Inspection visit

Health inspectionDecember 20, 2019

LEISURE COURT NURSING CENTERCMS #5555207 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to develop the comprehensive person-centered care plans for two of 21 final sampled residents (Residents 23 and 439). * Resident 23 was hearing impaired and required hearing aids. The facility failed to develop a care plan problem to address the resident's hearing deficit and use of hearing aids. This had the potential of Resident 23 not having their needs met due to inefficient communication. * The facility failed to develop a care plan problem to address Resident 439's use of an IV and increased sodium. This failure posed the risk of not providing appropriate, consistent, or individualized care to Resident 439. Findings: 1. Medical record review for Resident 23 was initiated on 12/13/19. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's history & physical examination dated 12/4/19, showed Resident 23 was hearing impaired. Review of the MDS dated [DATE], under Section B, showed Resident 23 had moderate hearing difficulty. Under the section for options showed the speaker had to increase their volume and had to speak distinctly. The MDS showed Resident 23 did not require hearing aids. Review of the plan of care showed a care plan problem dated 12/1/19, to address Resident 23's impaired communication. The interventions did not include the use of hearing aids. On 12/13/19 at 1127 hours, an observation of Resident 23 was conducted in the dining room during relaxing music time. When asked how he was enjoying the music, Resident 23 did not answer. On 12/13/19 at 1130 hours, an interview was conducted with LVN 2. LVN 2 verified Resident 23 was hearing impaired and had hearing aids. LVN 2 verified the hearing aids were not listed as an intervention in the care plan. On 12/13/19 at 1138 hours, an interview was conducted with CNA 1. CNA 1 verified Resident 23 was hard of hearing and had hearing aids locked in the medication cart. (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 11 Event ID: 555520 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/13/19 at 1421 hours, an interview was conducted with LVN 4. LVN 4 verified Resident 23 had hearing aids. LVN 4 stated resident 23 had pulled the hearing aids from his ears in the past and was at risk for losing them. On 12/17/19 at 0928 hours, an interview was conducted with the DON. The DON verified Resident 23's care plan failed to address the use of hearing aids. 2. On 12/12/19 at 1346 hours, and on 12/13/19 at 0717 hours, Resident 439 was observed with an IV fluids and an IV access to the left forearm. Medical record review for Resident 439 was initiated on 12/12/19. Resident 439 was admitted to the facility on [DATE]. Review of Resident 439's Physician Orders for Infusion Therapy showed an order dated 12/11/19, for D5 ½ NS (5% dextrose in half amount of normal saline, for fluid and electrolyte replenishment) one liter IV at 60 ml per hour for 72 hours for increased sodium. Review of Resident 439's plan of care did not show a care plan problem was developed to address Resident 439's use of a peripheral IV and for increased sodium. On 12/13/19 at 1543 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 439's IV and increased sodium were not addressed in Resident 439's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 2 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure a vascular access site was maintained and assessed as per the facility's P&P for one of 21 final sampled residents (Resident 76). This had the potential to place the resident at risk for developing a complication related to vascular access associated infections. Residents Affected - Few Findings: Review of the facility's P&P titled IV Therapy dated 6/2018 showed peripheral IV sites will be rotated at least every 96 hours and as needed. Documentation of IV therapy should include IV site assessment. On 12/12/19 at 1540 hours, an observation was conducted of Resident 76. Resident 76 was observed lying in bed with a peripheral IV inserted into her right wrist. The IV site dressing was unlabeled. Medical record review for Resident 76 was initiated on 12/12/19. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's medical record failed to show an order for IV therapy. On 12/12/19 at 1546 hours, a concurrent observation, interview, and medical record review was conducted with RN 3. RN 3 verified Resident 76's peripheral IV on her right wrist was unlabeled. RN 3 stated Resident 76 was at the acute care hospital for approximately eight days, and RN 3 had readmitted Resident 76 to the facility on [DATE]. RN 3 stated Resident 76 was readmitted with a peripheral IV to her right wrist. RN 3 stated she was uncertain as to whether Resident 76 needed the peripheral IV. RN 3 stated when Resident 76 was readmitted to the facility, she contacted the physician. RN 3 stated she failed to ask the physician whether or not Resident 76 needed the peripheral IV. RN 3 reviewed Resident 76's medical record and was unable to determine when Resident 76's peripheral IV was inserted or how long Resident 76 had the peripheral IV. RN 3 stated the facility's P&P for residents with peripheral IV's was to assess the IV site every shift for redness, infiltration, and infection. RN 3 reviewed Resident 76's medical record and verified the facility failed to document any IV site assessments for Resident 76 since her readmission to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 3 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care and services for one of 21 final sampled residents (Resident 438). The facility failed to ensure the oxygen treatment was documented. In addition, the facility failed to develop a care plan for the oxygen and nebulizer treatment. These failures posed the risk for complications related to respiratory care. Residents Affected - Few Findings: Medical record review for Resident 438 was initiated on 12/12/19. Resident 438 was readmitted to the facility on [DATE]. Review of Resident 438's Physician and Telephone Orders showed the following physician's orders: - 12/9/19, administer Duoneb (a bronchodilator, relaxes muscles in the airway) one unit dose every eight hours as needed for two weeks. - 12/10/19, apply oxygen inhalation 3 liters per minute via nasal cannula (flexible tube to deliver oxygen into the nose) to maintain the oxygen saturation above 90%. a. Review of Resident 438's Medication Record for December 2019 showed an entry dated 12/10/19, to adminster oxygen three liters per minute via nasal cannula to maintain the oxygen saturation above 90%, FYI (for your information). The Medication Record did not show the licensed nurses documented the administration of oxygen to Resident 438. b. Review of Resident 438's plan of care failed to show a care plan problem to address the use of oxygen and Duoneb. On 12/17/19 at 1031 hours, an interview and concurrent medical record review was conducted with LVN 1, with RN 2. LVN 1 and RN 2 verified the above findings. When asked about the oxygen administration for Resident 438, LVN 1 stated Resident 438 was receiving three liters of oxygen via nasal cannula. When asked where she documented the oxygen administration for Resident 438, LVN 1 reviewed the medication record and verified the medication record did not show the oxygen administration was documented. LVN 1 stated the licensed nurses did not have to sign the medication record because it was just an FYI. LVN 1 verified Resident 438's plan of care did not show the use of oxygen and Duoneb were addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 4 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure ferrous sulfate (an iron supplement) was administered as per the physician's order for one nonsampled resident (Resident 72). * Resident 72 had a physician's order for ferrous sulfate delayed release/enteric coated (DR/EC) 325 mg orally twice a day for anemia. Resident 72 received the incorrect dose (330 mg) and the incorrect form (non DR/EC) of ferrous sulfate on 10 occasions. This posed the risk of Resident 72 not receiving the therapeutic effect of the prescribed supplement. Findings: Medical Record review for Resident 72 was initiated on 12/12/19. Resident 72 was admitted to the facility on [DATE]. Resident 72 had a diagnosis of anemia. On 12/17/19 at 0815 hours, LVN 3 was observed administering Resident 72's prescribed medications. LVN 3 stated Resident 72's medications needed to be crushed before being administered to Resident 72. Resident 72 had a physician's order dated 6/14/19, for ferrous sulfate DR/EC 325 mg tablet orally twice a day for anemia. As LVN 3 prepared Resident 72's medications to be administered, LVN 3 stated ferrous sulfate DR/EC tablets could not be crushed, and she needed to clarify the order with Resident 72's physician. LVN 3 then obtained a new physician's order for ferrous sulfate liquid 330 mg/7.5 ml to be administered orally twice a day for anemia. LVN 3 then administered ferrous sulfate liquid 330 mg (7.5 ml) to Resident 72. Review of the December 2019 Medications Flowsheet showed documentation LVN 3 administered ferrous sulfate DR/EC 325 mg tablet orally to Resident 72 at 0900 hours on the following dates: 12/3, 12/4, 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/15, and 12/16/19. LVN 3 verified the findings; however, LVN 3 stated she did not administer ferrous sulfate DR/EC 325 mg tablet orally as ordered by the physician, to Resident 72 at 0900 hours, on 12/3, 12/4, 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/15, and 12/16/19. LVN 3 stated she had instead administered ferrous sulfate liquid (non DR/EC) 330 mg/7.5 ml orally to Resident 72 at 0900 hours, on 12/3, 12/4, 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/15, and 12/16/19. LVN 3 verified Resident 72 received the incorrect dose (330 mg) of ferrous sulfate (physician's order was for 325 mg) and the incorrect form (non DR/EC) on 12/3, 12/4, 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/15, and 12/16/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 5 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of 21 final sampled residents (Residents 53 and 438) were free from unnecessary psychotropic medications. * The facility failed to ensure two psychotropic medications had a specific behavior manifestation for Resident 53 and failed to accurately monitor the behavior. * The facility failed to ensure the behavior manifestations were monitored for Resident 438 related to the use of Ativan (antianxiety medication). These failures had the potential to negatively impact the residents' well-being. Findings: 1. Medical record review for Resident 53 was initiated on 12/13/19. Resident 53 was admitted to the facility on [DATE]. Review of Resident 53's Physician Order Report showed an order dated 7/29/29, for Depakene solution (a psychotropic medication used to treat mood disorders) 500 mg twice daily for yelling/screaming without provocation. Review of Resident 53's Physician Order Report showed another order dated 9/23/19, for buspirone (a psychotropic medication used to treat mood disorders) 5 mg daily for yelling/screaming. Review of Resident 53's Behavior & Psychotropic Summary/Dosage Reduction for Depakene showed the following: - For 10/1 - 10/31/19, there were 63 documented episodes of yelling/screaming. - For 11/1 - 11/30/19, there were 76 documented episodes of yelling/screaming. Review of Resident 53's Behavior & Psychotropic Summary/Dosage Reduction for buspirone showed the following: - For 10/1 - 10/31/19, there were 54 documented episodes of yelling/screaming. - For 11/1 - 11/30/19, there were 62 documented episodes of yelling/screaming. On 12/13/19 at 1635 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 was asked about Resident 53's behaviors. RN 3 reviewed Resident 53's medical record and stated Resident 53 had episodes of yelling/screaming. RN 3 stated Resident 53 was on both the above medications for the yelling/screaming behavior. RN 3 stated each medication should have specific behavior monitoring in order to tell if the medication was effective. On 12/20/19 at 1117 hours, a telephone interview and concurrent medical record review was conducted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 6 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 Level of Harm - Minimal harm or potential for actual harm with RN 4. RN 4 reviewed Resident 53's Behavior & Psychotropic Summary/Dosage Reduction sheets for Depakene and buspirone. RN 4 verified the episodes of yelling/screaming did not match for the medications for the months of October and November 2019. RN 4 stated the number of episodes should be the same since the monitoring was for the same behavior. RN 4 was unable to state why the number of episodes were inconsistent. Residents Affected - Few 2. Medical record review for Resident 438 was initiated on 12/12/19. Resident 438 was readmitted to the facility on [DATE]. Review of Resident 438's Physician's Orders showed the following orders: - 12/4/19, Ativan 0.5 mg via GT at bedtime for anxiety manifested by yelling or calling out for no reason. - 12/4/19, Ativan 1 mg via GT daily for anxiety manifested by yelling or calling out for no reason. Review of Resident 438's Physician Orders showed an order dated 12/4/19, to monitor episodes of yelling or calling out for no reason related to the use of Ativan. Review of Resident 438's Medication Record failed to show Resident 438's behavioral episodes of yelling or crying out for no reason were monitored. On 12/17/19 at 1046 hours, an interview and concurrent medical record review was conducted with LVN 1, with RN 2 present. LVN 1 and RN 2 verified the above findings. LVN 1 stated the behavioral episodes of yelling or crying out for no reason were monitored each shift and documented on the medication record. LVN 1 could not locate any documentation showing the monitoring for Resident 438's behavior episodes of yelling or crying out for no reason related to the use of Ativan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 7 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 locked, compartments for controlled drugs. Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. The facility failed to ensure the proper labeling of an insulin medication. * The facility failed to ensure orally administered medications were stored separate from externally used medications and failed to ensure the alcohol wipes were stored separately from medications. This posed the risk for cross-contamination of the medications. * The facility failed to ensure an insulin medication was accurately labeled with an open date for one of 21 final sampled residents (Resident 67). Findings: 1. Review of the facility's P&P Storage of Medications dated 4/2008 showed orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. Potentially harmful substances such as urine test reagent tablets, household poisons, cleaning supplies, and disinfectants are clearly identified and stored in a locked area separately from medications. On 12/13/19 at 1400 hours, an inspection of Station 2's medication cart was conducted with LVN 2. The following was observed: a. An opened tube of Refresh lacrilube eye ointment, and clonidine patches were stored in the same compartment with ibuprofen (nonsteroidal anti-inflammatory drug, used to treat fever and pain) tablets, omega-3 (supplement) capsules, and vitamin B12 (supplement) tablets. b. An opened box of acetaminophen suppositories (over the counter pain medication) was stored in the same compartment with an opened box of sudogest PE (nasal decongestant) tablets. c. An opened tube of muscle rub cream was stored in the same compartment with the thickener and fiber powder d. Albuterol (a bronchodilator, relaxes muscles in the airway) medications were stored in the same compartment with oral liquid medications. e. Two containers of sanitizing wipes were observed stored in the same compartment with residents' oral medications in bubble packs (pre-formed plastic blister packaging). LVN 2 verified the above findings. 2. On 12/13/19 at 1414 hours, an interview and concurrent inspection of the medication cart on Station 3 was conducted with LVN 3. Resident 67's Lantus solution pen was observed in the cart. LVN 3 stated insulin pens were stored in the refrigerator, then once opened, would be stored in the medication cart. LVN 3 stated the open date was to be written on the pen once opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 8 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 Level of Harm - Minimal harm or potential for actual harm The label on the Lantus solution pen for Resident 67 showed to discard unused portion after 28 days. The medication also showed a delivery date of 12/5/19. LVN 3 stated she knew the Lantus solution pen had been used because the pen showed a dose had been administered. No open date was observed written on the pen. LVN 3 verified the above and stated the medication should have been labeled with an open date to ensure it would be discarded after 28 days. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 9 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen. Residents Affected - Some * The facility failed to ensure food in the walk-in freezer was free from contamination. * There was a lack of glaze observed on the dishware. * The facility failed to ensure a refrigerated food item was properly labeled and dated. These failures had the potential to contaminate the food which could lead to food borne illness in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 12/13/19, showed 90 of 97 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017 Section 3-305.11 Food Storage, pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate .can be sources of microbial contamination for stored food. Review of the facility's P&P titled Food Storage (undated) showed proper food storage procedures are followed to allow for effective, safe, and sanitary kitchen operations. On 12/12/19 at 1249 hours, during the initial tour of the kitchen with the DSS, the walk-in freezer pipes were observed with ice build-up and a pan under the pipes. The DSS stated the pan was used to catch the dripping water. On 12/16/19 at 0904 hours, an observation of the walk-in freezer pipes and a concurrent interview was conducted with the Environmental Director (ED). The ED stated the freezer pipes collect condensation formed from warm air. The freezer pipes were covered with insulated tape to prevent the condensation from dripping; however, the freezer pipes still dripped condensation. The pan was used to catch the dripping condensation, but the pan did not catch all the drips. An opened box of hot dogs was observed directly under the dripping pipes. The opened box of hot dogs had an accumulation of one inch of ice on the box. The ED confirmed ice should not be on an opened box of food. On 12/16/19 at 1445 hours, and interview was conducted with the RD. The RD confirmed ice cannot be on an opened box of food. 2. According to the USDA Food Code 2017 Section 4-202.11 Food Contact Surfaces, food contact surface should be free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Review of the facility's P&P titled Food Handling (undated) showed dishware was to be free of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 10 of 11 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 555520 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2019 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 cracks, chips or broken areas and should not have lost its glaze/finish. Level of Harm - Minimal harm or potential for actual harm On 12/16/19 at 0910 hours, an observation of the maroon colored plastic bowls used for resident food and a concurrent interview was conducted with the DSS. More than ten maroon colored plastic bowls were observed to be scratched and the glaze was worn off the inside of the bowls. The DSS stated the maroon colored plastic bowls were ordered once in three years. The DSS agreed the maroon colored plastic bowls should be replaced. Residents Affected - Some On 12/16/19 at 1445 hours, an interview was conducted with the RD. The RD confirmed resident dishware should not be scratched or have glaze worn off the inside of the bowls. 3. On 12/13/19 at 1430 hours, an interview and concurrent inspection of the resident refrigerator, located in the medication room, was conducted with RN 1. RN 1 stated the food brought in for the residents was to be labeled with the resident's name and discard date. The freezer contained one croissant package, unlabeled and undated. The croissant package was observed with no manufacturer's expiration date. RN 1 stated she did not know who the item belonged to. RN 1 stated it could belong to the facility staff or a resident. RN 1 verified the above and stated the item should have been appropriately labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 11 of 11

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0694GeneralS&S Dpotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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 medications are only used when the medication is necessary and PRN use is limited.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
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 locked, compartments for controlled drugs.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the December 20, 2019 survey of LEISURE COURT NURSING CENTER?

This was a inspection survey of LEISURE COURT NURSING CENTER on December 20, 2019. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LEISURE COURT NURSING CENTER on December 20, 2019?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide for the safe, appropriate administration of IV fluids for a resident when needed."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 20, 2019