Health inspection·August 1, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for three of six sampled residents (Residents 1, 2, and 3). * The facility failed to ensure the risks of leaving the facility unsupervised without informing the staff were explained to Resident 1. * The facility failed to ensure Resident 1's smoking assessment was accurate and complete. * Resident 2 and 3's post fall neuro checks were not completed per their care plans. These failures had the potential to negatively affect Resident 1, 2, and 3's health condition and well-being.Findings: 1. a. Review of the facility's P&P titled Care Plans - Comprehensive (undated) showed each resident's care plan is designed to:- incorporate identified problem areas- incorporate risk factors associated with identified problems- build on resident's strengths- reflect the resident's expressed wishes regarding acre and treatment goals- reflect treatment goals, timetables and objectives in measurable outcomes- identify the professional services that are responsible for each element of care- aid in preventing or reducing declines in the resident's functional status and/or functional levels- enhance optimal functioning of the resident by focusing on a rehabilitative program- reflect currently recognized standards of practice for problem areas and conditions. Medical record review for Resident 1 was initiated on 7/30/25. Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 1's Change in Condition dated 7/10/25, showed the resident headed out of the facility after dinner without informing the staff. Resident 1 was being pulled by another resident on an electric chair. When passing over the gate frame, Resident 1's chair tilted over, and Resident 1 landed on her right shoulder. Resident 1 did not have any head or skin injury. The vitals signs were within normal limits. Resident 1 was transferred out to the acute care hospital. Review of Resident 1's care plan date initiated 7/11/25, showed a care plan problem for the fall incident on 7/10/25. Interventions included educating the resident of the importance of informing the staff every time she was going out of the facility, the resident was to comply with facility house rules and policies, and the risks of not informing the staff when leaving the facility were explained. Review of Resident 1's medical record failed to show documented evidence the facility informed the resident of the risks of leaving the facility without notifying the staff. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a BIMS score of 14, meaning the resident was cognitively intact. On 8/1/25 at 0925 hours, a concurrent interview and medical record review for Resident 1 was conducted with RN 1. RN 1 verified there was no documentation on educating the resident on the risks of leaving the facility without notifying the staff. b. Review of the facility's P&P titled admission Assessment and Follow Up: Role of Nurse revised on 9/2012 showed the following information should be recorded in the resident's medical record: - the date and time the assessment was performed- the name and title of the individual(s) who performed the procedure- all relevant assessment data obtained during the procedure- how the resident tolerated the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055742 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Villa Care Center 861 S. Harbor Blvd Anaheim, CA 92805 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)