Leisure Court Nursing Center

limited to receiving treatment and supports for daily living safely.

minimal harm Based on observation and interview, the facility failed to maintain a homelike environment for one of 24 final sampled residents (Resident 72) and one nonsampled resident (Resident 4).

* Resident 72 resided in Room A and Resident 4 resided in Room B.

Rooms A and B were observed with scratches and unpainted areas on the walls, adjacent to the residents' bed.

This failure had the potential to negatively impact the residents' quality of life.

Findings

• On 1/22/25 at 1211 hours, an observation and concurrent interview was conducted with Resident

72. Resident 72 was observed lying in her bed in Room A.

Room A was observed with scratches and unpainted areas on the wall adjacent to Resident 72's bed. Resident 72 stated having the wall repaired and painted would be nice.

• On 1/22/25 at 1217 hours, an observation and concurrent interview was conducted with Resident 4.

Resident 4 was observed lying in her bed watching television, in Room B.

Room B was observed with scratches and unpainted areas on the wall adjacent to Resident 4's bed. Resident 4 stated she spent most of her time in her room and would like the wall to be repaired.

On 1/27/25 at 1430 hours, an interview was conducted with the Administrator.

The Administrator was informed of the findings.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of the facility's P&P titled Discharge Process revised 1/2017 showed the facility will send a copy of the notice of transfer or discharge to a representative of the Office of the State Long-Term Care Ombudsman and record the reasons for the transfer or discharge in the resident's medical record.

On 1/23/25 at 0947 hours, a closed medical record review was initiated for Resident 109. Resident 109 was admitted to the facility on [DATE], and discharged [DATE].

On 1/23/25 at 0959 hours, an interview was conducted with the Ombudsman.

The Ombudsman stated she could not remember if she received the notice of discharge for Resident 109 but stated she would verify and call the survey team. On 1/23/25 at 1220 hours, the Ombudsman called and verified she did not receive the notification of discharge for Resident 109.

On 1/23/25 at 1304 hours, a concurrent interview and closed medical record review was conducted with the SSD.

Review of Resident 109's Physician Discharge summary dated [DATE], showed the resident's welfare and needs could not be met in the facility.

The SSD stated Resident 109 was only supposed to be there short term for respite care but was discharged after one day due to her aggressive and combative behaviors.

The SSD verified the notification of discharge was to be provided to the responsible party, Ombudsman, and in the case of Resident 109, the VA hospital.

The SSD was unable to locate the notice of transfer/discharge in Resident 109's medical record.

On 1/23/25 at 1332 hours, a concurrent interview and closed medical record review was conducted with RN 2. RN 2 verified she was in charge of notifying the Ombudsman of discharges. RN 2 stated she tried to fax the notice of discharge to the Ombudsman the same day of the resident's discharge.

RN 2 was unable to locate the notice of transfer/discharge in Resident 109's medical record.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of Resident 106's Level 1 PASRR screening (completed at Acute Care Hospital 1) dated 11/18/24, showed Resident 106 was positive for serious mental illness and a Level II mental health evaluation referral was required.

Review of Resident 106's Unable to Complete Level II Evaluation for Serious Mental Illness dated 11/18/24, showed a Level II Mental Health Evaluation was not scheduled for the following reason: Resident 106 was discharged from the facility (Acute Care Hospital 1).

The case is now closed. To reopen, the facility must submit another screening.

On 1/23/25 at 1037 hours, an interview and concurrent medical record review was conducted with RN

• RN 1 was asked if the California Department of Health Care Services Level II evaluators were

aware Resident 106 currently resided in the facility. RN 1 reviewed Resident 106's medical record and verified there was no documentation showing the California Department of Health Care Service Level II evaluators were aware of Resident 106's admission to the facility. RN 1 stated status post admission to the facility, the facility should have completed another PASRR Level 1 screening to ensure (if needed) Resident 106 received a Level II Mental Health Evaluation, to determine if Resident 106 could benefit from specialized services.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of Resident 28's PASRR Level 1 Screening dated 12/5/23, showed the Business Office Manager completed the screening.

On 1/24/25 at 1043 hours, an interview and concurrent medical record review for Residents 28 and 53 was conducted with RN 1. RN 1 verified the PASSR screenings forms for Resident 28 and 53 showed the Business Office Manager completed the form. RN 1 stated only the Business Office Manager's computer had the access to the PASSR website, so the nurses used the Business Office Manager's computer access to complete the PASSR screening.

When asked regarding completion of Resident 53's Level 1 screening as stated in the DHCS letter, RN 1 verified Resident 53's Level 1 screening was for categorical review, and a letter was sent by the DHCS showing the screening was not completed because the facility staff was unresponsive after two or more attempts of communication 48 hours after the Level 1 screening. RN 1 could not find documented evidence the DHCS letter was followed up or a new PASSR Level 1 screening was submitted for Resident 53.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Medical Assistant further stated Resident 82 did not have any new appointment scheduled with

On 1/23/25 at 1445 hours, a concurrent interview and medical record review was conducted with RN

received and if the resident had no family member who could bring the resident to a physician's appointment, the facility will coordinate with the transportation. RN 3 stated if the resident missed the scheduled physician's appointment, the licensed nurses should make a new appointment for the resident and any follow up regarding this should be documented. RN 3 further stated the resident could not miss any physician's appointment. RN 3 verified there was no follow up done regarding Resident 82's dermatology consult.

On 1/27/24 at 1445 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings for Resident 82.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of Resident 53's Restorative Nursing form for January 2025 showed Resident 53 was applied with the carrot splint on both hands, and AFO on both feet for two minutes daily for five days per week.

RNA 1 verified the above findings. RNA 1 stated they only documented the number of minutes spent in the application of the splint, and not the number of hours Resident 53 had the splints on. RNA 1 failed to show documented evidence of how many hours Resident 53 had the carrot splints on both hands, and the AFO on both feet.

On 1/27/25 at 0955 hours, an interview and concurrent medical record review for Resident 53 was conducted with the DON.

The DON verified the above findings.

The DON stated the RNAs should be documenting the number of hours Resident 53 had the carrot splint on both hands, and the AFO on both feet to know if the resident tolerated the splints.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

bracelet.

On 1/24/25 at 0902 hours, an interview for Resident 28 was conducted with CNA 6. CNA 6 stated Resident 28 wanted to get out of the facility, and the resident would often say she was leaving, and wanted to go outside with her daughter. CNA 6 stated Resident 28 had tried to leave the facility about a month ago, but she never got out, because the resident had always someone to get her back to her room. CNA 6 stated Resident 28 had a bracelet, and a Wander Guard.

On 1/24/25 at 0915 hours, observation for Resident 28 and concurrent interview was conducted with CNA 6. Resident 28 was observed in bed. Resident 28 was not observed with an ID bracelet nor a Wander Guard.

On 1/24/25 at 1033 hours, a follow-up interview was conducted with CNA 6. CNA 6 stated she spoke to the DSD about Resident 28, and per the DSD, Resident 28 did not have an ID bracelet because the resident refused, and it has been care planned.

On 1/24/25 at 1034 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 stated Resident 28 had wandered around the facility, and stood by the front door at times. RN 1 verified there was no documentation Resident 28's wandering around the facility, behavior of verbalizing her desire to go home or to leave the facility with her daughter, nor her behavior of going to the locked front door to wait for her daughter so she could leave the facility. RN 1 also verified there was no documentation Resident 28 was provided with an ID bracelet nor a documentation to show Resident 28 had refused or had taken off her ID bracelet. RN 1 also verified there was no care plan developed when Resident 28 was non-compliant with her ID bracelet.

On 1/24/25 at 1307 hours, an interview and concurrent medical record review for Resident 28 was conducted with the DSD.

The DSD stated Resident 28 had history of saying she wanted to go home, or Resident 28 thought she was getting picked up.

The DSD stated Resident 28 was observed packing her things while saying she was going home and would go to the locked front door.

The DSD stated Resident 28 had never physically attempted to open the door or sneaked out of the facility but would stand by the door and would look for the person to pick her up.

The DSD stated Resident 28 took off her ID bracelet and was non-compliant with the ID bracelet.

The DSD verified there was no documentation Resident 28 was provided with an ID bracelet nor refused or had taken off her ID bracelet.

The DSD also verified there was no care plan developed when Resident 28 was non-compliant with having an ID bracelet.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of the facility's P&P titled Gastrostomy Tube Feeding via Continuous Pump revised 1/2017 showed it is the policy of the facility to provide nourishment via continuous pump to the residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician.

On 1/22/25 at 1413 hours, Resident 62's GT feeding formula was observed running at 60ml/hr via GT feeding pump.

Medical record review for Resident 62 was initiated on 1/22/25. Resident 62 was readmitted to the facility on [DATE]. a.

Review of Resident 62's Nutritional assessment dated [DATE], showed the RD recommendation to increase the Jevity 1.5 (a GT feeding formula) to 65 ml/hr for 20 hrs to provide 1300 cc/1950 kcal.

Review of Resident 62's Order Summary Report showed the following physician's orders: - on 8/27/24, for Jevity 1.5 at 60 ml/hr (1200 ml/1800 kcal) via enteral feeding pump for 20 hours, to start at 1400 hours and off at 1000 hours or until dose is completed. - on 9/14/24, to infuse water at 35 ml/hr (700 ml/day) via enteral feeding pump for 20 hours, to start at 1400 hours and off at 1000 hours or until dose is completed.

The Order Summary dated 9/14/24, further showed to increase the GT feeding to Jevity 1.5 at 65 ml/hour for 20 hours. b.

Review of Resident 62's Plan of Care initiated on 4/7/24, showed a care plan problem addressing the use of the feeding tubes.

The interventions included to provide the entering feeding formula, Jevity 1.5 at 60 ml/hr for 20 hours as per the RD recommendation on 8/27/24.

On 1/22/25 at 1426 hours, a concurrent observation, interview, and medical record review was conducted with LVN 6. LVN 6 verified there were two conflicting GT enteral feeding orders for Resident 62. LVN 6 verified Resident 6's GT feeding pump was set and running at 60 ml/hr and acknowledged it was an incorrect rate. LVN 6 also verified Resident 6's GT feeding care plans were not revised to reflect the new order on 9/14/24.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

verified Resident 37's post-dialysis weight on 1/18/25, was not followed-up with the dialysis facility.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

order for the use of the side rails, an informed consent were obtained, the least restrictive

was observed getting out from Resident 13's room. CNA 5 stated when Resident 13 was in bed, the bilateral side rails were elevated at all times. CNA 5 further stated Resident 13 grabbed on the side rails when being assisted with turning.

On 1/23/25 at 1418 hours, a concurrent interview and medical record review for Resident 13 was conducted with LVN 1. LVN 1 stated prior to the use of the side rails, the resident should be assessed initially for the need of side rails, and the least restrictive alternatives should be attempted first like two person assistance, or the use of pillows or overhead trapeze. LVN 1 stated a physician's order and informed consent should be obtained and the care plan should also be developed to address the use of the side rails. LVN 1 verified there were no physician's order, informed consent, the least restrictive alternatives were not attempted, and the plan of care was not developed for Resident 13's use of the bilateral side rails.

On 1/27/24 at 1445 hours, an interview was conducted with the DON.

The DON was informed and acknowledged the above findings for Resident 13.

Cross reference to F-F909, example #1.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of Resident's 82's H&P examination dated 7/3/24, showed Resident 82 had no capacity to understand and make decisions.

Review of Resident 82's Order Summary Report showed a physician's order dated 6/27/24, for tramadol HCL (medication relieve pain) oral tablet, give 50 mg by mouth every six hours as needed for moderate pain (pain level 1-5, using the 0-10 pain scale; zero meaning no pain and 10 meaning worst pain).

Review of Resident 82's Antibiotic or Controlled Drug Record showed one tablet of the tramadol HCL 50 mg tablet was dispensed and signed out on 12/15/24 at 0900 hours.

Review of Resident 82's MAR for December 2024 showed the documentation of the administration for the tramadol HCL 50 mg dispensed and signed out on 12/15/24 at 0900 hours was missing.

On 1/23/25 at 1400 hours, an interview and concurrent record review was conducted with LVN 1.

LVN 1 verified the above findings and stated she pulled and signed the tramadol tablet and administered the medication to Resident 82, but forgot to document in the MAR.

Review of the facility's P&P titled Controlled Medication Storage dated 8/2014 showed at each of the shift change, a physical inventory of all the controlled medications is conducted by two licensed nurses and is documented on the controlled medication accountability record.

Review of Medication Cart B's Controlled Substances Book showed the Narcotic Check Sheet had multiple missing nurses' signatures during the shift change on the following dates and times: - on 6/20, 6/23, 7/21, 7/26, 8/7, 8/16, 8/30, 9/22, 10/19, and 12/22/24 at 0700 hours; - on 6/7, 6/9, 6/22, 6/23, 7/17, 8/5, 8/7, 8/12, 8/19, 8/30, and 10/19/24; and 1/7/25 at 1500 hours; and - on 6/9, 6/15, 6/24, 7/14, 7/17 , 7/25, 8/5, 8/7, 8/12, 8/19, 9/21, 9/22/24; and 1/5 and 1/18/25 at 2300 hours.

On 1/23/25 at 1418 hours, a concurrent interview and facility document review was conducted with RN 1. RN 1 reviewed Medication Cart B Narcotic Sheet Check and verified there were missing nurses' signatures during the narcotic inventory at the beginning of each shift for the above dates and times.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of Resident 53's Order Summary Report showed the following physician's order dated 5/12/24, to administer metoprolol 25 mg one tablet by mouth for hypertension and hold if SBP is less than 120 mmHg or heart rate less than 50 beats per minute.

Review of Resident 53's MARs for December 2024 and January 2025 showed Resident 53 was administered the metoprolol medication on the following: - dated 12/1/24 at 0900 hours, with a blood pressure of 116/77 mmHg, - dated 12/13/24 at 0900 hours, with a blood pressure of 116/77 mmHg, - dated 12/26/24 at 1700 hours, with a blood pressure of 115/79 mmHg, and - dated 1/3/25 at 0900 hours, with a blood pressure of 114/78 mmHg.

On 1/23/25 at 1325 hours, an interview and concurrent medical record review for Resident 53 was conducted with RN 3. RN 3 verified the above findings. RN 3 verified the metoprolol medication was administered to Resident 53 when the resident's blood pressures were below the parameter prescribed by the physician.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

medications: Depakote ER, fluvoxamine maleate, olanzapine, and risperidone.

When asked for the

months.

On 01/27/25 833 hours, interview with the DON was conducted.

The DON acknowledged and verified Resident 44's consents were not renewed on the Depakote ER, fluvoxamine maleate, olanzapine and risperidone medications use.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

20 was in the facility between 1/17 to 1/19/25.

Furthermore, LVN 1 stated the Zyprexa 10 mg

pharmacy.

On 1/23/25 at 1059 hours, an interview was conducted with the Pharmacy Technician.

The Pharmacy Technician was asked if the pharmacy received the new order for the Zyprexa 10 mg tablet medication and when was it delivered.

The Pharmacy Technician stated the pharmacy received an order for the Zyprexa 10 mg on 1/20/25, however, the medication was not sent.

The Pharmacy Technician further stated the pharmacy received another faxed order of Zyprexa on 1/22/25 at 1110 hours and medication was delivered on 1/22/25 at 2315 hours. b. On 1/23/25 at 1313 hours, an interview was conducted with LVN 2. LVN 2 was asked if she administered Resident 20's Zyprexa 10 mg on 1/17 to 1/19/25 at 2100 hours, and the reason for the missing documentations on the MAR. LVN 2 stated the medication did not arrive on 1/17/25 and she did not administer the Zyprexa medication. LVN 2 stated she documented on the nurse's progress notes the medication was not received.

Furthermore, LVN 2 was asked if the Zyprexa 10 mg was available on 1/20 and 1/21/25. LVN 2 stated she worked on 1/21/25 and Resident 20's Zyprexa medication was not available. LVN 2 verified she signed the MAR without administering the medication. LVN 2 acknowledged it was a medication error and supposed to make sure medications were given as ordered.

On 1/23/25 at 1457 hours, an interview was conducted with the DON.

The DON stated if the medications were not received, the charge nurses or RN should follow up with the pharmacy.

Furthermore, the DON stated it was unacceptable for the charge nurses to document in the MAR to show the medications were administered when the residents' medications were not available or on hand.

On 1/7/25 at 1334 hours, an interview was conducted with DON and Administrator.

The DON and Administrator verified and acknowledged above findings.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Based on observation, interview, facility document review, and facility P&P review, the facility failed

five Medication Cart (Medication Carts A and B) when: *

The facility failed to ensure the orally administered medications were stored separate from externally used medications and supplies in Medication Cart A. *

The facility failed to ensure Medication Cart B was not left unlocked and unattended by the licensed nurses while parked in the hallway.

These failures had the potential to negatively impact the residents' well-being and opportunities for drug diversion or drug misuse.

Findings

Reviewed of the facility's P&P titled Storage of Medications effective date 4/2008 showed the following: - Orally administered medications are kept separate from externally used medications. - Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

• On 1/23/25 at 1320 hours, a medication cart inspection for Medication Cart A was conducted with

LVN 1.

The following medications were observed stored in one compartment: - a box of loperamide HCL tablets (antidiarrheal medication); - a bottle of sodium chloride tablets (normal salt supplement); - Salonpas patches (topical pain medication); and - one tube of Refresh Celluvisc (lubricant eye gel).

LVN 1 verified the above findings. LVN 1 further stated those medications should not be stored together because they were administered in different route.

• On 1/27/25 at 0901 hours, Medication Cart B parked in the hallway was observed unlocked and

unattended.

The facility staff members and residents were observed passing by.

On 1/27/25 at 0909 hours, the DON and LVN 1 verified Medication Cart B was unlocked and unattended. LVN 1 stated she opened the cart and took the narcotic medications from Medication Cart B and forgot to lock it.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

ensured the kitchen employees were competent in their job duties.

The CDM stated he gave in-service

not involved in regular in-service training for the kitchen employees.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

American cheese for each grilled sandwich which was equivalent to nine grams of protein.

On 1/22/25 at 1550 hours an interview was conducted with [NAME] 3 and the CDM.

When asked if the facility provided a vegetarian diet, [NAME] 3 stated he provided meal entrees such as a grilled cheese sandwich, cheese ravioli, grilled quesadilla or tofu. [NAME] 3 confirmed the menu spreadsheet did not include a vegetarian diet.

When asked how he determined the appropriate portion size for a vegetarian diet, [NAME] 3 confirmed there were no portion sizes for vegetarian diets available.

On 1/23/25 at 1020 hours, a telephone interview was conducted with the RD.

The RD stated the facility did not have a vegetarian menu but stated ideally there should be a menu and a therapeutic spreadsheet with appropriate portions sizes available.

The RD confirmed the facility served meal entrees such as grilled cheese sandwiches or tofu for vegetarian diets.

The RD further stated that vegetarian meal entrees should be nutritionally equivalent to the regular menu entrée.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

tools such as brooms, mops, vacuum cleaners, and similar items shall be: A Stored so that they do not

On 1/21/25 at 805 hours, during the initial kitchen inspection with DA 1, two brooms were observed

On 01/23/25 1430 hours, a concurrent interview was conducted with the Administrator, Assistant Administrator, DON, and CDM.

The Administrator, Assistant Administrator, DON and CDM were informed and verified the above findings.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

the visitors on the safe food handling.

provided any education for the facility staff member on the safe food handling.

The IP stated he could

On 1/22/25 at 1107 hours, the IP confirmed he had not provided the facility staff members with the education on the safe food handing.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of Resident 8's POLST, Section D (advance directive) dated 10/14/20, failed to show documentation as to whether Resident 8 had formulated an advance directive.

Review of Resident 8's Advance Directive Acknowledgement form dated 8/22/24, failed to show documentation as to whether Resident 8 had formulated an advance directive.

The SSD verified the findings.

week.

instead of three visits as ordered.

There was no documented evidence of the SN visit during this

- During the week of 11/3/24 to 11/9/24, there was no CHHA visit conducted during this week. - During the following weeks there were only one visit a week conducted by the CHHA: week of 11/10/24 to 11/16/24, week of 11/24/24 to 11/30/24, week of 11/24/24 to 11/30/24, week of 12/8/24 to 12/14/24, and week of 12/22/24 to 12/28/24. In addition, there was no documented evidence of the SN visit was conducted to the resident.

On 1/23/25 at 1417 hours, an interview and concurrent Hospice Visit Record and Vital Signs Sheet review was conducted with the DON.

The DON verified the visitation logs have not been reviewed and the facility did not have a designated Hospice Coordinator to follow up with the plan for the hospice visitations for Resident 49.

On 1/23/25 at 1429 hours, an interview and concurrent Hospice Visit Record and Vital Signs Sheet review was conducted with the MDS Coordinator.

The MDS Coordinator verified that the facility did not have a Hospice Coordinator and stated the facility needed to have a Hospice Coordinator to make sure the plan for the visitations were conducted by the hospice company.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

containers used for medication administration on the side of the Medication Carts were observed as follows: - Medication Cart B's spoon container had some parts of it with broken pieces of plactic and - Medication Cart C spoon's container, the middle compartment was cracked and was taped.

In addition, Medication Cart B and C's spoons containers was observed with dirt and brown dry substance on the outside and inside.

On 1/22/25 at 1210 hours, an interview with an IP, who verified Medication Cart B and C spoon container were not clean, broken and has tape on them.

The IP further stated the spoons were used to give medications, and the spoon container should be clean to prevent the spread of infection.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

outside and concurrent inspection was conducted with RN 1. RN 1 stated the facility used the

would have maintenance removed the microwave right away.

On 1/21/25 at 1145 hours, an interview with the Maintenance Director was conducted on how the maintenance department was notified of any faulty equipment.

The Maintenance Director stated there was a maintenance logbook in the nurses' stations or they called directly.

The Maintenance Director further stated, they just called me now and I removed it when asked about the microwave in Station 1.

On 1/23/25 at 1430 hours, an interview was conducted with the Administrator, Assistant Administrator, DON and CDM regarding the above findings.

The Administrator, Assistant Administrator, DON and CDM acknowledged and verified the above findings. 3.a. On 01/22/25 at 1022 hours, a medication storage inspection for Station 1 was conducted with the DON.

The ice buildup was observed on the back wall of medication refrigerator in Station 1.

The DON verified the finding. b. On 01/22/25 at 1046 hours, a medication storage inspection for Station 3 was conducted with the DON.

The ice buildup was observed in the freezer compartment of medication refrigerator in Station 3.

The DON verified the finding. c. On 01/23/25 at 0814 hours, during an inspection of the specimen refrigerator with the Infection Preventionist, the freezer compartment of the specimen refrigerator was observed with ice buildup.

The Infection Preventionist verified the finding.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of Resident 5's MDS dated [DATE], showed Resident 5s BIMS score was not conducted due to the resident rarely or never understood.

Review of Resident 5's Order Summary Report dated 12/31/24, showed to use bilateral half side rails on both sides of the bed due to poor trunk control secondary to brain injury or seizures.

On 1/22/24 at hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 verified Resident 5 had the bilateral side rails elevated while in bed. CNA 1 stated Resident 5 required total assistance from staff with ADL cares.

On 1/24/25 at 1225 hours, a concurrent interview and record review was conducted with the ESD.

Review of the Side rail or Bed Rail Assessment Guidance to Reduce Entrapment Logs of Resident 5 dated 12/8/24, did not show Zone 2 entrapment assessment was completed.

The ESD verified the finding.

The ESD stated Zone 2 was not measured because it was close to the bed.

On 1/27/24 at 0856 hours, a concurrent observation and interview was conducted with LVN 3. LVN 3 verified Resident 5 had bilateral half side rails elevated while resident in bed.

On 1/27/25 1400 at hours, an interview was conducted with the DON and Administrator.

The DON and Administrator were informed and acknowledged the above findings.

555520 01/27/2025

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801

Review of Resident 20's H&P examination dated 10/16/24, showed Resident 20 had the capacity to understand and make decisions.

Review of Resident 20's MDS dated [DATE], showed Resident 20's Brief Interview for Mental Status (BIMS) score was 99 (indicates that the interview was incomplete.

This can happen if the patient refused to participate, or if the patient's responses were nonsensical or not provided).

On 1/21/25 at 0817 hours, a medication administration observation was conducted with LVN 1. LVN 1 prepared and administered the following medications for Resident 20:

- allopurinol (a medication to prevent uric acid production in the body) 300 mg one tablet;

555520

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555520 B.

Wing 01/27/2025

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

Leisure Court Nursing Center 1135 Leisure Court Anaheim, CA 92801