Health inspection·October 24, 2023

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 interview, medical record review, and facility P&P review, the facility failed to develop and implement the individualized resident-centered plans of care for one of two sampled residents (Resident 2). * Resident 2's care plan interventions were not implemented as recommended in PASRR Level II evaluation. * Resident 2's desire to be discharged to a lower level of care was not assessed by the IDT team and reflected in the plan of care. These failures posed the risk of not providing appropriate and individualized care to Resident 2 to maintain her highest practicable physical well-being. Findings: Review of the facility's P&P titled Comprehensive Care Planning revised 3/2019 showed there should be coordination of the assessment with the Preadmission Screening and Resident Review (PASRR) to ensure that residents with a mental disorder, intellectual disability or a related condition receive care and services in the most integrated setting appropriate to their needs. Coordination includes incorporating recommendations from the PASRR level II determination and the PASRR evaluation report into the resident's assessment, care planning and transitions of care. When the resident has no family or responsible party and is unable to make his/her own health care decisions, the IDT will act as surrogate decision maker. Review of the facility's P&P titled Discharge Planning Process revised 10/2017 showed to identify the discharge needs of each resident and result in the development of a discharge plan. If a resident expresses an interest in returning to the community, the facility should document any referrals to local contact agencies or other appropriate entities for this purpose. If discharge to the community is determined to not be feasible, the facility will document who made the determination and why this determination was made. Medical record review for Resident 2 was initiated on 10/24/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE],with a diagnosis of psychosis. Review of Resident 2's Individualized Determination Report following PASRR Level II dated 7/13/23, under the Recommended Specialized Services section, showed the social workers could also arrange for the safe and orderly transition to alternative levels of care when appropriate and facilitate 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 3 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 10/24/2023 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)