Health inspection·January 24, 2024

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 ensure one of three sampled residents (Resident 1) remained free from the accident hazards. * CNA 1 had provided ADL care to Resident 1 in bed by herself instead of two or more persons to assist as per the resident's MDS and plan of care. When CNA 1 turned the resident to the right side, the resident rolled and fell off the bed to the floor sustaining multiple bruises and a skin tear to the right cheek. This failure had the potential for Resident 1 to sustain serious injury. Findings: Review of the facility's P&P titled Fall Risk/Prevention revised 7/2018 showed the policy of the facility is to identify the residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. Upon admission, a Fall Risk Assessment will be completed for all residents. If the Fall Risk Assessment score is 10 or above, the resident is at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls. Review of the facility's P&P titled Safety and Supervision of Residents revised 2/2019 showed the policy of the facility is to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The resident-oriented approach to safety addresses safety and accident hazards for individual residents. The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for each resident. The care team shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented, and documenting interventions. Closed medical record review for Resident 1 was initiated on 1/23/24. Resident 1 was admitted to the facility on [DATE], and discharged on 1/16/24, to the acute care hospital. Review of Resident 1's H&P examination dated 7/10/23, showed Resident 1 could make needs known but could not make medical decisions. Resident 1's MDS, Section G Functional Status dated 8/15/23, showed Resident 1 required two or more persons for physical assistance for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed) and transfers (how resident moves between (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 01/24/2024 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)