admitted to the facility on [DATE REDACTED], with a diagnosis of hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the left non- dominant side.

Review of Resident 54's MDS dated [DATE REDACTED], showed Resident 54's had moderately impaired cognition and had one-sided impairment for both upper and lower extremity functional limitation. The MDS also showed Resident 54 required substantial to maximal assistance, where the helper would do more than half the effort, for rolling from left to right in bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 57 055983 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055983 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

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 0909 Review of Resident 54's Order Summary Report dated 7/31/24, showed a physician's order dated 5/16/24, to apply the left half side rail for bed mobility. Level of Harm - Minimal harm or potential for actual harm Review of Resident 54's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed an entrapment assessment was conducted by the Maintenance Supervisor for the left half side rail. The assessment Residents Affected - Few showed Zones 1, 2, 3, 4, 5, 6, 7, and 8 were marked as passed.

Further review of Resident 54's medical record failed to show the following:

- a physician's order for the use of the right half side rail,

- a informed consent for the use of the right half side rail,

- a bed rail safety evaluation, and

- a bed rail entrapment assessment prior to the use of the right half side rail.

On 7/31/24 at 1316 hours, an interview and concurrent observation was conducted with LVN 7. LVN 7 stated Resident 54 had left-sided weakness and used the left side rail to grab during care and repositioning. LVN 7 verified Resident 54's right half side rail was elevated and verified there were no side rails on the left side of

the bed .

On 8/1/24 at 1030 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he was responsible for the side rail entrapment assessments. The Maintenance Supervisor stated the nurse would provide him with the authorization form for the resident, which would indicate the specific rail and side. Concurrent review of Resident 54's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified he conducted the assessment for the left half side rail. The Maintenance Supervisor also verified Zone 5 was marked as pass. The Maintenance Supervisor acknowledged Zone 5 did not need to be measured and should be marked as not applicable.

On 8/1/24 at 1334 hours, an interview was conducted with the DON. The DON was asked about the facility's policy for the use of side rails. The DON stated after a physician's order was obtained, the facility's IDT would conduct a bed side rail assessment and obtain an informed consent; the maintenance would perform an entrapment assessment; and a care plan would be initiated. The DON stated if a resident was able to move

on one side of the body, the IDT would determine which side of the the side rail would be placed. Concurrent

record review for Resident 54 was conducted with the DON. The DON verified the above findings. The DON stated the side rails should be placed to match the physician's order.

On 8/1/24 at 1410 hours, the Administrator and DON were informed and acknowledged the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 57 055983