Health inspection·January 5, 2023

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 observation, interview, and medical record review, the facility failed to ensure two of 12 final sampled residents (Residents 16 and 17) and one nonsampled resident (Resident 4) remained free from accident hazards. * The facility failed to ensure the residents' side rails were padded as ordered by the physician and as care planned. These failures posed the risk for the residents to become entrapped or injured by the side rails. Findings: Review of the FDA issued safety alert titled Entrapment Hazards with Hospital Bed Side Rails showed the 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 bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. 1. On 1/3/23 at 0911 hours, Resident 4 was observed lying in bed with four full side rails elevated. Three side rails were observed padded; however, the upper left side rail was not padded. Medical record review for Resident 4 was initiated on 1/3/23. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Care Order/Instruction dated 7/20/17, showed to implement padded full side rails to prevent fall/injury secondary to seizure disorder with recurrent seizure activities and the behavior of bouncing back and forth while sitting in bed. Review of Resident 4's plan of care showed a care plan problem revised date 1/3/21, addressing the resident's risk for fall/injury, attempting to get out of the bed by scooting to the end of the bed, and found sitting at the edge of the bed. The interventions were to pad all of the side rails. On 1/3/23 at 1048 hours, Resident 4 was observed sitting in bed rocking back and forth. Four full side rails were elevated with only three side rails padded; the upper left side rail was not padded. On 1/3/23 at 1052 hours, an interview was conducted with RN 1. RN 1 verified the findings and stated all the side rails had to be padded to prevent Resident 4 from injuring herself since she had (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 8 Event ID: 555883 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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)