Inspection visit

Health inspectionApril 22, 2022

LEISURE COURT NURSING CENTERCMS #5555208 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **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 obtain a copy of advance directive for one of 22 final sampled residents (Resident 44). This had the potential for the residents' advanced care planning decisions regarding the health care and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 4/2017 showed prior to, or upon admission, the residents will be provided with written information concerning the residents' rights under State law to accept or refuse medical or surgical treatment and the residents' right to prepare an advance directive. The resident or their responsible party will be asked if the resident has completed an advance directive, and to provide a copy of the document for the resident's clinical record. Medical record review for Resident 44 was initiated on 4/18/22. Resident 44 was admitted to the facility on [DATE]. Review of the POLST dated 2/12/22, showed Resident 44 had an advance directive dated 1/6/22, and the Public Guardian was named as the Health Care Agent. The POLST was signed by Resident 44's daughter who identified herself on the POLST form as the conservator. However, there was no copy of the advance directive available to review in Resident 44's medical record. On 4/21/22 at 0848 hours, a concurrent interview and medical record review was conducted with the SSD. The SSD was asked regarding the facility's process when the POLST showed the resident had an advance directive. The SSD stated the facility collected the information from the responsible party and asked to provide a copy of the advance directive. The SSD verified Resident 44's advance directive was not in the medical record. On 4/21/22 at 0923 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator and the Admissions Coordinator. The Admissions Coordinator verified Resident 44's POLST dated 2/12/22, showed Resident 44 had an advance directive dated 1/16/22. When was asked if a copy of Resident 44's advance directive was requested, the Admissions Coordinator stated she called the Public Guardian's office when Resident 44 was admitted in February 2022, but did not document in the resident's medical record. When asked if she had followed through to request for a copy, the Admissions Coordinator stated no. The MDS Coordinator was asked what could potentially happen when the copy of Resident 44's advance directive was not available in the medical record, the MDS Coordinator stated it may result in a conflict with the resident's wishes. 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 13 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 04/22/2022 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and DHCS PASRR guidelines review, the facility failed to ensure PASRR Level II Mental Health Evaluation was conducted as required for two of 22 final sampled residents (Residents 44 and 60). This failure had the potential for the residents to not receive the specialized care and services appropriate for their condition. Findings: 1. According to the DHCS, federal law requires all individuals seeking admission to a Medicaid Certified Nursing Facility (NF) to receive a Level 1 Screening. The Level 1 Screening identifies if an individual has a suspected Mental Illness (MI) or an Intellectual/Developmental Disability or Related condition (ID/DD/RC). If MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services. This process is known as the Preadmission Screening and Resident Review (PASRR). Review of the facility's P&P titled PASRR (Preadmission Screening Resident Review) revised 03/2019, showed if the result of the level 1 screening is positive due to a diagnosed or suspected mental illness identified, the level 1 screening will automatically be sent to the DHCS Contractor for a level II prescreening call. Review of the facility document titled DHCS PASRR Updates dated 3/14/22, showed to submit medical records to within 48 hours upon submitting a positive Level 1 screening. The following medical records are to be requested: facesheet; History and Physical; most recent and complete MDS; Medication Administration Records; current physician orders; current notes from physicians/nursing/specialist; social services notes, psychosocial and discharge plan if available; discharge summary from previous acute hospital or psychiatric, if applicable; and care plans. If the medical records are not received within 48 hours from submitting the positive case, the case will be closed and the nursing facility will be required to submit a new Level 1 screening Review of Resident 44's medical record was initiated on 4/18/22. Resident 44 was admitted to the facility on [DATE]. Review of the PASRR evaluation dated 2/8/22, showed Resident 44 had a positive Level 1 Screening and the Level II Mental Health Evaluation was required. Further review of Resident 44's medical record did not show the result for the Level II Mental Health Evaluation. On 4/21/22 at 1546 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated she was responsible in conducting the PASRR Level 1 screening on the day of the resident's admission to the facility and submitted online. RN 2 verified the PASRR Level 1 evaluation dated 2/8/22, showed the Level II Mental Health Evaluation was required for Resident 44. When asked what the result was for the Level II screening, RN 2 stated she did not know what happened and was not aware if the Level II screening was done or not. On 4/21/22 at 1601 hours, an interview and concurrent medical record review was conducted with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 2 of 13 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 04/22/2022 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few BOM. The BOM stated she was in charge of printing the results for the PASRR Level II Mental Health Evaluation. The BOM stated the PASRR evaluator would call the facility to check if the resident was still in the facility or had been discharged . The BOM verified Resident 44's PASRR Level II Mental Health Evaluation was not conducted. The BOM verified there was no documentation to show the attempts were made by the facility to reach out to the DHCS to inquire about Resident 44's Level II Mental Health Evaluation. On 4/21/22 at 1715 hours, an interview and concurrent medical record review was conducted with the Administrator and MRD. The Administrator verified and acknowledged the information received from the DHCS. The MRD stated she was responsible for sending documents to the PASRR. The MRD stated she was not able to send the documents to the PASRR because the documents were never requested. However, the letter from the DHCS showed to efficiently complete the PASRR Level II Evaluations, the DHCS requested the SNFs send medical records to Kepro within 48 hours upon submitting a positive Level 1 screening. The Administrator acknowledged the findings and stated she would call the DHCS to follow up. 2. Review of Resident 60's medical record was initiated on 4/21/22. Resident 60 was admitted to the facility on [DATE]. Review of the PASRR evaluation dated 2/24/22, showed Resident 60 had a positive Level I Screening and a Level II Mental Health Evaluation was required. Further review of Resident 60's medical record did not show the result for the Level II Mental Health Evaluation. On 4/21/22 at 1630 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified Resident 60 required to have PASRR level II evaluation. When asked about the result of the level II mental health evalutiona, RN 2 verified there was none. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 3 of 13 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 04/22/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 22 final sampled residents (Resident 36) and one nonsampled resident (Resident 35). Residents Affected - Few * Resident 36's Floranex (probiotic supplement) was not administered as ordered by the physician. * Resident 35's florastor (probiotic supplement) and carbonyl iron (supplement) were not administered as ordered by the physician. These failures posed the risk for possible complications related to residents not receiving the prescribed medications. Findings: Review of the facility's P&P titled Preparation and General guidelines IIA2: Medication Administration General Guidelines dated 10/2017, under the section for Administration, showed the medications are administered in accordance with the written orders of the attending physician. 1. On 4/20/22 at 0929 hours, a medication administration observation for Resident 36 was conducted with LVN 2. LVN 2 prepared and administered the following medications: - 30 ml of active liquid protein (supplement), - 7.5 ml of ferrous sulfate (iron supplement) 220 g/5 ml, - 15 ml of lactulose solution (laxative)10 g/15 ml, - one tablet of metoprolol tartrate (medication for hypertension) 25 mg, - 10 ml of valproic acid (antiseizure medication) 250 mg/5 ml, - one tablet of acetaminophen (analgesic) 325 mg. Review of Resident 36's medical record was initiated on 4/20/22. Resident 36 was admitted to the facility on [DATE]. Review of the Physician Order Report showed a physician's order dated 8/6/19, to administer Floranex one million cells tablet via gastric tube (a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications) once a day for supplement. Review of the MAR dated April 2022 showed the Floranex medication was not administered to Resident 36 for the entire month. On 4/20/22 at 1315 hours, an interview was conducted with LVN 2. LVN 2 verified Resident 36's Floranex was not administered as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 4 of 13 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 04/22/2022 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 0684 2. On 4/20/22 at 0838 hours, a medication administration observation for Resident 35 was conducted with LVN 1. LVN 1 prepared and administered the following medications: Level of Harm - Minimal harm or potential for actual harm - one tablet of Trajenta (medication for blood sugar control) 5 mg, Residents Affected - Few - one tablet of oxybutynin chloride ER (urinary bladder medication)5 mg, - one tablet of Tamsuloatsin HCL (Urinary retention medication) 0.4 mg, - 15 ml of potassium chloride (supplement) 10% 20 meq/15 ml, - one tablet of buspirone (antianxiety medication) 5 mg, - one and half tablets of midodrine HCL (blood pressure medication) 10 mg, - one tablet of vitamin with mineral (supplement), - one tablet of senna (stool softener) 8.6 mg, - one tablet of sodium chloride (supplement) 1 gm, and - one tablet of magnesium oxide (laxative) 400 mg. Review of Resident 35's medical records was initiated on 4/20/22. Resident 35 was admitted to facility on 1/25/21. Review of the Physician Order Report showed the following: - the order dated 2/22/21, to administer florastor (supplement) 250 mg by mouth once a day for supplement - the order dated 6/30/21, to administer carbonyl iron (supplement) 50 mg by mouth once a day for supplement. On 4/21/22 at 1449 hours,an interview was conducted with LVN 1. LVN 1 verified Resident's 35's florastor and carbonyl iron were not administered as ordered by the physician. Cross reference to F842. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 5 of 13 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 04/22/2022 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **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 provide the necessary care and services for one of 22 final sampled residents (Resident 45). * Resident 45 who had bilateral ½ sides in bed was not assessed for risk for entrapment. This failure posed the risk for injury from side rail use. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and ed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. According to the facility's P&P titled Siderails or Bedrails revised 8/2018, the residents will be assessed for risk for entrapment from the bedrails prior to installation. On 4/18/22 at 1432 hours, and 4/20/22 at 0838 hours, Resident 45 was observed lying in bed. Resident 45 had ½ siderails up on both side of the bed. Review of Resident 45's medical record was initiated on 4/20/22. Resident 45 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Physician's Orders dated 12/4/14, showed to provide ½ bilateral side rails in bed due to poor trunk control. Review the MDS dated [DATE], showed Resident 45 was totally dependent on one staff for bed mobility. Review of the Physical Restraints Form dated 2/14/22, showed Resident 45 had poor trunk control. The recommendation for Resident 45 was to continue to provide 1/2 padded bilateral side rails for safety. Review of the Bedrail/Grab Bar use and Entrapment Risk Evaluation dated 2/14/22, showed Resident 45 had 1/2 padded side rails on both sides of the bed. The documentation did not show Resident 45 was assessed for the risk for entrapment. Review of the care plan showed a care plan problem addressing Resident 45 risk for falls updated on 8/18/21, showed the interventions to provide the padded 1/2 side rails on both sides of the bed. On 4/20/22 at 0909 hours, an interview conducted with CNA 1. CNA 1 stated Resident 45 was totally dependent on the staff with his ADL care. CNA 1 stated Resident 45 had been using the bilateral side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 6 of 13 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 04/22/2022 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 0700 rails for safety. Level of Harm - Minimal harm or potential for actual harm On 4/20/22 at 1518 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. When asked about the process for the residents who used the side rails, the MDS Coordinator stated the licensed nurses and DON were responsible for conducting the side rail assessments. The MDS Coordinator stated the residents using the side rails had to be assessed for their risk for entrapment. When asked to show if Resident 45 was assessed for the risk for entrapment, the MDS Coordinator verified there was none. Cross reference to F909. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 7 of 13 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 04/22/2022 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. 2. According to the facility's P&P titled Food Preparation dated 2011, the employees will prepare food in a clean and safe manner to protect residents and staff from foodborne illness. Residents Affected - Some On 4/20/22 at 1038 hours, a puree preparation observation was conducted with the Cook. The [NAME] stated the puree food preparation was for 24 residents. The [NAME] took out a pan of garden meatloaf from the oven and proceeded to slice the meatloaf. The [NAME] picked up a portion of the meatloaf and placed it on the weighing scale. A piece of the meatloaf dropped on the kitchen counter. The [NAME] picked up the piece of meatloaf and placed it back on the weighing scale. The [NAME] then poured the meatloaf in the blender. After blending the meatloaf, the [NAME] transferred the pureed meatloaf in the serving pan. On 4/20/22 at 1110 hours, an interview was conducted with the Cook. When asked what to do when the food was dropped on the kitchen counter, the [NAME] stated the food should be thrown away and not be served since it could make the resident sick. The [NAME] acknowledged he dropped a piece of the meatloaf on the kitchen counter and placed it back in the blender when he prepared the puree food. On 4/20/22 at 1310 hours, an interview was conducted with the Assistant DSS. The Assistant DSS acknowledged the above findings and stated she saw the [NAME] dropped a piece of meatloaf on the kitchen counter and should not have been placed back in the blender. The Assistant DSS verified the above findings and stated the piece of meatloaf that dropped on the kitchen counter should not have been put into the blender. Based on observation, interview, 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 ice machine was maintained in sanitary condition. * The facility failed to follow proper sanitation and food handling practices to prevent a potential outbreak of foodborne illnesses during the preparation of pureed foods. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: 1. Review of the form CMS-672 titled Resident Census and Conditions of residents completed by the DON dated 4/18/22, showed 106 of 106 residents residing in the facility received food prepared in the kitchen. According to the FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility form titled Monthly Cleaning and Sanitation of the Ice Machine with multiple dates showed the ice machine cleaning was completed on 3/23/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 8 of 13 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 04/22/2022 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 On 4/19/22 at 1547 hours, an observation and concurrent interview was conducted with the Maintenance Director/Supervisor. The ice machine was observed with black substance when the inside of the ice machine was wiped with a white paper towel. The Maintenance Director/Supervisor verified and acknowledged above findings. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 9 of 13 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 04/22/2022 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 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on the observation, interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one nonsampled resident (Resident 35). Residents Affected - Few * LVN 1 documented on the MAR for Resident 35's Florastor (supplement) and carbonyl iron (iron supplement) as given when they were not administered during the medication administration observation. In addition, LVN 1 documented both of Resident 35's medications as administered even when they were not available. These failures had the potential for the resident's care not being met as his medication administration was inaccurate. Findings: According to the facility's P&P titled Preparation and General guidelines IIA2: Medication Administration General Guidelines dated 10/2017, under the section for Documentation, it showed the following: - if a dose of a regularly scheduled medication is withheld, refused or given at other than the schedule time (e.g. the resident is not in the facility at scheduled dose time, or a started dose of antibiotic is needed, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. On 4/20/22 at 0838 hours, a medication administration observation for Resident 35 was conducted with LVN 1. Resident 35's Florastor (supplement) and carbonyl iron (supplement) were not administered to the resident. Review of Resident 35's medical records was initiated on 4/20/22. Resident 35 was admitted to facility on 1/25/21. Review of Physician Order Report showed the following: - the order dated 2/22/21, to administer florastor (supplement) 250 mg by mouth once a day for supplement, - the order dated 6/30/21, to administer carbonyl iron (supplement) 50 mg by mouth once a day for supplement. Review of the MAR dated April 2022 showed LVN 2's initials for Resident 35's Florastor and carbonyl iron indicating the two medications were administered on the following dates: - 4/18/22 - 4/19/22 - 4/20/22 - 4/21/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 10 of 13 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 04/22/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/21/22 at 1449 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 stated during the medication administration observation conducted on 4/20/22, Resident 35's florastor and carbonyl iron were not administered because they were not available. LVN 1 stated both medications were not available since 4/18/22. When asked about her initials on both medications in the MAR from 4/18-4/21/22, LVN 1 acknowledged she wrote her initials on Resident 35's florastor and carbonyl iron but did not administer the medications. LVN 1 stated she should have encircled her initials for Resident 35's florastor and carbonyl iron and documented the reason for not administering the medications on the back of the MAR. LVN 1 verified Resident 35 had run out of the medications since 4/18/22, and the medications were documented as administered in the MAR. 4/22/22 1415 hours, an interview was conducted with the DON. The DON stated when a resident's medication was not given, the nurse should encircle her initial on the date as it was not administered and documented the reason for not administering the medication on the back of MAR. Cross reference to F684, example #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 11 of 13 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 04/22/2022 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 potential for actual harm Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment were implemented. Residents Affected - Few * The facility failed to use the appropriate disinfectant to clean the porous foam on Resident 45's bilateral siderails. This posed the risk for not adequately cleaning and disinfecting the resident's equipment. Findings: Review of the facility's P&P titled Infection Control revised 5/2018 showed the facility has established infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the manufacturer's information for Clorox Bleach Germicidal Wipes showed the recommended use is for hard, non-porous surfaces. On 4/20/22 at 0838 hours, Resident 45 bed was observed with the bilateral side rails padded with a gray porous (full of tiny holes or opening, where fluids could go through) material. The pads were attached to the bed with a tape. The pads were frayed and torn. On 4/20/22 at 0909 hours, an interview was conducted with CNA 1. When asked what the side rail padding was for, CNA 1 stated the padding was to protect Resident 45 from developing skin tears. When asked who was responsible for cleaning the side rail paddings, CNA 1 stated the housekeeping staff was responsible for cleaning but did not know how often it was cleaned. On 4/20/22 at 0921 hours, an interview was conducted with LVN 3. When asked what type of material was used for the padding, LVN 3 stated she did not know. When asked about how the padding was cleaned, LVN 3 stated the housekeeper was responsible for cleaning the pads. LVN 3 stated the Clorox sanitizer was used for cleaning the paddings. LVN 3 showed the Clorox container with information on the label showing for cleaning the hard and nonporous surfaces. When asked what if the pads were not cleaned properly, LVN 3 stated it would smell and put the resident at risk for infection from the bacteria building up in the pads. On 4/20/22 at 0940 hours, an observation and concurrent interview was conducted with Housekeeper 1. When asked how the pads on the side rails were cleaned, Housekeeper 1 stated she used the Clorox wipes. When asked what type of material was the padding made of, the Housekeeper 1 stated it was made of porous material. Reviewed the label of the Clorox container with Housekeeper 1 and she acknowledged it was only for cleaning and disinfecting hard and nonporous surface. When asked if the Clorox wipes would be appropriate for cleaning the padding, Housekeeper 1 stated no. When asked what could potentially happen when the pads were not thoroughly cleaned, Housekeeper 1 stated the microorganism would remain in the paddings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 12 of 13 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 04/22/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and facility P&P review, the facility failed to ensure regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents in the facility. Findings: According to the facility's P&P titled Siderails or Bedrails revised 8/2018, the facility will make sure the bed dimensions are appropriate for the resident's size and weight. The maintenance department will check side rails and bed rails prior to resident's use and monthly for proper installation and functioning. The maintenance department will maintain a log of the side rails check. On 4/18/22 at 1432 hours, and 4/20/22 at 0838 hours , Resident 45 was observed lying in bed. Resident 45 had ½ siderails up on both side of the bed. On 4/20/22 at 1610 hours, an interview was conducted with the Maintenance Supervisor. When asked what the process was for the residents who needed a side rail installed, the Maintenance Supervisor stated the licensed nurses would inform him if the resident will need one. The Maintenance Supervisor stated he would just install the side rail and check if the bed was working properly. The Maintenance Supervisor stated he would also check if there was a gap between the mattress and the grab bars or side rails. When asked why it was necessary to check the beds prior to the installation of bed rails, the Maintenance Supervisor stated the resident could get stuck in between the bed and rail. On 4/20/22 at 1711 hours, a follow-up interview was conducted with the Maintenance Supervisor and MDS Coordinator. The Maintenance Supervisor verified he had not been checking the beds and siderails for entrapment zones for the past two years. The MDS Coordinator stated the facility had been moving a lot of beds and were not able to follow up on checking the residents' beds. The Maintenance Supervisor acknowledged he had no documentation to show Resident 45's bed was checked on a regular basis to ensure safety of the siderail use. Cross reference to F700. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555520 If continuation sheet Page 13 of 13

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Citations

8 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.

0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0909GeneralS&S Dpotential for harm
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
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.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the April 22, 2022 survey of LEISURE COURT NURSING CENTER?

This was a inspection survey of LEISURE COURT NURSING CENTER on April 22, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LEISURE COURT NURSING CENTER on April 22, 2022?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

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.

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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·April 22, 2022