Leisure Court Nursing Center

F-F909, example #1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. 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 provide the necessary pharmaceutical services to one final sampled resident (Resident 82) and one nonsampled resident (Resident 20).

* The facility failed to ensure Resident 20's medications were administered as ordered by the physician and accurately documented in the MAR.

* The facility failed to ensure the documentation for Resident 82's controlled medication administrations were accurate and complete.

* The facility failed to ensure the narcotic sheets inventory were properly conducted showing the nurses' initials and signatures for Medication Cart B.

Theses failures had the potential for the resident not to receive the necessary medications and posed the risk for diversion of the medications.

Findings:

Reviewed of the facility P&P titled Medication Administration revised on 5/2019 showed the following:

-Medications must be administered in accordance with the physician orders;

-The licensed nurse administering the medication must initial the MAR for the resident on the appropriate line

after giving the medication; and

-The licensed nurse administering the medication will record on the MAR.

1. Medical record review for Resident 20 was initiated on 1/22/25. Resident 20 was admitted to the facility on [DATE REDACTED].

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 REDACTED], 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;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0755 - folic acid (vitamin) 1 mg one tablet;

Level of Harm - Minimal harm or - furosemide (diuretic used to treat fluid retention) 40 mg one tablet potential for actual harm - Keppra (medication to prevent seizure) 100 mg/ml solution, 5 ml; Residents Affected - Few - Ingrezza (used to treat symptoms of tardive dyskinesia) 40 mg one capsule;

- memantine (medication use to treat memory loss) 10 mg one tablet;

- potassium chloride (supplement) solution 15 ml;

- Zoloft (medication for depression) 25 mg one tablet;

- aspirin (medication used to prevent blood clot) chewable 81 mg one tablet;

- ferrous sulfate (mineral the body need to produce red blood cells) 7.5 ml solution;

- multivitamins (supplement) one tablet;

- vitamin B-1 (supplement) 100 mg one tablet; and

- vitamin D (supplement) 25 mcg 1000 IU one tablet.

a. During the medication preparation for Resident 20, LVN 1 stated would not administer the docusate sodium (stool softener) 250 mg capsule until she clarified the order with the physician.

Review of Resident 20's Order Summary Report showed a physician's order dated 12/31/24, to administer docusate sodium capsule 250 mg, give one capsule via GT one time a day for bowel management. Hold with loose stools or diarrhea.

Review of Resident 20's MAR for January 2025 did not show the administration of docusate sodium per physician's order on 1/21/25.

On 1/22/25 at 1023 hours, a follow-up interview was conducted with LVN 1. LVN 1 was asked if she administered the docusate sodium on 1/21/25 after she clarified the medication from the physician and LVN 1 stated, No, I did not give a dose of docusate sodium yesterday.

b. On 1/21/25 at 0847 hours, an interview was conducted with LVN 1. LVN 1 stated she completed the medication administration for Resident 20's morning medications. Asked LVN 1 if she must document after medication administration, LVN 1 stated she had documented on Resident 20's MAR while preparing the medications. Furthermore, LVN 1 stated her usual process was to document on the MAR prior to the administration of medications.

Review of Resident 20's Medication Administration Audit Report dated 1/21/25, showed the administration time for the morning medications were documented prior to the administration completion time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0755 On 1/23/25 at 1457 hours, an interview was conducted with the DON. The DON stated medication administration process expectation must be to pour, pass, and sign the MAR. Furthermore, the DON stated Level of Harm - Minimal harm or the licensed nurses should administer the resident's medications as ordered by the physician. potential for actual harm

On 1/27/25 1400 at hours, an interview was conducted with the DON and Administrator. The DON and Residents Affected - Few Administrator were informed and acknowledged the above findings.

45064

2. Medical record review for Resident 82 was initiated on 1/23/25. Resident 82 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED].

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.

3. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453 potential for actual harm Based on interview and medical record review, the facility failed to ensure two of 24 final sampled residents Residents Affected - Few (Residents 37 and 53) were free from unnecessary drugs.

* The facility failed ensure Resident 37 was not administered metoprolol (medication to treat high blood pressure) and clonidine (medication to treat high blood pressure) medications when Resident 37's blood pressure was below the parameter prescribed by the physician.

* The facility failed to ensure Resident 53 was administered with metoprolol medication when Resident 53's blood pressure was below the parameter prescribed by the physician.

These failures had the potential for the residents to develop the significant side effects such as hypotension and negatively affect the residents' health condition and well-being.

Findings:

1. According to DailyMed, the most common adverse effects of the metoprolol and clonidine medications included hypotension.

Medical record review for Resident 37 was initiated on 1/21/25. Resident 37 was readmitted to the facility on [DATE REDACTED].

Review of Resident 37's Order Summary Report showed the following physician's orders dated 10/2/24:

- To administer clonidine 0.2 mg one tablet by mouth in the morning for hypertension and hold if SBP is less than 110 mmHg; and

-To administer metoprolol 100 mg one tablet by mouth for hypertension and hold if SBP is less than 110 mmHg or heart rate less than 60 beats per minute.

Review of Resident 37's MARs for December 2024 and January 2025 showed Resident 37 was administered the metoprolol medication on the following:

- dated 12/19/24 at 0900 hours, with a blood pressure of 109/57 mmHg;

- dated 1/3/25 at 2100 hours, with a blood pressure of 104/56 mmHg, and

- dated 1/14/25 at 0900 hours, with a blood pressure of 101/57 mmHg.

In addition, the MAR showed Resident 37 was administered the clonidine medication on 12/26/24 at 0900 hours, with a blood pressure of 99/55 mmHg.

The MARs for December 2024 and January 2025 showed the use of the metoprolol and clonidine medications ordered parameters were not followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0757 On 1/24/25 at 1000 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 1. RN 1 verified the above findings. RN 1 verified the metoprolol and clonidine medications were Level of Harm - Minimal harm or administered to Resident 37 when the resident's blood pressures were below the parameter prescribed by potential for actual harm the physician.

Residents Affected - Few 2. Medical record review for Resident 53 was initiated on 1/21/25. Resident 53 was readmitted to the facility

on [DATE REDACTED].

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453 Residents Affected - Few Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure 7 of 11 final sampled residents (Residents 12, 13, 28, 37, 44, 53, and 73) reviewed for unnecessary medications were free from unnecessary psychotropic drugs.

* The facility failed to ensure Resident 37's was accurately monitored related to the use of Remeron (antidepressant medication). Resident 37's meal intake documentation was inconsistent, showing either a % or a hashmark, and did not match the CNA's Documentation Survey Report. In addition, the monthly behavior summary of the episodes of Resident 37's meal intake less than 50% did not match the MAR nor

the CNA's Documentation Survey Report.

* The facility failed to renew the informed consent related to the use of Depakene (mood stabilizer medication), Remeron (antidepressant medication), and risperidone (antipsychotic medication) for Resident 53. In addition, the facility failed to monitor Resident 53's blood pressure for orthostatic hypotension was monitored as ordered by the physician related to the use of risperidone.

* The facility failed to ensure Resident 73 was monitored for the side effects related to the use of lorazepam (antianxiety medication).

* The facility failed to ensure the informed consent was obtained prior to the administration of risperidone for Resident 28.

* The facility failed to ensure Resident 13's the informed consents for trazodone, Zyprexa, and bupropion were renewed after 6 months.

* The facility failed to ensure Resident 12's informed consents for Seroquel and Depakote were renewed

after 6 months.

* The facility failed to ensure Resident 44's informed consents for Depakote ER, fluvoxamine maleate, olanzapine, and risperidone were renewed after six months.

These failures had the potential for the residents to have adverse complications from the medications and

the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents. In addition, these failures had the potential for the residents and their responsible parties not being informed of their medications and the potential side effects of the psychotropic medications.

Findings:

Review of the facility's P&P titled Informed Consent Policy revised 4/2024 showed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0758 - There is a requirement for the facility to renew informed consent every six months. There is no need to renew the consent form if the dosage or therapy is being decreased unless it has been six months. There is Level of Harm - Minimal harm or no need to renew informed consent if the resident is transferred to a hospital and returns with no change in potential for actual harm orders and the facility has a copy of the informed consent in the resident's clinical record unless it has been more than six months since consent has been renewed; and Residents Affected - Few - The facility shall verify that informed consent has been informed prior to the administration of psychotherapeutic medication.

Review of the facility's P&P titled Psychotropic Drug Treatment dated 9/2017 showed the following:

- The resident or his/ her representative will be given information regarding the need for, the desired effect and the potential side effects of the medication. This enables the resident or his/ her representative to make

an informed consent regarding the use of any psychoactive medication. The resident or their representative should be involved in the medication management process and aware of the benefits and risks of medications and the goals of treatment; and

- Each resident's drug regimen review must be free from unnecessary drugs. Unnecessary drugs are any drugs when used without adequate monitoring.

Review of the facility's P&P titled Informed Consent revised 4/2024 showed it is the policy of the facility that if

the attending physician, physician assistant (PA), or nurse practitioner (NP) for a resident prescribes, orders, or increase an order for a psychotherapeutic medication the physician, PA or NP or the facility shall do the following:

- There is a requirement for the facility to renew informed consent every six months. There is no need to renew the consent form if the dosage or therapy is being decreased unless it has been six months.

1. Medical record review for Resident 37 was initiated on 1/21/25. Resident 37 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 37's H&P Examination dated 10/4/24, showed Resident 37 had the capacity to understand and make decision.

Review of Resident 37's Order Summary Order showed the following physician's orders dated 10/2/25:

- To administer Remeron 22.5 mg by mouth at bedtime for depression manifested by poor oral intake less than 50% meal; and to

- To monitor meal percentage less than 50% related to the use of Remeron.

Review of Resident 37's MAR for December 2024 and January 2025 showed the following:

- Resident 37 was administered Remeron 22.5 mg on 12/1 to 12/31/24, and from 1/1 to 1/22/25; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0758 - Resident 37's meal intake was 10 on 12/30/24 at 1700 hours, and on 12/31/24 at 1200 and 1700 hours; 20

on 12/23/24 at 1200 hours, and 12/31/24 at 0700 hours; 50 on 12/26 and 12/27/24 at 0700 and 1200 hours, Level of Harm - Minimal harm or and on 12/26/24 at 1700 hours; and 60 on 12/28/24 at 0700 and 1200 hours, and 12/27/24 at 1700 hours. potential for actual harm However, Resident 37's meal intake was 1 on 12/7/24 at 0700 hours, 12/14 and 12/19/24 at 1700 hours, 12/24/24 at 1200 hours, on 12/10, 12/11, 12/10, 12/11, 12/22, and 12/29/24 at 0700 and 1200 hours, and on Residents Affected - Few 12/8, 12/15, 12/20, and 12/21/24 at 0700, 1200, ad 1700 hours. In addition, Resident 37 meal intake was 0

on 12/7/24 at 1200 hours, 12/10 12/11, 12/22, 12/23, 12/28 and 12/29/24 at 1700 hours, on 12/14, 12/19 and 12/30/24 at 0700 and 1200 hours, and on 12/1 to 12/6/25, 12/12, 12/13, 12/16, and 12/25/24 at 0700, 1200 and 1700 hours; and

- Resident 37's meal intake was 20 on 1/1/25 at 0700, hours; 30 on 1/2/25 at 0700 and 1200 hours; 50 on 1/5/25 at 1700 hours; and 40 on 1/7/25 at 0700 hours. However, Resident 37's meal intake was X on 1/14/25 at 1700 hours, and 0 on 1/7 and 1/13 at 0700 hours, and on 1/3 and 1/4/25 at 1700 hours. In addition, Resident 37's meal intake was 1 on 1/2/25 at 1200 and 1700 hours, on 1/3, 1/4, 1/5 and 1/14/25 at 0700 and 1200 hours, on 1/6/25 at 1200 and 1700 hours, and on 1/8 to 1/12/25 at 0700, 1200, and 1700 hours, and in 1/14 to 1/22/25 at 0700, 1200, and 1700 hours.

Review of Resident 37's CNA - Documentation Survey Report for December 2024 and January 2025 showed Resident 37 consumed less than 50% for 75 out of 93 meals for December 2024, and 59 out of 71 meals for January 2025.

a. Further review of Resident 37's meal intake documentation in the MAR was inconsistent, showing either a % or a hashmark Resident 37's monitoring of meal intake at 0700, 1200 and 1700 hours, was documented either as NA, X, 0, 1, 10, 20, 30, 40, 50, or 60. In addition, Resident 37's meal intake documentation in the MAR did not match Resident 37's meal intake documentation in the CNA - Documentation Survey Report.

Review of Resident 37's Behavior and Psychotropic Summary/Dosage Reduction for December 2024 for Resident 37's poor meal intake less than 50 % related to use of Remeron showed Resident 37 had 14 episodes at 0700 hours, 12 episodes at 1200 hours, and 10 episodes at 1700 hours, for a total of 36 episodes for December 2024.

b. Further review of the monthly behavior summary of the episodes of Resident 37's meal intake less than 50% did not match the MAR nor the CNA - Documentation Survey Report.

On 1/24/25 at 1000 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the licensed nurses should verify with the CNAs regarding Resident 37's meal intake, and the licensed nurses should be documenting the percentage of Resident 37's meal intake in the MAR.

2. Medical record review for Resident 53 was initiated on 1/21/25. Resident 53 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 53's H&P examination dated 5/14/24, showed Resident 53 had no capacity to understand and make decision.

Review of Resident 53's Order Summary Order showed the following physician's orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0758 - dated 5/12/24, to administer Depakene 250 mg/ml 10 ml via GT two times a day for mood stabilizer/ labile mood. This physician's order was discontinued on 1/10/25. Level of Harm - Minimal harm or potential for actual harm - dated 5/27/24, to monitor blood pressure lying and sitting for orthostatic hypotension every week on Tuesday in 1500 to 2300 hours shift related to the use of risperidone. Notify the physician if the difference in Residents Affected - Few SBP of 20 mmHg or if the difference in DBP of 10 mmHg or greater.

- dated 12/12/24, to administer Remeron 7.5 mg via GT at bedtime for depression;

- dated 12/12/24, to administer risperidone 0.5 mg via GT at bedtime; and

a. Review of Resident 53's Informed Consent dated 5/16/24, showed an informed consent was obtained for

the Risperdal (risperidone), Depakene, and Remeron medications. However, the informed consent for Risperdal, Depakene, and Remeron medications was not renewed after six months.

b. Review of Resident 53's MAR for December 2024 and January 2025 showed the following:

- Resident 53 was administered Depakene 250 mg/5 ml 10 ml via GT on 12/1 to 12/31/24 at 0900 and 1700 hours, on 1/1 to 1/9/25 at 0900 and 1700 hours, and on 1/10/25 at 0900 hours;

- Resident 53 was administered Remeron 7.5 mg via GT on 12/12 to 12/31/24 at 2100 hours, and on 1/1 to 1/22/25 at 2100 hours;

- Resident 53 was administered risperidone 0.5 mg via GT on 12/12 to 12/31/24 at 2100 hours, and on 1/1 to 1/22/25 at 2100 hours; and

- Resident 53's blood pressures were monitored for orthostatic hypotension related to the use of risperidone. However, the blood pressure readings for both positions (lying and sitting) were the same as follows:

- On 12/3/24, the blood pressure readings were 128/78 mmHg for the lying position and 128/78 mmHg for

the sitting position;

- On 12/17/24, the blood pressure readings were 140/75 mmHg for the lying position and 140/75 mmHg for

the sitting position;

- On 12/31/24, the blood pressure readings were 131/77 mmHg for the lying position and 131/77 mmHg for

the sitting position;

- On 1/14/25, the blood pressure readings were 133/75 mmHg for the lying position and 133/75 mmHg for

the sitting position; and

- On 1/22/25, the blood pressure readings were 142/83 mmHg for the lying position and 142/83 mmHg for

the sitting position.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0758 On 1/23/25 at 1043 hours, an interview and concurrent medical record review for Resident 53 was conducted with RN 1. RN 1 verified the above findings. RN 1 acknowledged the informed consent for the Risperdal, Level of Harm - Minimal harm or Depakene, and Remeron medications was not renewed after six months. RN 1 also verified the licensed potential for actual harm nurses were not checking for orthostatic hypotension accurately because of the same blood pressure readings for both sitting and lying positions. Residents Affected - Few 3. Medical record review for Resident 73 was initiated on 1/21/25. Resident 73 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 73's H&P Examination dated 7/20/24 showed Resident 73 could make needs known but cannot make medical decisions.

Review of Resident 73's Order Summary Order showed the following physician's orders:

- dated 1/14/25, to monitor behavior of striking out towards the staff during care every shift.

- dated 1/17/25, to administer lorazepam 0.5 mg one tablet two times a day for anxiety manifested by striking out, for 14 days;

Review of Resident 73's MAR for January 2025 showed Resident 73 was administered the lorazepam medication from 1/19 to 1/20/25 at 1700 hours, and on 1/22 to 1/25/25 at 0900 and 1700 hours.

Further review of Resident 73's medical record did not show Resident 73 was monitored for the side effects related to the use of the lorazepam medication.

On 1/27/25 at 0948 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 licensed nurses had to make sure

the resident was monitored for the behavior and side effects related to the use of psychotropic medications.

4. Medical record review for Resident 28 was initiated on 1/21/25. Resident 28 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 28's H&P Examination dated 11/7/24, showed Resident 28 had no capacity to understand and make decision.

Review of Resident 28's Order Summary Order showed the following physician's orders dated 1/21/25:

- To administer risperidone 0.5 mg by mouth one time a day for schizophrenia and

- To administer risperidone 1 mg by mouth at bedtime for schizophrenia.

Review of Resident 28's Informed Consent dated 1/21/25, for risperidone 0.5 mg by mouth one time a day for schizophrenia and risperidone 1 mg by mouth at bedtime for schizophrenia, but the informed consent form was not signed by the physician.

Further review of Resident 28's medical record failed to show an informed consent for the risperidone medication was obtained from the resident or her responsible party.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0758 On 1/24/25 at 1033 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the physician who ordered the medications Level of Harm - Minimal harm or obtained the consent, and the facility had to fax the informed consent to the physician's office. RN 1 potential for actual harm reviewed Resident 28's medical record and was unable to find documentation the informed consent was obtained from the resident or their responsible party for the use of the risperidone medication. Residents Affected - Few 49258

5. Medical record review for Resident 13 was initiated on 1/22/25. Resident 13 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 13's H&P examination dated 4/30/24, showed Resident 13 had the capacity to understand and make decisions.

Review of Resident 13's Order Summary Report showed the following physician's orders dated 4/29/24:

- to administer trazodone 100 mg two tablets by mouth at bedtime for depression as manifested by inability to sleep;

- to administer Zyprexa 15 mg one tablet by mouth at bedtime for schizoactive disorder (mental health condition) as manifested by paranoid delusion (false belief that someone is being threatened or mistreated); and

- to administer bupropion hydrochloride extended release 200 mg one tablet by mouth two times a day for depression as manifested by withdrawal from activities of interest.

Review of Resident 13's MAR for November 2024, December 2024 and January 2025, showed Resident 13 received the following:

- trazodone medication from 11/1 to 11/30/24 at 21 hours, 12/1 to 12/31/24 at 2100 hours, and 1/1 to 1/21/25 at 2100 hours;

- Zyprexa medication from 11/1 to 11/30/24 at 2100 hours, 12/1 to 12/31/24 at 2100 hours, and 1/1 to 1/21/25 at 2100 hours; and

- bupropion hydrochloride extended release medication from 11/1 to 11/30/24 at 0900 hours and 1700 hours, 12/1 to 12/31/24 at 0900 hours and 1700 hours, 1/1 to 1/21/25 at 0900 hours and 1700 hours, and 1/22/25 at 0900 hours.

Further review of Resident 13's medical record did not show documented evidence the informed consents for

the trazodone, Zyprexa, and bupropion hydrochloride extended release medications were renewed six months after 5/1/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0758 On 1/24/25 at 1327 hours, a concurrent interview and medical record review for Resident 13 was conducted with RN 2. RN 2 stated the informed consents for psychotropic medications should be obtained initially once Level of Harm - Minimal harm or the physician's ordered it and it should be renewed every six months. RN 2 verified the consents for the potential for actual harm trazodone, Zyprexa, and bupropion hydrochloride extended release medications were not renewed after 6 months. Residents Affected - Few

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.

51920

6. Medical record review for Resident 12 was initiated on 1/24/25. Resident 12 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 12's Order Summary Report showed the following physician's orders:

- dated 3/12/24, to administer Depakote 500 mg by mouth two times a day for mood stabilizer for labile mood m/b yelling and screaming without provocation

- dated 10/7/24, to administer Seroquel 25 mg by mouth in the morning for schizoaffective disorder m/b paranoid delusions people are stealing his money

- dated 10/7/24, to administer Seroquel 200 mg by mouth at bedtime for schizoaffective disorder m/b paranoid delusions people are stealing his money

Review of the Informed Consent dated 6/4/24, showed Seroquel 50 mg and Depakote 500 mg.

Further review of Resident 12's medical record did not show documented evidence the informed consents for

the Seroquel and Depakote were renewed six months after 6/4/24.

On 1/24/25 at 1041 hours, a concurrent interview and medical record review for Resident 12 was conducted with RN 2. RN 2 stated the informed consents for psychotropic medications should be obtained upon admission, with an increase in medication, and every 6 months. RN 2 verified the informed consents for the Seroquel and Depakote were not renewed after 6 months.

50787

7. Review of Resident 44's medical record was initiated on 1/24/25. Resident 44 was admitted on [DATE REDACTED].

Resident 44's MDS asseesment showed the resident's BIMS score was 99 (indicates that the Brief Interview for Mental Status (BIMS) was incomplete. This can happen if the patient refused to participate, gave nonsensical answers, or the interview was stopped. ).

Review of Resident 44's Order Summary Report showed the following physician's orders:

- dated 12/20/24, to administer Depakote ER 500 mg by mouth two times a day for mood stabilizer,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0758 - dated 5/23/24, to administer fluvoxamine maleate 100 mg tablet at bedtime for depression,

Level of Harm - Minimal harm or - dated 5/23/24, to administer olanzapine 5 mg tablet one tablet by mouth two times a day for schizophrenia potential for actual harm (a mental illness that is characterized by disturbances in thought), and

Residents Affected - Few - dated 12/20/24, to administer risperidone oral tablet 2.5 mg two times daily for schizophrenia.

Review of Resident 44's informed consents showed consents were obtained for the above medications from Resident 44's daughter on 5/24/24

Review of Resident 44's MAR for January 2025 showed:

- Resident 44 was administered Depakote ER from 1/1/25 to 1/23/25.

- Resdient 44 was administered fluvoxamine maleate from 1/1/25 to 1/23/25.

- Resdient 44 was administered olanzapine 5 mg tablet from 1/1/25 to 1/23.

- Resident 44 was administered risperidone from 1/1/25 to 1/23/25

Review of the facility's P&P on Informed Consent dated 4/2024 showed there is a requirement for the facility to renew informed consent every six months. The facility shall verify the informed consent has been obtained prior to the administration of psychotherapeutic medications.

On 01/24/25 at 1333 hours, an interview and concurrent review of Resident 44's informed consent was conducted with RN 2. RN 2 showed informed consent dated 5/24/24, for the following medications: Depakote ER, fluvoxamine maleate, olanzapine, and risperidone. When asked for the renewal of the informed consents as per the facility's P&P, RN2 stated no, that's it for the consents. RN 2 acknowledged and verified Resident 44's consents were supposed to be renewed every six 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50967 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Residents Affected - Few one nonsampled resident (Resident 20) was free from the significant medication errors.

* The facility failed to provide Resident 20's Zyprexa (antipsychotic medication) as ordered by the physician and accurately document the Zyprexa administration. This failure placed Resident 20 at risk for medical complications.

Findings:

Review of the facility's P&P titled Medication Administration dated 5/2019 showed the medications are administered in a safe and timely manner, and as prescribed. The medications must be administered in accordance with prescriber orders, including any required time frame.

Review of the facility's P&P titled Physician Services and Orders dated 1/2017 showed:

- Signed orders for drugs shall be transmitted to the issuing pharmacy within 48 hours of the receipt of the order;

- The charge nurse or the DON shall place the order for all prescribed medications; and

- Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy no less that three days prior to the last dosage being administered to assure that the refills are on hand.

Medical record review for Resident 20 was initiated on 1/22/25. Resident 20 was admitted to the facility on [DATE REDACTED].

Review of Resident 20's Order Summary Report showed a physician's order dated 1/17/25, to administer Zyprex 10 mg one tablet medication via GT at bedtime for schizoaffective disorder (a severe brain disorder in which people interpret reality abnormally) manifested by paranoid delusion (a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion) with angry outburst from responding to internal stimuli.

Review of Resident 20's MAR for January 2025 showed the following:

- on 1/17 to 1/19/25 at 2100 hours, the section to document for the Zyprexa medication administration were blank.

- on 1/20 and 1/21/25 at 2100 hours, the section to document for the Zyprexa medication administration were signed by the nurse.

The MAR failed to show documentation to explain why the Zyprexa medication was not admistered from 1/7 to 1/19/25 at 2100 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0760 a. On 1/22/25 at 1023 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified the missing documentations on Resident 20's MAR on 1/17 to 1/19/25 at 2100 hours. Level of Harm - Minimal harm or potential for actual harm On 1/23/25 at 1030 hours, a follow-up interview was conducted with LVN 1. LVN 1 stated Resident 20 was in

the facility between 1/17 to 1/19/25. Furthermore, LVN 1 stated the Zyprexa 10 mg medication was received Residents Affected - Few last night by the night shift nurse. LVN 1 verified the Zyprexa 10 mg bubble pack was still complete and the label showed the medication was filled on 1/22/25 from the 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 45064 Residents Affected - Few Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of the medications for two of 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.

1. 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.

39453

2. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 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 Level of Harm - Minimal harm or lock it. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 39856

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

the kitchen staff were competent in their position related duties when:

1. Two of 13 kitchen employees (Dietary Aides 2 and 3) were unable to correctly test the sanitizing solution used to sanitize the food preparation surfaces in the kitchen and sanitize the food preparation equipment washed in the manual ware washing sink.

2. One of 13 kitchen employees (Cook 1) did not know the correct cutting board to be use when preparing raw poultry.

These failures posed the risk for exposure to unsafe food handling practices which could lead to food borne illness in the 94 vulnerable residents who received food prepared in the kitchen.

Findings:

Review of the facility's undated matrix showed 94 residents received food prepared in the kitchen.

1. Review of the facility's document titled Employee Evaluation Form dated 10/3/24, signed by the CDM and Dietary Aide (DA) 2 showed DA 2 met expectations in quality of work; work was completed accurately (few or no errors) efficiently and within deadlines with minimal supervision.

Review of the facility's document titled Dietary Competency Evaluation dated 10/3/24, signed by the CDM and DA 2, did not include a competency evaluation on the testing of the sanitizing solution used to sanitize

the food preparation surfaces.

Review of the sanitizing solution test strip instructions located on the container of the sanitizing solution test strips showed to immerse the test strip in the sanitizing solution for ten seconds then compare the wet test strip to the color chart located on test strip container.

On 1/21/25 at 1418 hours, an observation and concurrent interview was conducted with DA 2. DA 2 was asked to demonstrate how to test the sanitizing solution used to sanitize food preparation surfaces in the kitchen. DA 2 obtained a test strip, held it in the sanitizing solution for two seconds then compared the test strip to the color chart. The test strip read 150 parts per million (ppm), a measurement used to determine concentration of the sanitizing chemical. DA 2 was asked if 150 ppm was ok. DA 2 did not respond. DA 2 was asked to test the sanitizing solution a second time and hold the strip in the sanitizing solution for ten seconds. DA 2 inserted a clean test strip into the sanitizing solution for four seconds then compared the test strip to the color chart. The test strip read 150 ppm. DA 2 confirmed 150 ppm was not ok.

On 1/23/25 at 0956 an interview was conducted with the CDM. The CDM was asked how he ensured the kitchen employees were competent in their job duties. The CDM stated he gave in-service training however

the CDM confirmed he had not given in-service training on testing the sanitizing solution for kitchen staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0802 On 1/23/25 at 1020 hours, a telephone interview was conducted with the RD. The RD stated she was not involved in regular in-service training for the kitchen employees. Level of Harm - Minimal harm or potential for actual harm a. Review of the facility document titled Employee Evaluation Form dated 8/6/24 signed by the CDM and DA 3 showed, DA 3 met expectations in quality of work; work was completed accurately (few or no errors) Residents Affected - Few efficiently and within deadlines with minimal supervision.

Review of the facility document titled Dietary Competency Evaluation dated 8/19/24 signed by the CDM and DA 3, did not include a competency evaluation on the manual dishwashing procedure.

Review of the facility's job description titled Dishwasher signed by DA 3 on 8/19/18, showed General Duties and Responsibilities: wash and clean utensils as directed and perform dishwashing/cleaning procedures.

Review of the facility document titled Record of Departmental In-service and Trainings, Three Compartment Washing dated 9/25/24, showed DA 3 was in attendance.

On 1/21/25 at 1426 hours, an interview was conducted with DA 3 using the COTA as a translator and the CDM present. DA 3 was asked to describe the manual dishwashing procedure used in an emergency when

the automatic dishwasher was not operable. DA 3 was not able to demonstrate or describe how to test the concentration of the sanitizing solution used to sanitize the dishes or what the correct concentration of the sanitizing solution should be. The CDM then asked DA 3 in English how to check the concentration of the sanitizing solution however DA 3 was not able to provide the correct information.

On 1/21/24 at 1435 hours, an interview was conducted with the CDM. The CDM was asked if DA 3 had been trained on the manual dishwashing procedure. The CDM stated he provided an in-service in September and December of 2024. DA 3 attended the in-service in September 2024. The CDM was asked how he evaluated

the employee's competency. The CDM stated he demonstrated the manual ware washing process and provided the process in writing in the appropriate language of the employee. The CDM confirmed he did not however, require a return demonstration from the employee on the manual dishwashing process to evaluate

the employee's competency.

On 1/23/25 at 1020 hours, a telephone interview was conducted with the RD. The RD stated she was not involved in regular in-service training for the kitchen employees.

2. Review of the facility document titled Dietary Competency Evaluation dated 10/4/24 and signed by the CDM and [NAME] 1, showed [NAME] 1 was competent in demonstrating preparation of food.

Review of the facility's job description titled [NAME] signed by [NAME] 1 on 8/5/18, showed General Duties and Responsibilities: Prepare food in accordance with sanitary regulations and as well as with our policies and procedures.

Review of the facility document undated titled, US Cutting Board Color Chart showed, Red - raw beef, pork, lamb, and other types of raw meat; Yellow - raw poultry, such as chicken, turkey and duck; Blue - raw fish, shellfish, and other seafood products; [NAME] - dairy and baked goods; [NAME] - fruits, vegetables and salads; [NAME] - cooked meat, such as roast, beef or ham.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0802 During the initial inspection of the kitchen on 1/21/25 at 0800 hours, an observation of [NAME] 1 and concurrent interview was conducted with Diet Aid 1. [NAME] 1 was observed using a red cutting board for Level of Harm - Minimal harm or raw poultry. When asked if it was ok to use a red cutting board for raw poultry, [NAME] 1 did not respond. DA potential for actual harm 1 confirmed raw poultry should be prepared using a yellow cutting board.

Residents Affected - Few On 1/23/25 at 0956 hours, an interview was conducted with the CDM. The CDM was asked how he ensured

the kitchen employees were competent in their job duties. The CDM stated he gave in-service training however the CDM confirmed he had not given in-service training on the proper use of cutting boards in 2024.

On 1/23/25 at 1020 hours, a telephone interview was conducted with the RD. The RD stated she was not involved in regular in-service training for the kitchen employees.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39856

Residents Affected - Few Based on observation, interview, and facility document review, the facility failed to ensure the nutritional needs were met for two of 82 nonsampled residents (Residents 11 and 70) who received a vegetarian diet preference when the lunch meal served provided nine grams of protein vs 28 grams of protein per the regular menu. This failure posed the threat of the nutritional needs; specifically the protein needs for Residents 11 and 70 to not be met which could lead to medical complications.

Findings:

1. According to the California Health and Safety Code Section 1265.10: Effective 1/1/19, the skilled nursing facilities must make available wholesome, plant-based meals of such variety as to meet the needs of patients in accordance with their physicians' orders.

Review of the facility's document titled Cooks Spreadsheet showed the following:

Week 4 Wednesday dated 1/22/25, showed for the lunch meal, four ounces Old Fashioned Meatloaf for the entree for regular diets. The lunch meal entree served for 1/22/25, was equivalent to 28 grams (gm) of protein.

Review of the facility's document titled Recipe: Grilled Cheese Sandwich Week 4 Tuesday undated, showed one sandwich was equivalent to two ounces of protein. The Grilled Cheese Sandwich recipe showed Do not use American Cheese. Directions: 1) Make sandwiches: two ounces of cheese per sandwich.

Review of the nutritional information for the American Cheese used to make the Grilled Cheese Sandwiches showed one slice of cheese provided 60 calories and three grams of protein.

Medical record review for Residents 11 and 70 was intiated on 1/22/25.

* Review of the medical record for Resident 11 showed Resident 11 was admitted to the facility on [DATE REDACTED] with medical diagnoses which included vitamin D deficiency and hypocalcemia (low blood calcium). Further

review of the medical record showed a physcian's order dated 10/10/24, for a Regular diet, regular texture no meat, no fish diet.

During the lunch meal tray line service on 1/22/25 at 1144 hours, the following was observed:

Res 11's lunch meal tray consisted of one grilled cheese sandwich, peas, orange juice and cranberry juice.

* Review of the medical record for Resident 70 showed Resident 70 was admitted to the facility on [DATE REDACTED] with medical diagnoses which included severe protein calorie malnutrition and pulmonary (lung) disease. Further review of the resident's medical record showed a physician's order dated 1/6/25, for a Vegetarian Lacto (dairy products) diet, regular texture.

During the lunch meal tray line service on 1/22/25 at 1144 hours, the following was observed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0806 Resident 70's lunch meal tray consisted of one grilled cheese sandwich, peas, jello, milk, and juice.

Level of Harm - Minimal harm or On 1/22/25 at 1200 hours, an interview was conducted with [NAME] 2. [NAME] 2 was asked how he potential for actual harm prepared the grilled cheese sandwiches for the lunch meal. [NAME] 2 stated he used three slices of American cheese for each grilled sandwich which was equivalent to nine grams of protein. Residents Affected - Few

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 entree.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 50787

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

the sanitary requirements were met in the kitchen as evidenced by:

* The facility failed to ensure the correct cutting board was used for raw poultry.

* The facility failed to ensure the sanitizing solution used to sanitize food preparation surfaces was the proper concentration.

* The facility failed to ensure kitchen equipment and utensils were clean .

* The facility failed to ensure kitchen equipment and utensils were air dried .

* The facility failed to ensure maintenance tools were stored in a sanitary manner .

These failures had the potential to cause bloodborne illness in a medically vulnerable resident population of 94 who consumed food prepared from the kitchen.

Findings:

Review of the facility's undated matrix showed 94 of 106 residents received food prepared in the kitchen.

1. According to US Food and Drug Administration (USFDA) Food Code Section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.

(A) Food shall be protected from cross contamination by: (2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (a) Using separate equipment for each type.

Review of the facility's document titled US Cutting Board Color Chart undated showed Red - raw beef, pork, lamb, and other types of raw meat; Yellow - raw poultry, such as chicken, turkey and duck; Blue - raw fish, shellfish, and other seafood products; [NAME] - dairy and baked goods; [NAME] - fruits, vegetables and salads; [NAME] - cooked meat, such as roast, beef or ham.

On 1/21/25 at 805 hours, during the initial inspection of the facility's kitchen with Dietary Aide (DA) 1, [NAME] 1 was observed cutting raw chicken using a red cutting board. [NAME] 1 was asked if it was okay to use the red cutting board for raw chicken, [NAME] 1 did not answer. DA 1 verified a yellow cutting board must be used for the raw poultry.

2. According to the USFDA Food Code Section 3-304.14 Wiping Cloths, Use Limitation. (B) Cloths in-use for wiping counters and other surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 Review of the facility's P&P titled Quaternary Ammonium Log Policy dated 2018 showed . the quaternary solution will be replaced when the reading is below 200 parts per million (ppm). Level of Harm - Minimal harm or potential for actual harm On 1/21/25 at 1419 hours, DA 2 was asked to test the sanitizing solution in the sanitizing bucket. DA 2 used

the sanitizing test strip to check the concentration of the sanitizing solution. The sanitizing solution test strip Residents Affected - Some showed the concentration of the sanitizing solution was 150 ppm. DA 2 confirmed the concentration of the sanitizing solution was not the correct concentration.

On 1/23/25 at 956 hours, an interview was conducted with the CDM. The CDM stated the sanitizing solution should be changed every four hours and as needed.

3. According to USFDA Food Code 2022 Section 4-601.11Equipment, Food Contact Surfaces, Non- Food Contact Surfaces and Utensils. (A) Equipment, food- contact surfaces and utensils shall be clean to sight and touch.

On 1/21/24 at 805 hours, during the initial tour of the kitchen with DA 1, the following were observed:

- a blender had a brown residue on the inside of the pitcher;

- a microwave had food residue on the turntable and inner part of the microwave door;

- a toaster with a thick brown, greasy build up; and

- a robocoupe (a device used to chop and puree food), blade and bearing assembly had a brown residue.

DA 1 confirmed the above findings.

4. According to the USFDA Food Code 2022 Annex, Section 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils.

On 1/21/24, at 0805 hours, during the initial tour of the kitchen with DA 1, the following were observed

- six steam table pans stacked and stored wet,

- the robot coupe, was stored wet with the top on, and

- the blender was stored wet with the top on .

DA 1 confirmed the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 5. According to the USDA Food Code 2022 section 6- 501.113 Storing Maintenance Tools. Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: A Stored so that they do not Level of Harm - Minimal harm or contaminate food, equipment, utensils. potential for actual harm

On 1/21/25 at 805 hours, during the initial kitchen inspection with DA 1, two brooms were observed on the Residents Affected - Some floor, DA1 verified and moved the brooms to the designated storage by the wall.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 39856 potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure food brought to the Residents Affected - Few facility from family members or visitors was stored, prepared and safe food handling practices were followed.

This failure had the potential for unsafe food handling which could lead to food borne illness in the 94 residents receiving an oral diet who resided in the facility.

Findings:

Review of the facility P&P titled Food and Liquids from Outside Sources or Other Than the Dietary Department revised 7/2019 showed the food and liquids brought in by visitors for the residents is discouraged due to problems of infection control and conflicts between diets and consistency .Visitors are discouraged from bringing in potentially hazardous foods, i.e. meat, fish, eggs, custards, milk products, etc. If such foods are brought to the resident, they should be consumed immediately and not shared with other residents within the facility .Food items brought into the facility for residents cannot be reheated or stored.

They are to be consumed or discarded.

On 1/21/25 at 1115 hours, an interview was conducted with RN 1. When asked about how the food brought to the facility for the residents from the visitors was handled, RN 1 stated the food from the visitors could be stored for 24 hours. RN 1 was asked if she had received training on safe food handling. RN 1 stated she had not received training on safe food handling recently. RN 1 was asked if the facility allowed food from the resident's visitors to be heated. RN 1 stated there was a microwave at Nursing Station 1.

On 1/21/25 at 1121 hours, an interview was conducted with RN 4 at Nursing Station 1. RN 4 confirmed the food from the resident's visitors could be heated in the microwave located at Nursing station 1. The microwave at Nursing Station 1 was observed to have a brown burned residue on the inside top of the microwave. RN 4 stated she would have the microwave removed. RN 4 was asked if the information on safe food handling was provided to the visitors. RN 4 stated she was not aware of any information on safe food handling for the visitors, but she would check with the Admissions Coordinator.

On 1/21/25 at 1127 hours, an interview was conducted with the DSD. The DSD was asked if she had given

an in-service training to the staff members on safe food handling. The DSD stated she would check her records.

On 1/21/25 at 1130 hours, an interview was conducted with the Admission Coordinator. When asked if he was aware of any information on safe food handling provided to the residents or visitors, the Admission Coordinator stated he was not aware of any.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 On 1/22/25 at 0854 hours, an interview was conducted with the DON. The DON was asked to explain the process when the visitors brought food for the residents from the outside. The DON stated when the visitors Level of Harm - Minimal harm or brought food for the residents from the outside, the residents were encouraged to finish the food right away potential for actual harm however, there was a refrigerator where the food could be stored until the following day. The DON added no sharing of food with other residents was allowed. When asked about the staff member education of the safe Residents Affected - Few food handing, the DON stated the DSD and Infection Preventionist (IP) gave in-service training on safe food handling. The DON was asked how visitors were educated on safe food handling. The DON stated she was not aware how the visitors were educated on the safe food handling.

On 1/22/25 at 0921 hours, the DON confirmed the facility did not provide any information in writing to the visitors on the safe food handling.

On 1/22/25 at 0938 hours, an interview was conducted with the IP. The IP was asked if he had provided any education for the facility staff member on the safe food handling. The IP stated he could not recall but would check his education records.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37726

Residents Affected - Some Based on interview and medical record review, the facility failed to ensure the medical record was complete and accurately maintained for one of 24 final sampled residents (Resident 8).

* Resident 8's POLST and Advance Directive Acknowledgement form failed to show documentation as to whether Resident 8 had formulated an advance directive. This failure had the potential for the resident's wishes specific to health care interventions not being honored.

Findings:

Medical record review for Resident 8 was initiated on 1/21/25. Resident 8 was admitted to the facility on [DATE REDACTED].

On 1/22/25 at 1554 hours, an interview and concurrent medical record review was conducted with the SSD.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51539

Residents Affected - Few Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident reviewed for hospice services (Resident 49).

* The facility failed to ensure Resident 49 received the hospice care visits three times a week by the Certified Home Health Aid and one to three visits a week from the Skilled Nurse.

* The facility failed to assign a designated hospice coordinator for Resident 49.

These failures posed the risk for delays in the communication between the hospice provider and the facility which may affect resident care.

Findings:

Review of the facility's P&P titled Hospice Care revised 9/2018 showed the following:

- The facility is responsible for ensuring that hospice services meet professional standards and the timelines of the services.

- The facility must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the facility staff and hospice staff.

Medical record review for Resident 49 was initiated on 1/22/25. Resident 49 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 49's physician's order dated 10/2/24, showed resident was admitted to Hospice Agency 1 under routine level of care with primary diagnosis of senile degeneration of brain, unspecified.

Review of Resident 49's Physician Order Summary Report dated 12/31/24, showed an order for the Hospice Certified Home Health Aide (CHHA) visits three times a week and Hospice Skilled Nurse (SN) visits one to three times a week and as needed for change of condition.

Review of Resident 49's Visit Record and Vital Signs Sheet from Hospice Agency 1 showed the following visits were conducted by the hospice nurses:

- During the week of 9/29/24 to 10/5/24, there were CHHA visits on 10/2 and on 10/3/24, instead of three visits as ordered. There was no documented evidence of the SN visit during this week.

- During the week of 10/6/24 to 10/12/24, there were CHHA visits on 10/9 and on 10/12/24 instead of three visits as ordered. There was no documented evidence of the SN visit during this week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 0849 - During the week of 10/13/24 to 10/19/24, there were no visits from the CHHA and SN.

Level of Harm - Minimal harm or - During the week of 10/20/24 to 10/26 24, there was only one visit conducted by CHHA on 10/23/24, instead potential for actual harm of three visits as ordered. There was no documented evidence of the SN visit during this week.

Residents Affected - Few - During the week of 10/27/24 to 11/2/24, there was only one visit conducted by CHHA on 10/30/24, instead of three visits as ordered. There was no documented evidence of the SN visit during this week.

- 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 49258 potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection Residents Affected - Few control practices were implemented as evidenced by:

* The employees and residents' personal belongings were in the laundry room's clean folding area.

* The facility failed to clean the spoon container on the Medication Carts for two of five medication carts inspected (Medication Carts B and C).

These failures had the potential for spread of infection.

Findings:

Review of the facility's P&P titled Infection Control Program System revised 1/2023 showed the personnel must handle, store, process, and transport linens to prevent the spread of infection.

Review of the facility's P&P titled Policy for Laundry - Nursing P&P Manual revised 8/2016 showed the linens are handled, stored, processed, and transported in such a manner as to prevent the spread of infection.

1. On 1/27/25 at 1245 hours, a concurrent observation of the laundry room and interview was conducted with

the Environmental Services Director (ESD). The following items were observed in the clean folding area:

- a large pink purse;

- a white cellphone charger;

- a plastic botttle of lotion;

- an eye goggle;

- two plastic bottled water;

- a black remote control; and

- two reading eye glasses.

The ESD verified the above findings. The ESD stated the two reading eye glasses and remote control were mixed from the soiled linens which were taken out from the residents' rooms. The ESD was unable to answer when asked if the reading eye glasses and remote control were sanitized since it came from the soiled linens. The ESD stated the rest of the items were owned by the laundry staff. The ESD stated these items should not be in the clean folding area because it could cause contamination to the clean clothes and linens used by the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 1/27/25 at 1347 hours, a interview was conducted with the IP. The IP stated the laundry room's clean folding area should be free of any employees and residents' personal belongings to prevent spread of Level of Harm - Minimal harm or infection and contamination of linens. The IP was informed and acknowledged the above findings. potential for actual harm 45064 Residents Affected - Few 2. Review of facility's P&P titled Storage of Medications effective 4/2008 showed the medication storage areas are kept clean.

On 1/22/25 at 1200 hours, an observation of Medication Carts B and C was conducted. Spoon 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 - Minimal harm or 50787 potential for actual harm Based on observation, interview, and facility document and facility's P&P review, the facility failed to ensure Residents Affected - Few the essential equipment was maintained in proper working order when:

* The ice machine manufacturer's guidelines for cleaning and sanitizing were not followed.

* The microwave located on Station 1 was not maintained in a safe operating condition.

* Two medication refrigerators and one specimen refrigerator were observed with ice buildup.

These failures had the potential for equipment hazards or unsafe practices which could affect the residents' well-being in the facility.

Findings:

1. Review of the facility's P&P titled Cleaning the Ice Machine revised date of 4/2022 showed the ice machine shall be cleaned for maintenance of sanitary conditions in order to prevent food contamination and

the growth of disease- producing organism and toxins. The ice machine shall be cleaned in accordance with

the manufacturer's requirements.

Review of the [Manitowoc] ice machine model 1-300/420/620 manufacturer's instructions located on the inside panel of the ice machine cover showed in part, the following:

- Step 5- Remove parts for the cleaning.

- Step 6- Mix a solution of cleaner and lukewarm water .one gallon water to 16 ounces(oz) cleaner.

- Step 7- Use half of the cleaner mixture to clean all components . Rinse all components with clean water. Sanitizing Procedure:

- Step 9- Mix a solution of two ounces sanitizer with three gallons of lukewarm water.

- Step 10- Use half of the sanitizer/water solution to sanitize all removed components. Use a spray bottle to liberally apply the solution to all the surfaces of the removed parts or soak the removed parts (top, bottom, and sides), bin or dispenser. Do not rinse parts after sanitizing.

On 1/21/25 at 907 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the facility's ice machine was cleaned monthly by the facility's maintenance staff and annually by the company and the ice machine manufacturer instructions were followed. The Maintenance Director further stated to clean the ice machine, he used five ounces of the descaler (a chemical solution that removes mineral deposits, or scale, from surfaces) mixed with one gallon of water. To sanitize the ice machine, he used one gallon of water mixed with three ounces of descaler. However, the Maintenance Director's methods of cleaning and sanitizing were not in accordance with the manufacturer's guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 2. Review of the facility's P&P titled Sanitation dated 2018 showed all utensils, counters, shelves and equipment shall be kept clean, maintained and in good repair and shall be free from breaks, corrosions, open Level of Harm - Minimal harm or seam, cracks and chipped areas. potential for actual harm

On 1/21/25 at 1121 hours, an interview regarding heating food brought for the residents from the outside and Residents Affected - Few concurrent inspection was conducted with RN 1. RN 1 stated the facility used the microwave located at Station 1 to heat food brought from the outside for the residents. The microwave was observed to have charred, burnt interior. RN1 confirmed the finding and stated she 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.

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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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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** 49258

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 complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for four of four sampled residents (Residents 5, 13, 29, and 37) reviewed for side rails use. The facility also failed to ensure all the beds in the facility were regularly inspected. 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 Bed Safety revised 8/2018 showed to try to prevent death/injury from the beds and related equipment (including frame, mattress, side rails, grab bars, headboard, footboard, and bed accessories), the facility shall promote the following approaches:

- Inspection by maintenance staff of all beds and related equipment as part of the facility's regular bed safety program to identify any risks or problems including potential entrapment risks;

- Review to ensure that gaps in the bed system do not present a hazard to the resident due to the resident's height and/or weight or due to the resident's movement or bed position; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 - Ensure that if a grab bar or bed side rails are to be utilized those are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, Level of Harm - Minimal harm or ensure proper distance from the headboard and footboard, etc.). potential for actual harm

Review of the facility's P&P titled Side Rails or Bed Rails revised 8/2018 showed if a bed or side rail is used Residents Affected - Few even for episodic use, the facility will make sure that it is installed correctly, used correctly, and maintained.

The resident will be assessed for the risk of entrapment from the bed rails prior to its installation and the facility will make sure that the bed's dimensions are appropriate for the resident's size and weight.

Review of the facility's P&P titled Side Rail or Bed Rail Assessment Guidance to Reduce Entrapment revised 8/2018, showed the facility had to assess the resident's risk for entrapment prior to the installation of side rails or bed rails to ensure the bed dimensions are appropriate for the resident's size and weight. The facility will assess the resident's risk for entrapment for the use of a grab bar using the facility's grab bar assessment.

A concurrent observation, medical record review, and facility document review for Residents 5, 13, 29, and 37 showed the residents' bed entrapment assessments were not completed or the bed inspection gap measurement for Zone 2 was recorded. For example:

1. During the initial tour of the facility on 1/21/25 at 0958 hours, Resident 13 was observed awake and sitting

in the wheelchair beside the bed. The bed was observed with bilateral upper side rails elevated. Resident 13 stated he grabbed the side rails during turning or when he was getting out of the bed.

Medical record review for Resident 13 was initiated on 1/22/25. Resident 13 was readmitted to the facility on [DATE REDACTED].

Review of Resident 13's H&P examination dated 4/30/24, showed Resident 13 had the capacity to understand and make decisions. The H&P examination also showed Resident 13 had a significant diagnosis of morbid obesity.

Review of Resident 13's MDS dated [DATE REDACTED], showed Resident 13 required partial to moderate assistance for bed mobility.

Further review of Resident 13's medical record failed to show documented evidence an entrapment assessment was completed prior to installation of the side rails.

On 1/22/25 at 0934 hours, an observation and concurrent interview was conducted with Resident 13. Resident 13 was observed awake and lying in the bed with the bilateral upper side rails elevated. Resident 13 stated he had been using the side rails for a long time and not just a month ago. Resident 13 further stated he needed the side rails to grab when he turned from side to side or when he was getting out of bed.

On 1/22/25 at 1553 hours, a concurrent observation and interview was conducted with CNA 5. CNA 5 was observed leaving Resident 13's room. CNA 5 stated she just assisted Resident 13 with the bedpan. CNA 5 stated when Resident 13 was in bed, the bilateral side rails were always elevated. CNA 5 further stated Resident 13 grabbed on the side rails when being assisted with turning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 1/23/25 at 1418 hours, a concurrent interview and medical record review for Resident 13 was conducted with LVN 1. LVN 1 stated an entrapment risk assessment should be completed prior to installation of side Level of Harm - Minimal harm or rails. LVN 1 stated the maintenance department was responsible for installing the side rails and measuring potential for actual harm the gaps in bed. LVN 1 verified no assessment for the risk of entrapment from elevated side rails was done for Resident 13 prior to installation. Residents Affected - Few 2. During the initial tour of the facility on 1/21/25 at 0855 hours, Resident 29 was observed awake and lying

in the bed with the bilateral upper side rails elevated. Resident 29 stated she grabbed on the side rails when being turned for care provided or when she needed to get in or out of the bed.

Medical record review for Resident 29 was initiated on 1/21/25. Resident 29 was readmitted to the facility on [DATE REDACTED].

Review of Resident 29's H&P examination dated 10/25/24, showed Resident 29 had the capacity to understand and make decisions. The H&P also showed Resident 29 had a diagnosis of left hip fracture status post left hip replacement.

Review of Resident 29's MDS dated [DATE REDACTED], showed Resident 29 required partial to moderate assistance for bed mobility.

Review of Resident 29's Order Summary Report showed a physician's order dated 10/28/24, for grab bars

on both sides of the bed as enabler for turning/repositioning due to osteoporosis (a condition in which bones become weak and brittle)/rheumatoid arthritis (a chronic inflammatory disorder that affects the joints).

Review of Resident 29's Bedrail/Grab bar use and Entrapment Risk Evaluation dated 10/28/24, showed the following:

- The grab bars were requested by the resident, and the resident demonstrated the ability to use the grab bars;

- The possible risks of entrapment were discussed, and verbalized understanding and agreement for continued use.

- The Entrapment Zones 1 to 4, and the boxes for yes were checked off; and

- The IDT recommended bilateral grab bars for enabler, turning/repositioning on bed.

Review of Resident 29's Informed Consent for the Use of Anything Attached to a Bed dated 10/28/24, showed if a bed rail or siderail is used, the facility will make sure that it is installed correctly, used correctly and maintained. The resident will be assessed for entrapment from the bedrails/side rails prior to their installation and the facility will make sure that the bed's dimensions are appropriate for the resident's size and weight.

Review of Resident 29's plan of care showed a care plan problem dated 10/28/24, to address the use of grab bar as an enabling device that does not limit freedom of movement. The approach plan included to assess

the resident for risk for entrapment prior to installation, ensure bed dimensions appropriate for the resident's size and weight, and maintenance to check grab bars monthly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 1/22/25 at 1041 hours, a concurrent observation of Resident 29 and interview with CNA 4 was conducted. Resident 29 was transferring from the wheelchair to the bed and being assisted by CNA 4. Level of Harm - Minimal harm or Resident 29 was observed grabbing to the right grab rail. CNA 4 stated Resident 29 had always have the potential for actual harm side rails. CNA 4 stated Resident 29 held on the rails during repositioning or when she was getting out or in

the bed. Residents Affected - Few

On 1/23/25 at 1446 hours, a concurrent interview and medical record review for Resident 29 was conducted with RN 3. When asked about the entrapment assessment related to the use of grab bars, RN 3 stated the CNAs could conduct the assessment to the make sure the resident was safe in using and really in need of

the grab bars. RN 3 stated the licensed nurses would verify the assessment as well. When asked about the bed evaluation of Zones 1 to 4 marked yes in the evaluation form, RN 3 stated the maintenance staff was the one who was filling up the sections for Zones 1 to 4.

On 1/24/25 at 1225 hours, a concurrent interview and facility document review for Residents 13 and 29 was conducted with the Environmental Services Director (ESD). The ESD stated the maintenance department was responsible for the monthly bed inspection of all the beds in the facility, where they checked the whole bed, bed functionality, frame, bed control, and grab bars. The ESD stated the maintenance department also installed the grab bars. When asked what was used to measure the entrapment zones on each bed, the Environmental Services Director showed a piece of wood marked with different measurements. When asked to show the documentation of the results of bed inspection including the entrapment assessment, the ESD showed the Siderail or Bedrail Assessment Guidance to Reduce Entrapment forms.

Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for November 2024 showed the following:

- Resident 13's bed was inspected on 11/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a.

- Resident 29's bed was inspected on 11/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a.

Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for December 2024 showed the following:

- Resident 13's bed was inspected on 12/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a.

- Resident 29's bed was inspected on 12/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a.

Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for January 2025 showed the following:

- Resident 13's bed was not inspected.

- Resident 29's bed was inspected on 1/20/25. The form showed Zones 1, 2, 3, 4, and 7, and frame were marked ok and Zones 5 and 6 were marked n/a.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 The ESD verified the above findings. The ESD stated the entrapment assessment was conducted when the resident was not in the bed. The ESD stated they only marked ok when the bed passed the inspection, and Level of Harm - Minimal harm or n/a or not applicable. The ESD verified Zone 2 should have been checked. When asked about the other potential for actual harm rooms that were marked with vertical lines, the ESD stated those were the rooms with beds without grab bars but was not able to explain why those rooms were marked with vertical lines. The ESD was not able to Residents Affected - Few show documented evidence of the regular inspection of the beds without grab bars.

On 1/27/24 at 1445 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

39453

3. On 1/21/25 at 0900 hours, during the initial tour of the facility, Resident 37 was observed in bed with bilateral grab rails elevated. Resident 37 stated she used the grab rails when turning and repositioning during incontinence care.

Medical record review for Resident 37 was initiated on 1/30/25. Resident 37 was readmitted to the facility on [DATE REDACTED].

Review of Resident 37's MDS dated [DATE REDACTED], showed Resident 37 was cognitively intact, with impairment to

the upper extremities, and required partial/moderate assistance for mobility.

Review of Resident 37's Bedrail/ Grab bar use and Entrapment Risk Evaluation dated 1/3/25, showed the following:

- The grab bars were requested by the resident, and the resident demonstrated the ability to use the grab bars;

- The possible risks of entrapment were discussed, and verbalized understanding and agreement for continued use.

- The Entrapment Zones 1 to 4, and the boxes for yes were checked off; and

- The IDT recommended bilateral grab bars for bed mobility/repositioning.

Review of Resident 37's Informed Consent for the Use of Anything Attached to a Bed dated 1/3/25, showed if a bed rail or side rail is used, the facility will make sure that it is installed correctly, used correctly and maintained. The resident will be assessed for entrapment from the bed rails/[NAME] ails prior to their installation and the facility will make sure that the bed's dimensions are appropriate for the resident's size and weight.

Review of Resident 37's Order Summary Report showed a physician's order dated 1/3/25, to provide grab bars on bilateral sides of the bed as enabler for bed mobility, turning and repositioning secondary to generalized weakness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 37's plan of care showed a care plan problem dated 1/3/25, addressing the use of grab bar as an enabling device that does not limit freedom of movement. The approach plan included to assess Level of Harm - Minimal harm or the resident for risk for entrapment prior to installation, ensure bed dimensions appropriate for the resident's potential for actual harm size and weight, and for the maintenance to check grab bars monthly.

Residents Affected - Few On 1/22/25 at 1215 and 1544 hours, and 1/23/25 at 0835 hours, Resident 37 was observed in bed with bilateral grab rails elevated.

On 1/23/25 at 0932 hours, an interview was conducted with CNA 3. When asked about Resident 37's use of bed rails, CNA 3 stated Resident 37 required extensive assist with mobility, but she could hold on to the grab bars when turning.

On 1/23/25 at 1351 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 3. When asked about the entrapment assessment related to the use of grab bars, RN 3 stated the CNAs conducted the assessment to the make sure the resident was safe in using the grab bars. RN 3 stated, if there are concerns, then it will be delegated to the charge nurses, or if there was a problem, such as when the resident was tired from dialysis and could not grab the rails, then the CNAs would have to report to the charge nurse. When asked about the bed evaluation of Zones 1 to 4 marked yes in the evaluation form, RN 3 stated the bed evaluation was self-explanatory. When asked to elaborate, RN 3 was not able to identify and explain the zones of entrapment, specifically Zones 1 to 4. RN 3 stated RN 1 checked the bed and completed the grab bar evaluation form. RN 3 stated was not shown how to do the bed evaluation.

On 1/24/25 at 1225 hours, a concurrent interview and facility document review for Resident 37 was conducted with the ESD. The ESD stated the maintenance department was responsible for the monthly bed inspection of all the beds in the facility, where they checked the whole bed, bed functionality, frame, bed control and the grab bars. The EDS stated the maintenance department also installed the grab bars. When asked what was used to measure the entrapment zones on each bed, the Environmental Services Director showed a piece of wood marked with different measurements. When asked to show the documentation of

the results of bed inspection including the entrapment assessment, the Environmental Services Director showed the Siderail or Bedrail Assessment Guidance to Reduce Entrapment forms.

Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for November 2024 showed Resident 37's bed was inspected on 11/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a for Resident 37's bed. Further review of the form showed other beds were left blank.

Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for December 2024 showed Resident 37's bed was inspected on 12/18/24. The form showed Zones 1, 3, and 7, and frame were marked ok, and Zones 2, 4, 5, and 6 were marked n/a for Resident 37's bed. Further review of the form showed other bed were marked with vertical lines.

Review of the Siderail or Bedrail Assessment Guidance to Reduce Entrapment form for January 2025 showed Resident 37's bed was inspected on 1/20/25. The form showed Zones 1, 2, 3, 4, and 7, and frame were marked ok and Zones 5 and 6 were marked N/A for Resident 37's bed. Further review of the form showed other beds were marked with vertical lines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 60 555520 Department of Health & Human Services Printed: 09/10/2025 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 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

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 The ESD verified the above findings. The ESD stated the entrapment assessment was conducted when the resident was not in the bed. The ESD stated they only marked ok when the bed passed the inspection, and Level of Harm - Minimal harm or n/a or not applicable. The ESD verified Zone 2 should have been checked. When asked about the other potential for actual harm beds that were marked with vertical lines, the ESD stated those were the beds without grab bars, but the ESD was not able to explain why those rooms were marked with vertical lines. The ESD was not able to Residents Affected - Few show a documented evidence of the regular inspection conducted for the beds without grab bars.

50967

4. Medical record review for Resident 5 was initiated on 1/22/25. Resident 5 was admitted to the facility on [DATE REDACTED].

Review of Resident 5's H&P examination dated 2/3/24, showed Resident 5 had no capacity to understand and make decisions.

Review of Resident 5's MDS dated [DATE REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 60 555520