Other·January 23, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the concurrent RECERTIFICATION and RELICENSING surveys. Representing the California Department of Public Health: Surveyor 34325, HFEN; Surveyor 36872, HFEN; Surveyor 32179, HFEN; Surveyor 36871, HFEN; Surveyor 37856, HFEN; Surveyor 37698, HFEN; Surveyor 37726, HFEN; Surveyor 37663, HFEN; Surveyor 33434, HFEN; Surveyor 35346, HFEN; Surveyor 29650, HFES; and Surveyor 28952, HFES. The surveyors entered the facility on 11/30/16 at 1100 hours. The census was 157, with no bed holds. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living CAI - Community Acquired Infection (an infection present prior to admission to the facility or developed within 48 hours of the admission) cm - centimeter(s) CHHA - Certified Home Health Aide CMS - Centers of Medicaid and Medicare Services CNA - Certified Nurse Assistant COPD - chronic obstructive pulmonary disease DON - Director of Nursing DSD - Director of Staff Development DSS - Dietary Services Supervisor Eschar - black or brown necrotic tissue, can be loose or firmly adherent, hard, soft, or soggy ESRD - end-stage renal disease (kidney failure) LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 1 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE F - Fahrenheit HAI - Healthcare Acquired Infection (an infection developed 48 hours after admission to the facility) Hallucination - perception of something not present Hemodialysis/dialysis - a medical procedure to remove fluid and waste products from the blood due to kidney failure IDT - Interdisciplinary Team IV - intravenous LVN - Licensed Vocational Nurse MAR - Medication Administration Record MDS - Minimum Data Set (a standardized assessment tool) mg - milligram(s) MRSA - Methicillin Resistant Staphylococcus Aureus (an infection caused by staph bacteria that is resistant to multiple antibiotics) NP - Nurse Practitioner Osteoarthritis - a type of arthritis that occurs when flexible tissue at the ends of bones wears down OT - Occupational Therapist ORIF - open reduction internal fixation (surgical procedure to repair broken bones) P&P - policy and procedure Parkinson's disease - a neurological condition causing tremors and an unsteady gait when walking PRN - as needed RD - Registered Dietitian RN - Registered Nurse RNA - Restorative Nurse Assistant SBAR - Situation, Background, Assessment, Recommendation Stage III pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling Stage IV pressure ulcer - full thickness skin and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 2 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone Unstageable ulcer - full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 03/10/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 3 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure one staff member was aware who the Abuse Coordinator was and who to report an allegation of abuse. This posed the risk for allegations of abuse not being appropriately addressed or investigated. Findings: During an interview with CNA 1 on 12/1/16 at 0815 hours, CNA 1 was asked who the facility's Abuse Coordinator was. CNA 1 initially replied she could not remember. CNA 1 was asked if she heard or observed a resident being yelled at or hit, what would she do. CNA 1 stated she would report to the RN Supervisor. CNA 1 was asked, aside from the RN Supervisor, who should she report an allegation of abuse. CNA 1 stated she would complete a report and give it to the DON right away. CNA 1 was asked again, aside from the RN Supervisor and DON, who should she report allegations of abuse. CNA 1 replied those two were people she would report to. When asked again who the facility's Abuse Coordinator was, CNA 1 replied the DSD. An interview was conducted with the Administrator on 12/1/16 at 1545 hours. The Administrator was asked who the facility's Abuse Coordinator was. The Administrator replied, "me." The Administrator walked towards a bulletin board at the conference room. The posting on the bulletin board showed the Administrator was the Abuse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 4 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Coordinator. The Administrator stated all allegations of abuse should be reported to him immediately.

F241 SS=D DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 01/15/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility P&P review, the facility failed to ensure care was provided in a manner promoting the dignity and respect of five of nine nonsampled residents (Residents B, C, D, E, and G) and one of 24 sampled residents (Resident 7). * The facility failed to answer the call lights for Residents B, C, D, and E in a timely manner, causing three residents to be incontinent in bed and one resident to endure prolonged pain and feel miserable. * Staff failed to knock and wait for a response prior to entering the rooms of Residents 7, B, C, D and G, causing the residents to feel they were not being treated with respect. * Staff failed to respect the private space and personal belongings of Residents 7 and B without permission. These failures lead to the residents feeling upset and posed a risk to the residents' physical and emotional well-being. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 5 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. During the resident group interview on 12/1/16 at 1100 hours, Residents B, C, D, E, and 7 stated the staff did not answer call lights in a timely manner. a. Resident B stated she had to wait up to 25 minutes for her call light to be answered. Resident B stated she had an accident in bed because the staff did not answer her call light in a timely manner to assist her to the bathroom. This made the resident feel humiliated. b. Resident C stated he turned on his call light and staff turned off his call light without helping him. Resident C stated he had to turn his call light right back on. Resident C stated he has been in pain and waited two and a half hours before staff responded to his call for pain medication and before he received pain medication. c. Resident D stated he waited 20 to 30 minutes for staff to answer his call light. Resident D stated he had an accident in bed while waiting for staff to answer his call light. Resident D stated this made him upset. Resident D stated he got a rash from lying in wet sheets. d. Resident E stated she waited a long time for staff to answer the call light. Sometimes the staff turned the call light off without addressing her needs. Resident E stated she felt she was not being treated with respect and turned the call light back on. e. Resident 7 stated staff took a long time to answer his call light. He stated when the staff finally did answer the call light, they acted like they were doing him a favor. Resident 7 stated he did not feel the staff treated him with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 6 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE respect. Cross references to F312 and F353. 2. During the resident group interview on 12/1/16 at 1100 hours, Residents 7, B, C, D, and G stated it made them upset and angry when the staff did not knock and wait for permission prior to entering the residents' private space. Resident C stated he was upset when the staff barged into the bathroom while he was using the toilet, without waiting for a response. 3a. On 12/1/16 at 0830 hours, an interview was conducted with Resident 7. Resident 7 stated he observed CNA 5 opening and removing items from his and his roommate's drawers and closet when the residents were not in the room. Resident 7 stated he observed CNA 5 place items into a plastic bag and dispose of the bag. Resident 7 stated he was upset and told CNA 5 he should not handle the residents' property without their permission. Resident 7 requested a lock to secure his belongings. On 12/5/16 at 0640 hours, an interview was conducted with CNA 5. CNA 5 stated it was his responsibility to go through the residents' items and property and discard items into the trash. CNA 5 stated Resident 7 became angry when CNA 5 was handling the residents' belongings in Resident 7's room. CNA 5 stated if a resident was not present in their room, he would go through the items in their nightstand. On 12/6/16 at 1020 hours an interview was conducted with the DON. The DON stated it was the CNAs' responsibility to clean out the residents' rooms by going through the nightstand drawers and closets. The DON stated the CNA should gain consent from the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 7 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents prior to going through the residents' property. b. During the resident group interview on 12/1/16 at 1100 hours, Resident B stated she observed staff go through drawers and belongings in residents' rooms. Resident B stated she did not like her items being touched without her permission. Resident B stated she requested safety locks to secure her personal items. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 8 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F246 REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES CFR(s): 483.10(e)(3)

F246 01/15/2017

F250 03/10/2017 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: (e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure the call light for one of 24 sampled residents (Resident 10) was within reach. This failure posed the risk for Resident 10's call light not being accessible in the event Resident 10 needed assistance. Findings: On 11/30/16 at 1600 hours, Resident 10's call light was observed entangled with the light cord and bed control while the resident was sitting in the wheelchair facing the foot of the bed. This finding was verified with LVN 5.

F250 SS=D PROVISION OF MEDICALLY RELATED SOCIAL SERVICE CFR(s): 483.40(d) (d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 9 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and clinical record review, the facility failed to ensure medically related social services was provided for one of 24 sampled residents (Resident 6) related to scheduling a psychiatric evaluation. Resident 6 was not seen by a psychiatrist for five months for a psychiatric evaluation. Resident 6 had a history of a suicide attempt and major depressive behavior. This failure had the potential to delay necessary care and treatment needed by the resident. Findings: Clinical record review for Resident 6 was initiated on 11/30/16. Resident 6 was admitted to the facility on 2/12/16, and readmitted on 11/28/16, with diagnoses including major depressive disorder. Review of a psychiatric evaluation dated 9/11/16, showed a NP's evaluation notes for Resident 6. On 12/2/16 at 1340 hours, a concurrent interview and clinical record review was conducted with LVN 4. LVN 4 stated the physician's orders dated 3/15 and 4/5/16, showed an order for a psychiatric evaluation for Resident 6. LVN 4 was asked if there were other notes written by psychiatry aside from the note dated 9/11/16. LVN 4 stated she would look in the closed clinical record located in medical records department and would call the psychiatric clinic if she could not find notes in the closed clinical record. On 12/2/16 at 1630 hours, LVN 4 stated she did not find any other psychiatry notes in Resident 6's closed clinical record and had to call the psychiatric clinic to ask for copies of the written notes. LVN 4 provided the psychiatric FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 10 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE notes from the clinic. Review of the psychiatric notes from two different facilities sent by the clinic dated 12/22/15, showed a discharge summary for Resident 6 had a history of a suicide attempt in March 2015 when the resident overdosed on tramadol (a narcotic-like pain medication) and an initial evaluation dated 1/6/16, showed Resident 6 had a major depressive disorder with recurrent and severe psychosis. On 12/5/16 at 0843 hours, a concurrent interview and clinical record review was conducted with the Social Services Manager. The Social Services Manager stated it was her responsibility to call for all residents' psychiatric referrals, evaluations, and follow ups. When asked about the referral for a psychiatric evaluation physician's orders for Resident 6 dated 3/15 and 4/5/16, the Social Services Manager stated she did not check Resident 6's clinical record to see if the psychiatrist wrote notes and did not know if the resident was evaluated and seen. The Social Services Manager also stated there were no follow-up notes in the clinical record two to four weeks after the resident was initially evaluated by the NP on 9/11/16, as written. On 12/5/16 at 1515 hours, a faxed copy of the psychiatry notes dated 10/23/16, was provided by the Social Services Manager.

F252 SS=D SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT CFR(s): 483.10(e)(2)(i)(1)(i)(ii)

F252 01/15/2017 (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 11 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure a safe, clean, and homelike environment in two resident bathrooms (Bathrooms A and B). The facility failed to label residents' personal items. This posed the potential risk for cross contamination. Findings: 1. During an initial tour on 11/30/16 at 1220 hours, Bathroom A was observed to have two unlabeled urinals and one unlabeled bedpan hanging on the rail next to the toilet. LVN 5 stated Bathroom A was shared by four residents. During an interview with CNA 10 on 11/30/16 at 1555 hours, when asked how many residents shared Bathroom A, she stated four residents shared the bathroom. CNA 10 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 12 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE verified the two unlabeled urinals and one unlabeled bedpan hanging on the rail next to the toilet. When asked how they knew who the urinals and bedpan belonged to, she stated she did not know. CNA 10 stated residents' belongings should be labeled with the residents' names. 2. During an initial tour on 110/30/16 at 1125 hours, Bathroom B was observed to have two unlabeled urinals hanging on the rail next to the toilet. LVN 5 stated Bathroom B was shared by three residents. LVN 5 verified the two unlabeled urinals should have been labeled with the residents' names.

F278 SS=D ASSESSMENT ACCURACY/COORDINATION/CERTIFIED CFR(s): 483.20(g)-(j)

F278 01/15/2017 (g) Accuracy of Assessments. The assessment must accurately reflect the resident’s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. (j) Penalty for Falsification FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 13 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (1) Under Medicare and Medicaid, an individual who willfully and knowingly(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. (2) Clinical disagreement does not constitute a material and false statement. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and clinical record review, the facility failed to ensure accurate coding of the MDS for two of 24 sampled residents (Residents 6 and 20). This posed the risk of the residents not receiving appropriate care interventions due to incorrect health assessments. Findings: 1. Clinical record review for Resident 6 was initiated on 11/30/16. Resident 6 was admitted to the facility on 2/12/16, and readmitted on 11/28/16. a. Review of the MDS dated 7/2/16, showed Resident 6 had a right heel unstageable, Stage III - IV pressure ulcer, measuring 4.5 cm by 0.8 cm with eschar. The MDS dated 10/2/16, showed the right heel unstageable, Stage III IV pressure ulcer measured 4.5 cm by 9 cm with eschar. On 12/2/16 at 1100 hours, an interview and concurrent clinical record review was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 14 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with LVN 1. Review of Resident 6's Skin - Weekly Non-Pressure Condition Report dated 4/24/16, showed an arterial wound measuring 4 cm x 5 cm, depth was unstageable. LVN 1 stated the right heel wound was an arterial ulcer. LVN 1 stated a bilateral lower extremities arterial doppler (a study to determine blood flow) done on 4/18/16, showed arterial occlusion (blockage) and was noted on the surgical consult note. On 12/5/16 at 1100 hours, an interview and concurrent clinical record review concerning Resident 6 was conducted with MDS Coordinator 1. MDS Coordinator 1 verified the MDSs dated 7/2/16, and 10/2/16, were coded incorrectly. 2. Clinical record review for Resident 20 was initiated on 12/5/16. Resident 20 was admitted to the facility on 4/13/16. Review of the History and Physical Examination form dated 4/14/16, showed Resident 20 had the capacity to understand and make decisions. Review of the MDSs dated 4/26/16, and dated 10/27/16, showed Resident 20 had severely impaired cognition. Review of the MDS dated 7/27/16, showed Resident 20 did not complete the interview and a staff assessment was to be conducted. Review of the Nursing Weekly Summary dated 9/20/16, showed Resident 20 was alert and oriented to person, place, and time and Resident 20 had no memory problems. Review of Social Service Assessment Note dated 11/1/16, showed Resident 20 could not complete the BIMS (Brief Interview for Mental Status) Assessment and had short and long FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 15 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE term memory problems. During an interview with the Social Services Assistant on 12/5/16 at 1555 hours, the Social Services Assistant stated, when she evaluated Resident 20's cognitive condition in April 2016, Resident 20 could not repeat sock, blue, and bed and this was why she determined Resident 20 had severe cognitive impairment. During an interview with MDS Coordinator 1 on 12/5/16 at 1540 hours, MDS Coordinator 1 stated Resident 20 was alert and oriented, his cognition should have been assessed to be moderately impaired since he was able to remember the date and time. During an interview with Resident 20's family member on 12/6/16 at 0915 hours, Resident 20's family member stated the resident was very sharp and alert to date and time with some forgetfulness, like the year.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 03/10/2017 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 16 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 17 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and clinical record review, the facility failed to revise the plan of care to reflect the care needs for five of 24 sampled residents (Residents 3, 4, 6, 20, and 24). * The facility failed to implement nonpharmacological interventions in Resident 3's care plan for antianxiety medication. * The facility failed to revise resident 4's care plan for antianxiety medication and implement non-pharmacological interventions before administering antianxiety and antidepressant medications. * The facility failed to revise Resident 6's care plan problems and interventions related to infection, and the use of side rails according to the physician's order in Resident 6's care plan. * Resident 24's care plan failed to address the resident's required care for activities of daily living. * Resident 20's care plan incorrectly showed the resident had dementia. These had the potential to not identify the residents' care needs. Findings: 1. Clinical record review for Resident 3 was initiated on 11/30/16. Resident 3 was admitted to the facility on 12/26/15, and readmitted on 8/18/16. Review of a physician's order dated 8/16/16, showed Ativan 0.5 mg, one tablet by mouth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 18 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE every six hours as needed for anxiety manifested by inability to relax. Review of Resident 3's care plan showed a care plan problem dated 10/25/16, to address anxiety manifested by inability to relax. The interventions included to administer antianxiety medications as ordered by physician, educate the resident/family/caregiver about the risks, benefits and side effects and/or toxic symptoms of Ativan, observe/document/report as needed any adverse reactions to antianxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision and observe/record occurrences of targeted behavior symptoms (verbalization of anxiety) and document per facility protocol. However, it failed to show attempting nonpharmacological interventions prior to the administration of antianxiety medication. On 12/6/16 at 0900 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 was asked to show any documentation for attempting nonpharmacological interventions before administering antianxiety medication in the care plan. LVN 4 stated it was not in the care plan. 2. Clinical record review for Resident 4 was initiated on 11/30/16. Resident 4 was admitted to the facility on 6/13/15. Review of a physician's order dated 8/28/15, showed setraline hydrochloride 1000 mg, two tablets by mouth one time a day manifested by angry outbursts. Review of a physician's order dated 11/5/16, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 19 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE showed Ativan 0.5 mg, one tablet by mouth every 24 hours as needed for anxiety manifested by pacing in the wheelchair. Discontinue Ativan tablet as needed for anxiety manifested by angry outbursts. Review of Resident 4's care plan showed a problem dated 10/14/15, to address anxiety manifested by sudden angry outbursts. The interventions included to administer antianxiety medications as ordered by the physician, educate the resident about the risks, benefits and side effects and/or toxic symptoms of Ativan, observe the resident for safety and observe/document/report as needed any adverse reactions to antianxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. However, it failed to show attempts of non-pharmacological interventions prior to the administration of antianxiety medication. Review of Resident 4's care plan showed a problem dated 6/14/15, to address depression manifested by angry outbursts. The interventions included to administer antidepressant medications as ordered by physician, educate the resident/family/caregiver about the risks, benefits and side effects and/or toxic symptoms, and observe/document/report as needed any adverse reactions to antidepressant therapy. It failed to show nonpharmacological attempts prior to the administration of the antianxiety medication. On 12/6/16 at 0900 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 was asked to show any documentation in the care plan of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 20 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE non-pharmacological interventions were to be attempted prior to the administration of antianxiety and antidepressant medications. LVN 4 stated it was not in the care plan. LVN 4 stated the care plan should be updated for the indication of antianxiety medication. 3. Closed clinical record review for Resident 24 was initiated on 12/5/16. Resident 24 was admitted on 9/28/16, and discharged on 10/15/16. Resident 24 was admitted to the facility for rehabilitation status post weakness. Review of Resident 24's MDS showed Resident 24 needed extensive assistance with dressing, feeding, hygiene and bathing. Review of Resident 24's plan of care did not show care plan problems to address Resident 24's dressing, feeding, hygiene, or bathing needs. On 12/6/16 at 0710 hours, an interview with MDS Coordinator 2 was conducted. MDS Coordinator 2 verified the above findings. 4. Clinical record review for Resident 6 was initiated on 11/30/16. Resident 6 was readmitted to the facility on 11/28/16. a. Review of Resident 6's plan of care showed a care plan problem dated 11/28/16, to address MRSA of a right foot ulcer. The care plan interventions showed contact isolation due to positive MRSA of the right foot ulcer and the administration of intravenous antibiotic medication. On 12/5/16 at 1015 hours, an interview and concurrent clinical record review was conducted with the DSD. The DSD stated a wound culture was done on 11/8/16, and the result did not show MRSA on 11/9/16. The DSD stated Resident 6 was cleared from MRSA on 11/11/16, and the resident was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 21 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE moved to another room with four residents in the room. The DSD verified the care plan was not updated. b. On 11/30/16 at 1100 hours, during initial tour, Resident 6 was observed lying in bed, on his back with upper 1/4 bilateral side rails elevated. Review of a physician's order dated 11/28/16, showed 1/4 side rails elevated while in bed as an enabler to assist in repositioning and turning. Review of Resident 6's clinical record showed a Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or "Prolonged Use of Active Device" dated 11/28/16, showed both 1/4 side rails up in bed as an enabler to assist in turning and repositioning. On 11/30/16 at 1550 hours, an interview was conducted with CNA 3. CNA 3 stated the side rails were used for mobility and repositioning; Resident 6 could hold on to the side rails when instructed and cued. Review of Resident 6's plan of care showed a care plan problem dated 11/28/16, to address the increased potential for falls. The goal showed to decrease the increased potential for falls. The interventions showed to use device 1/4 side rails as ordered for fall prevention. On 12/5/16 at 1130 hours, interview and clinical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 stated the side rails were used as an enabler, not for fall prevention. MDS Coordinator 1 stated the care plan was incorrect; the side rails were not used for fall prevention for Resident 6. 5. Clinical record review for Resident 20 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 22 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE initiated on 12/5/16. Resident 20 was admitted to the facility on 4/13/16. Review of the History and Physical Examination form dated 4/14/16, showed Resident 20 had no diagnosis of dementia and showed Resident 20 had the capacity to understand and make decisions. Review of Resident 20's care plan showed a care plan problem dated 8/16/16, to address impaired cognitive function/dementia or impaired thought processes related to impaired decision making, long-term memory loss, shortterm memory loss. During an interview with LVN 4 on 12/6/16 at 0849 hours, LVN 4 confirmed Resident 20 did not have dementia and it should not have been documented on the care plan.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 04/28/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 23 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview, observation, clinical record review, and facility document review, the facility failed to provide the necessary care and services for four of 24 sampled residents (Residents 11, 18, 20, and 21) to ensure the residents maintained their highest physical well-being. * The facility failed to ensure complete documentation of Resident 18's dialysis care in the clinical record. This posed the risk of Resident 18's not being communicated between the facility and the dialysis center regarding changes in the resident's status. * The facility failed to ensure the communication form for Resident 20 between the dialysis center and the facility was completed to ensure coordination of care between the two providers. This posed the potential for the providers not being informed of important changes and information in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 24 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents' condition related to their kidney diseases and possible medical complications from their dialysis treatment. * Resident 11's Duragesic-50 patch (contains an opioid/narcotic used to manage severe pain) was not administered per the physician's order. * The facility failed to ensure complete documentation of Resident 21's post-dialysis care in the clinical record. This posed the risk of Resident 21 not receiving appropriate postdialysis care in the event of an adverse reaction or medical emergency. Findings: According to the facility's P&P titled Hemodialysis, Care of Resident dated 2008, all documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. 1. Review of the clinical record for Resident 18 was initiated on 12/5/16. Resident 18 was readmitted to the facility on 11/25/16, with a diagnosis of chronic kidney disease requiring dialysis. Review of the physician's orders dated 11/25/16, showed dialysis on Tuesday, Thursday, and Saturday at 0530 hours. Review of the Dialysis Communication Records dated 12/1 and 12/3/16, showed documentation pre dialysis assessments were incomplete by the facility 's nurses, which included the time out to dialysis, medications administered, medications sent with the resident and meal provision. There was no Dialysis Communication Record for Tuesday, 11/29/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 25 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE An interview and concurrent clinical record review was conducted with RN 2 on 12/5/16 at 1035 hours. RN 2 verified the Dialysis Communication Records were incomplete and the nurses should have filled out the sections to show the time the resident went out to dialysis, medications administered, medications sent with the resident, and any meal provision. RN 2 verified there was no Dialysis Communication Record for 11/29/16. 2. On 11/30/16 at 1130 hours, an initial tour of the facility was conducted with LVN 9. During the tour, Resident 11 asked LVN 9 to check the date on her Duragesic patch. LVN 9 stated the date on the patch was 11/26/16. Resident 11 stated a new patch should have been applied yesterday, on 11/29/16. LVN 9 reviewed the MAR. The MAR showed the Duragesic-50 patch was scheduled to be applied on 11/29/16, but was signed as not given. LVN 9 was unable to locate a note as to why it was not given. Observation of the box for Resident 11's Duragesic-50 patch showed it was empty. LVN 9 verified the Duragesic-50 patch should have been applied on 11/29/16, but there was no Duragesic-50 patch available for Resident 11. Clinical record review for Resident 11 was initiated on 11/30/16. Resident 11 was admitted to the facility on 10/13/16, with chronic pain and a new fracture of the cervical spine. Review of Resident 11's physician's order dated 10/18/16, showed to apply a Duragesic-50 patch transdermally, and remove the used patch, every 72 hours. On 11/30/16 at 1630 hours, an interview was conducted with Resident 11. Resident 11 stated, if she had not asked about her patch, she would have had to wait even longer; it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 26 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE made her mad because her pain was so bad. Resident 11 wanted to know what happened to residents who did not ask. 3. According to the facility's P&P titled Hemodialysis, Care of Resident revised date July 2014, showed to check vital signs every shift for the 24 hours post-dialysis, monitor for signs of postural hypotension (low-blood pressure) and upon return from dialysis, the nurse will assess the condition of the access site for bleeding, redness, tenderness or swelling. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. Review of the clinical record for Resident 21 was initiated on 12/5/16. Resident 21 was readmitted to the facility on 11/3/16. The History and Physical Examination form dated 11/16/16, showed Resident 21 had a history of sepsis (infection in the blood) from the dialysis catheter, end stage renal disease on dialysis and hypertension (high blood pressure). Review of the physician's recapitulated orders for November 2016 showed orders for dialysis on Tuesday, Thursday, and Saturday at 1400 hours. Review of the Nurses Notes dated 12/3/16, showed a post-dialysis assessment with incomplete documentation. Review of the daily vital signs summary for the month of December 2016 did not show documented vital signs for 12/3/16. An interview and concurrent clinical record review was conducted with LVN 12 on 12/5/16 at 1453 hours. LVN 12 verified resident 12 went to dialysis on 12/3/16, and the postFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 27 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dialysis nursing notes for 12/3/16, did not document the dialysis catheter site assessment. LVN 12 also verified there were no documented vital signs for Resident 21 on 12/3/16. 4. Review of the facility's P&P titled Hemodialysis, care of Residents revised July 2014 showed a Dialysis Communication Record is initiated and sent to the dialysis center for each appointment. Ensure it is received upon return. Clinical record review for Resident 20 was initiated on 12/5/16. Resident 20 was admitted to the facility on 4/13/16. Resident 20's diagnosis included ESRD with hemodialysis. Review of the care plan showed a care plan problem revised date 11/17/16, to address hemodialysis showing Resident 20 was to receive hemodialysis at a dialysis center every Monday, Wednesday, and Friday. Review of the Dialysis Communication Records for Resident 20 showed forms date 11/25/16, and 11/28/16. There were no other reports found in the clinical record. According to Resident 20's clinical records, Resident 20 should have had dialysis on 11/30/16, and 12/2/16. An interview and concurrent clinical record review was conducted with LVN 2 and RN 1 on 12/5/16 at 1100 hours. LVN 2 stated Resident 20 did receive dialysis treatments on 11/30/16, and 12/2/16, and the Dialysis Communication Records should have been filed by any licensed nurse in the clinical record after it was reviewed for any new orders. LVN 1 showed an envelope with Dialysis Communication Records from a drawer at the nurses' station. Both RN 1 and LVN 2 confirmed the Dialysis Communication Record dated 11/30/16, for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 28 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 20 should have been reviewed and filed in Resident 20's clinical record. In addition, both RN 1 and LVN 2 verified the Dialysis Communication Record for 12/2/16, was missing. An interview was conducted with Resident 20's family member on 12/6/16 at 0915 hours. Resident 20's family member stated the resident went to the dialysis center for hemodialysis treatment on 12/2/16, and he did not have the Dialysis Communication Record with him.

F312 SS=F ADL CARE PROVIDED FOR DEPENDENT RESIDENTS CFR(s): 483.24(a)(2)

F312 01/15/2017 (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This REQUIREMENT is not met as evidenced by: Based on observation, interview, clinical record review, and facility document review, the facility failed to ensure ADL and incontinence care was provided to the residents throughout the facility due to insufficient nursing staff to attain and maintain the basic physical and psychosocial needs of each resident. Failure to provide necessary ADL and incontinence care had the potential to cause negative psychosocial and physical effects, including development of skin irritations, pressure ulcers and/or worsening of pressure ulcers, and increasing the risk of accidents due to falls. Cross references to F241, F314, F323, and

F353. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 29 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the CMS 672 completed by the DON dated 11/30/16, showed the facility had a census of 157 residents, of which 153 residents needed physical assistance with their ADL and incontinence care. 1. Review of the facility's Daily Nursing Sign-In sheet for the 11-7 shift on 11/30/16, showed five CNA had called off, leaving five CNAs taking care of 157 residents throughout the facility (about 31 residents assigned to each CNA). For the 11-7 shift on 12/10/16, there were 6 CNAs taking care of 153 residents throughout the facility (about 25 residents assigned to each CNA). Cross reference to

F353. 2. During the resident group interview on 12/1/16 at 1100 hours, Residents B, C, D, E, and 7 stated the staff did not answer the call lights in a timely manner. Residents B and D had to wait up to 25-30 minutes and had accidents in their beds. Resident C had his light turned off and had to wait over two hours before he received his pain medication. Residents E and 7 stated staff took a long time to answer the call light and sometimes turned it off without addressing their needs. Cross reference to F241. 3. On 12/2/16 at 0915 hours, CNA 9 stated Resident 3 could press the call light and ask for assistance to go to the toilet but could not wait long. CNA 9 stated she was very busy helping other residents. Sometimes she helped other residents in the restroom, so she could not go to Resident 3 right away. As a result, Resident 3 would get up unassisted to go to the toilet. Cross reference to F323, example #3. 4. On 12/1/16 at 0805 hours, an interview was conducted with Resident 15's responsible party. Resident 15's responsible party stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 30 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the facility was always short-staffed and the CNAs got upset because of the heavy workload. The responsible party stated she came into the facility a few months ago at 0200 hours and found Resident 15 and her linens being soaked with urine. On 12/5/16 at 1030 hours, an interview was conducted with LVN 2. LVN 2 verified the CNAs had 14-16 residents each for today. LVN 2 stated the licensed nurses were trying to help as much as they could, but she felt bad for the residents and CNAs due to the workload. On 12/5/16 at 1120 hours, an interview was conducted with CNA 5. CNA 5 stated he worked last night and provided two showers that were scheduled for this morning because he knew the facility would be short-staffed and it would be bad. On 12/5/16 at 1110 hours, Resident N was observed retrieving linens out of the hallway linen cart. Resident N stated the CNAs were usually short-staffed in the mornings and they did not have time to help the residents, so the residents got their own towels out of the linen cart. On 12/5/16 at 1130 hours, an interview was conducted with CNA 2. CNA 2 stated she took care of the bed bound residents last; she tried to assist the residents who got up or wanted to go to activities first. On 12/5/16 at 1145 hours, an interview was conducted with CNA 1. CNA 1 stated she was unable to provide the two showers scheduled for today because she had 15 residents to assist. CNA 1 stated she still had not seen or provided morning ADL care for the four residents in Room L. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 31 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/5/16 at 1220 hours, an interview was conducted with CNA 2. CNA 2 stated she still had four residents (Residents 9, P, Q, and R) she had not seen or assisted with morning ADL care. CNA 2 verified Residents 9 and R were incontinent and stayed in bed. Resident P was incontinent and needed to be assisted to the wheelchair. Resident Q was incontinent at times and needed to be checked and have his clothes changed. On 12/5/16 at 1310 hours, an interview was conducted with the DON. The DON stated staffing had been a challenge for the last six weeks; a lot of staff had quit on the day shift. The DON was not aware the residents had not been assisted with their ADL morning care or were not given showers. The DON stated nobody told her they could not get their work done. The DON stated the facility would like the CNAs' workload on the 7-3 shift to be 8-12 residents each. The DON verified the 7-3 shift CNAs had 14-16 residents assigned to them today. On 12/13/16 at 0515 hours, CNA 11 was observed cleaning, changing the bed linens, and repositioning Resident 15, which took approximately 20 minutes. CNA 11 stated she had 31 residents to provide care for during her 11-7 shift. CNA 11 stated she had changed everyone one time during the shift except four incontinent residents (Residents E, X, Y, and Z), which she had not seen or provided care for since the beginning of her shift (6.25 hours earlier) because she had been so busy. CNA 11 was asked about the call light for Resident W, which had been on for approximately 25 minutes. CNA 11 stated she had changed Resident W one time during the shift and spent 45 minutes with her; she had to help the residents she had not seen yet, so she did not answer the call light. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 32 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/13/16 at 0535 hours, CNA 11 stopped to answer a call light for Resident L. CNA 11 spoke to the resident in Spanish, turned off the call light, and left the room. CNA 11 stated the resident asked her to come back and change her before she left if she had time since the resident knew she was busy. At 0540 hours, CNA 11 proceeded to Resident E for the first time during the shift to provide incontinence care. A second CNA helped CNA 11 to provide incontinence care for Residents X and Y for the first time during the shift; they finished at 0615 hours. CNA 11 stated she still had to provide incontinence care to Resident BB whom she had not provided care for throughout the shift and she needed to finish her charting before the end of her shift at 0700 hours. CNA 11 stated she tried to start at one side and work her way through the rooms; she knew who the "heavy wetters" were and would try to start with them. CNA 11 stated an incontinent resident could take from 10 to 15 minutes; it depended on the residents and what they needed and if they could help. CNA 11 stated the residents depended on the staff and needed them. CNA 11 stated she felt bad for the residents and frustrated when they could not take the time with them and do what was needed, but she stated she did the best she could. On 12/13/16 at 0640 hours, an interview was conducted with CNA 12. CNA 12 stated he had 30 residents to provide care for during his 11-7 shift. CNA 12 stated he would change the "heavy wetters" first and try to get back to them a second time. The biggest problem was getting to the residents and meeting their FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 33 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE needs. CNA 12 stated he had to prioritize. If there were two or three call lights to answer, he let the residents know he would be back as soon as he could. On 12/13/16 at 0715 hours, an interview was conducted with LVN 5. LVN 5 stated she was working a double shift and tried to help the CNAs; she answered the call lights and emptied urinals when she could. LVN 5 stated she still had a lot of charting to complete. On 12/13/16 at 0745 hours, an interview was conducted with Resident W. Resident W stated she was changed once during the 11-7 shift around 0030 hours. Resident W stated she tried to keep her fluids down at night so she would not have to be changed very often; she did not want to lay in a wet diaper. Resident W stated the facility was usually short-staffed. On 12/13/16 at 1330 hours, an interview was conducted with the DON. The DON stated she had not been aware four CNAs had called off and not been replaced for the 11-7 shift. The DON stated the Supervisor would try to replace the call offs and inform her if there was a serious problem or a crisis. The DON stated she did not think working with five CNAs for a census of 153 residents was a problem she needed to be notified about. The DON stated the 11-7 staff were expected to monitor for falls and check the residents every two hours. The DON stated it took five minutes to change a resident, and not everyone needed to be changed; they just needed to be checked. The DON verified CNA 11 had approximately 25 incontinent and six continent residents assigned to her but did not know the amount of assistance needed by the continent residents. The DON stated she felt the staff would be able to provide the needed care, but it might not be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 34 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE timely. Cross reference to F353. 5. Clinical record review for Resident 10 was initiated on 11/30/16. Resident 10 was readmitted to the facility on 7/2/16. Review of Resident 10's MDS dated 10/9/16, showed Resident 10 had no cognitive impairment, required extensive assistance of two persons for transfers, was not ambulatory, required extensive assistance for dressing and personal hygiene and was always incontinent of bladder. On 12/5/16 at 0940 hours, during a resident interview with Resident 10, Resident 10 stated he has often had to wait an hour for facility staff to assist him when he activated his call light. Resident 10 stated facility staff came into his room, turned his call light off, and left his room without assisting him. Resident 10 stated last night at 2330 hours, he was checked by staff. He became incontinent of urine but was not checked again by staff until 0500 hours this morning. 6. On 12/13/16 at 0510 hours, a strong odor of urine and feces was noted in the lobby and hallways upon entry to the facility. On 12/13/16 at 0525 hours, CNA 13 was observed in Station C outside of Room K gathering supplies to change an incontinent resident. CNA 13 stated while continuing to work, she had 31 residents to care for during her shift (11-7 shift) because four CNAs had called in sick. CNA 13 stated she had just finished changing a heavily soiled resident who required an hour to change. CNA 13 then cleaned, dried, changed, and repositioned Resident Z who was incontinent of urine, which took approximately eight minutes to complete. CNA 13 changed Resident AA who was incontinent of stool, which took approximately 11 minutes to complete. CNA 13 then went to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 35 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Room M to assist CNA 11 with changing two residents who required extensive assistance due to their physical condition and cognitive impairment. A trash/soiled linen cart was observed outside Room K with the linen overflowing and the trash full. There was a strong odor of urine and feces outside Room K. CNA 13 was asked how she was able to care for all 31 residents assigned to her during the 11-7 shift on 12/12/16. CNA 13 stated she started the shift by making rounds and changing the residents who were incontinent. However, she had to interrupt her rounds repeatedly to answer call lights of the "alert" residents and prioritize her care to those alert residents requesting assistance. She then continued her rounds she had begun at the beginning of her shift, however, was required to respond to the call lights of the alert residents throughout her shift. CNA 13 stated she also helped CNA 11 as needed during the shift to help care for more heavily dependent residents who required two staff members to change them. On 12/13/16 at 0620 hours, CNA 13 stated she had to take her soiled linen and trash cart to the basement to empty. When asked if there was a housekeeper to do so, she stated no, it was her responsibility. When asked how many times during a shift she went to the basement to dispose of soiled linen and trash, she stated usually three times. CNA 13 was observed taking the full cart to the basement via the elevator and returning back to the floor, which took approximately five minutes. Cross reference to F353. 7. On 12/13/16 at 0515 hours, CNA 15 was observed at Resident CC's bedside performing ADL care. CNA 15 stated they were assigned FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 36 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to 30 residents today as they were extremely short-staffed because a few CNAs had called off. CNA 15 stated they started their shift with the residents who needed their diapers changed. CNA 15 stated they had six residents just in this hallway who were incontinent. CNA 15 stated they started their shift by checking the incontinent residents and then started their second rounds again before 0400 hours. CNA 15 stated they had one resident who needed to be changed before they left for dialysis this morning, and in between changing residents, they tried to answer the call lights Further observation of CNA 15 performing incontinence care, oral hygiene, changing the bed linens, and repositioning Resident CC took approximately 30 minutes to complete. 8. On 12/13/16 at 0540 hours, CNA 15 initiated incontinence care for Resident T. CNA 15 was unable to complete the pericare for Resident T until the dressing to the pressure ulcer was changed by LVN 14. CNA 15 continued to her next incontinence resident and returned to Resident T's bedside at 0620 hours to assist LVN 14 with the pressure ulcer dressing change, then to complete the pericare, change the bed linen and soiled gown, which took approximately 40 minutes to complete. An interview was conducted with CNA 15 on 12/13/16 at 0720 hours. CNA 15 was asked how often she checked on her incontinence residents. CNA 15 stated she checked and changed her residents every two hours, turned, and repositioned her residents every two hours. CNA 15 stated, "I'm not going to lie, a night like tonight, it is impossible to get to everyone on time." Cross reference to F314, example #3. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 37 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9. On 12/13/16 at 0720 hours, CNA 15 was observed providing incontinence care for Resident V. Resident V was observed to have a urine soaked incontinence brief with a soiled dressing to the coccyx area. CNA 15 agreed the dressing to the coccyx area was soaked with urine, kept the dressing in place, performed pericare for Resident V, and placed a new incontinence brief on Resident V. CNA 15 stated the dressing would be changed later today by the treatment nurse and stated the last time she checked and changed Resident V was between 0100 and 0200 hours this morning. Cross reference to F314, example #2. 10. On 12/12/16, four CNAs had called off for the 11-7 shift and not been replaced, leaving five CNAs assigned to care for 153 residents. Each CNA had from 29-31 residents each. On 12/13/16 at 0521 hours, RN 3 was observed checking the IV cart. RN 3 was asked what the census was. RN 3 replied 153. RN 3 was asked how many CNAs working during the 11-7 shift. RN 3 replied five CNAs and one of the CNAs had been working double shifts (3-11 and 11-7 shifts) already. RN 3 was asked how many LVNs were working during the 11-7 shift. RN 3 replied four LVNs and two of the LVNs had been working double shifts too. Cross reference to F353. 11. On 12/13/16, CNA 14 was assigned to care for 12 residents during the 7-3 shift. CNA 14 stated today he had 12 residents but often had between 12-14 residents on an average day. CNA 14 stated he was supposed to have the day off but came in upon request. CNA 14 stated his duties included getting residents out of bed and taking them to the dining room, assisting with passing trays, assisting the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 38 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents with eating, giving showers and bed baths, and performing incontinence care. Cross reference to F353.

F314 SS=G TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 01/15/2017 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, clinical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and promote healing of pressure ulcers for one of 24 sampled residents (Resident 11) and two nonsampled residents (Residents T and V) * Resident 11 informed staff of pain to the right heel for a week before the staff identified the resident had developed a DTI (deep tissue injury) to the right heel. This resulted in the resident requiring further treatment to attempt FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 39 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to heal the pressure ulcer, further discomfort due to having to wear a special boot, and posing the risk of a possible infection. * Resident V was incontinent and had no pressure ulcers upon admission to the facility on 11/22/16. There was no care plan intervention to address incontinence care for the resident. Seven days later later, on 11/29/16, the resident developed a Stage III pressure ulcer to the coccyx (tailbone) area. Resident V's incontinence brief and wound dressing on his coccyx were observed to be heavily soaked with urine. The resident was not provided with necessary care timely to prevent worsening of the pressure ulcer due to the facility not having enough nursing staff to provide proper care for the residents throughout the facility. The facility had five CNAs on 12/12/16, during the 11-7 shift to care for 153 residents. Cross references to F312 and F353. * Resident T was admitted to the facility with a Stage IV pressure ulcer to the sacrococcyx area. The resident's pressure ulcer was observed to be covered with loose stool. There was no documentation the staff had turned, repositioned, checked every two hours, and provided the resident's pericare after each incontinence episode as care planned, due to the facility not having enough nursing staff to provide proper care for the residents throughout the facility. Cross references to

F312 and F353. Findings: Review of the facility's P&P titled Skin Management dated 8/2012 showed upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment and completing the Braden Scale FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 40 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (for predicting pressure sore risk). Appropriate preventive surfaces of beds, wheelchairs, etc. will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale). Following admission, the Braden Scale will be completed weekly for three additional weeks (for a total of four weeks, including admission). A weekly skin check will be conducted and documented on the Head to Toe Skin Check. 1. Review of the facility's Skin - Weekly Pressure Ulcer Record described a DTI as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Clinical record review for Resident 11 was initiated on 11/30/16. Resident 11 was admitted to the facility on 10/13/16. The MDS dated 10/29/16, showed Resident 11 to be cognitively intact. On 11/30/16 at 1630 hours, an interview was conducted with Resident 11. Resident 11 stated she needed assistance with bed mobility, transfers, and toileting. Resident 11 stated she had a sore on her right heel which needed treatment and had to wear a boot which was uncomfortable. Resident 11 stated she had been telling the staff her right heel was hurting for at least a week before the blister was found, but nobody had paid attention. Review of Resident 11's physician's order dated 12/1/16, showed to cleanse the right heel blister (dark purple in color) with normal saline, pat dry, paint with betadine (topical antiseptic), and cover with a dry dressing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 41 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Braden Scale for Predicting Pressure Sore Risk dated 10/13/16, showed Resident 11 was at moderate risk with slightly limited mobility (makes frequent though slight changes in body or extremity position independently). Friction and shear was a problem showing Resident 11 required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. Review of the Head to Toe Skin Checks dated 10/13/16, showed Resident 11 was admitted with a Stage 1 pressure area (intact skin with non-blanchable redness) to the coccyx area, bruising to the right upper extremity, and redness to the left under-breast. There was no documentation of any skin breakdown on the heels. Review of Resident 11's care plan problem dated 10/14/16, titled Resident having Potential/Actual Skin Issues related to pressure ulcer related to mobility showed the interventions were to conduct weekly skin checks per facility protocol, document the findings, turn, and reposition frequently to decrease pressure. Review of the clinical record showed no documented evidence of any weekly skin checks and/or assessments as per the care plan. Review of the Nursing Weekly Summary showed no documented evidence the nurse had completed a weekly nursing summary to address the resident's weekly skin assessments. Not until 11/11/16 (almost four weeks since the resident's admission), a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 42 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Nursing Weekly Summary was completed on 11/11/16, and showed Resident 11 did not have a pressure ulcer; the area for skin conditions was blank. However, review of the Weekly Pressure Ulcer Record dated 11/11/16, showed a new right heel DTI, measuring 3 cm (length) x 2 cm (width) of dark purple skin with an onset date of 11/9/16. Review of the Weekly Pressure Ulcer Record dated 11/29/16, showed a right heel DTI measured 4.5 cm x 4 cm and covered with black and purple colored skin. Review of Resident 11's care plan problem dated 11/30/16, titled ADL self-care performance deficit related to cervical fracture and chronic pain in the left shoulder showed Resident 11 was at risk for ADL decline and required extensive assistance of two staff persons for repositioning and turning in bed. On 12/5/16 at 1500 hours, an interview was conducted with RN 2. RN 2 verified Resident 11 was admitted without a pressure ulcer to the heels. RN 2 verified a skin assessment/weekly summary should be done weekly, but Resident 11 failed to have one completed until 11/11/16, four weeks after the admission Head to Toe Skin Check dated 10/13/16. RN 2 was unable to find any documentation of preventative care regarding Resident 11's heels. RN 2 verified Resident 11's right heel DTI could have been avoided. On 12/6/16 at 1000 hours, an interview and concurrent clinical record review was conducted with the DON. Upon review of the Incident/Accident Investigation Follow-Up dated 11/9/16, the DON verified the section showing past interventions attempted showed "N/A" (not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 43 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE applicable). The DON was unable to find any documentation of a skin assessment completed between 10/13 and 11/10/16, and was unable to find any documentation regarding preventative measures being done to prevent the right heel pressure ulcer. On 12/8/16 at 1345 hours, a telephone interview was conducted with the DON. The DON verified the facility's Skin Management P&P was not followed. A Braden Scale should have been completed weekly for three additional weeks following admission and a weekly skin check should have been conducted and documented for Resident 11, neither of which were completed. 2. On 12/13/16 at 0735 hours, CNA 15 was observed going in Resident V's room. CNA 15 stated she had changed Resident V's incontinence brief between 0100 to 0200 hours (more than five hours ago). Resident V's incontinence brief was observed soaked with urine. In addition, Resident V had a dressing on his coccyx which was also soaked with urine. CNA 15 was informed the dressing on Resident V's coccyx was soaked. CNA 15 stated the treatment nurse would change it later. CNA 15 was observed putting on a new incontinence brief over the soaked dressing to Resident V's coccyx. Clinical record review for Resident V was initiated on 12/13/16. Resident V was readmitted to the facility on 11/22/16. The MDS dated 11/29/16, showed Resident V was incontinent of bowel and bladder. The Readmission Skin - Head to Toe Skin Check dated 11/22/16, showed Resident V's skin was intact. Review of Resident V's care plan showed a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 44 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care plan problem to address increased risk for altered skin integrity. The interventions included providing pressure relieving cushion and low air low mattress. Further review of Resident V's care plan showed there was no intervention included to address Resident V's incontinence in preventing the development of pressure ulcers. The Skin - Head to Toe Skin Check dated 11/28/16, showed Resident V's skin was intact. The Skin - Head to Toe Skin Check dated 11/29/16, showed Resident V had a new stage III pressure ulcer to the coccyx, measuring 1.5 cm (length) x 1.2 cm (width) x 0.2 cm (depth). The Skin - Weekly Pressure Ulcer dated 12/2/16, showed Resident V's pressure ulcer on the coccyx measured 1.5 cm x 1.2 cm x 0.2 cm with 20% slough (dead tissue) with a small amount of serosanguineous (pinkish blood tinged) drainage. The Skin - Weekly Pressure Ulcer dated 12/9/16, showed Resident V's pressure ulcer on the coccyx measured 1 cm x 1.2 x 0.2 cm with 10% slough. On 12/13/16 at 1105 hours, LVN 1 was observed providing wound treatment to Resident V. LVN 1 was asked if Resident V developed the pressure ulcer while at the facility. LVN 1 replied yes. LVN 1 removed the dry dressing on Resident V's coccyx and measured the pressure ulcer. The measurements were 1.4 cm x 1.5 cm with superficial depth. During a telephone interview with RN 1 on 12/14/16 at 1130 hours, RN 1 acknowledged Resident V developed a new pressure ulcer on 11/29/16. RN 1 was asked what the facility's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 45 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE protocol was in identifying skin impairment. RN 1 stated the CNA who provided ADL care should report any skin impairment, i.e. redness, open area to the charge nurse. RN 1 stated the licensed nurse also completed a weekly summary of the resident's status, including a head to toe assessment. RN 1 was informed the Skin - Head to Toe Skin Check for Resident V dated 11/28/16, showed the resident's skin was intact and the next day (11/29/16), the documentation showed Resident V had a Stage III pressure ulcer. RN 1 verified the skin assessment dated 11/28/16, showed Resident V's skin was intact. RN 1 was asked if Resident V had redness to the coccyx. RN 1 replied the documentation showed no redness. RN 1 was unable to explain how Resident V had developed a Stage III pressure ulcer in one day. RN 1 was asked what interventions the facility should have implemented to prevent the development of a pressure ulcer. RN 1 replied the staff should have provided incontinence care every two hours and as needed. RN 1 was asked if the care plan problem to address increased risk for the development of pressure ulcers included an intervention to provide incontinence care every two hours and as needed. RN 1 acknowledged there was no intervention in the care plan to provide incontinence care every two hours and as needed. RN 1 was informed of the above observation of Resident V on 12/13/16 at 0735 hours. RN 1 acknowledged they were shortstaffed during that shift and tried their best, but they did not get "enough help." The facility had five CNAs on 12/12/16 during the 11-7 shift to care for 153 residents. 3. On 12/13/16 at 0515 hours, an interview was conducted with CNA 15. CNA 15 stated she was assigned to care for 30 Residents today because a few CNAs had called off. She started her shift with focusing on residents who needed their diapers changed. CNA 15 also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 46 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated she had six residents in one hallway who were incontinent and that was not including the other hallway she was assigned to. CNA 15 stated she also tried to answer the call lights in between changing her residents. On 12/13/16 at 0540 hours, CNA 15 was observed at resident T's bedside. Resident T was observed lying on her left side. CNA 15 initiated pericare by removing Resident T's incontinence brief. During the process of removing Resident T's incontinence brief, the dressing to Resident T's pressure ulcer fell off into the soiled brief, exposing the pressure ulcer. Loose stool was noted up on Resident T's lower back and around Resident T's pressure ulcer. CNA 15 wiped the stool from Resident T's lower back, removed the soiled brief and sheet, placed a new sheet under Resident T, and covered Resident T with a clean sheet. CNA 15 stated she needed to inform LVN 14 about placing a new dressing to Resident T's pressure ulcer before she placed a new brief on Resident T. CNA 15 then proceeded to inform LVN 14 of Resident T's dressing and continued with other Resident assignments. On 12/13/16 at 0620 hours, LVN 14 placed a new dressing to Resident T's pressure ulcer and completed Resident T's pericare. Resident T continued to lay on her left side. On 12/1316 at 0720 hours, an interview was conducted with CNA 15. CNA 15 stated she typically changed a Resident's diaper every two hours. CNA 15 stated Resident T was last changed between 0100 and 0200 hours this morning. CNA 15 stated she changed and turned her residents with pressure ulcers every two hours, but "I'm not going to lie; a night like tonight, it is impossible to get to everyone on time." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 47 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Clinical record review for Resident T was initiated on 12/13/16. Resident T was admitted to the facility on 6/20/16. Review of the MDS dated 9/27/16, showed Resident T had severe cognitive impairment was incontinent of bowel and bladder with a urinary catheter in place. Resident T was admitted to the facility on 6/20/16, with a Stage IV pressure ulcer to the sacrococcyx area (tailbone). Review of Resident T's care plan showed a care plan problem to address bowel incontinence. The interventions included checking the resident every two hours and providing pericare after each incontinent episode. Further review of Resident T's care plan showed a care plan problem to address the pressure ulcer. The interventions included to provide wound care and preventative skin care, and turn and reposition frequently. On 12/13/16 at 0830 hours, 0930 hours, Resident T was observed lying on her left side. On 12/13/16 at 0945 hours, LVN 1 was at Resident T's bedside performing daily wound care to Resident T's pressure ulcer. Resident T's incontinence brief was soiled with loose stool. LVN 1 was asked how often Resident T's incontinence brief should be checked. LVN 1 stated very two hours. On 12/13/16 at 1000 hours, CNA 17 was at Resident T's bedside performing pericare. Resident T was placed on her right side. CNA 17 was asked how often she checked Resident T's incontinence brief and turn her. CNA 17 stated every two hours. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 48 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a telephone interview with RN 1 on 12/14/16 at 1150 hours, RN 1 was asked what the facility protocol was for a resident who was incontinent of bowel and had a pressure ulcer to the sacrococcyx area. RN 1 stated to keep the resident dry, turned and repositioned every two hours, perform good hand hygiene, check and change soiled diapers every two hours and as needed, perform urinary catheter care, and the treatment nurse should change the dressing daily.

F315 SS=D NO CATHETER, PREVENT UTI, RESTORE BLADDER CFR(s): 483.25(e)(1)-(3)

F315 04/28/2017 (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 49 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident’s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and clinical record review, the facility failed to ensure one nonsampled Resident (Resident T) received appropriate care and services for an indwelling urinary catheter (a tube placed in the bladder to drain urine). Resident T had been treated for a urinary tract infection in August 2016. The staff failed to ensure Resident T was provided daily catheter care. This posed the risk of Resident T developing recurring urinary tract infections. Findings: Clinical record review for resident T was initiated on 12/13/16. Resident T was admitted to the facility on 6/20/16. Review of the MDS dated 6/27/16, showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 50 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident T was incontinent of bowel and bladder and showed Resident T had an indwelling urinary catheter. Resident T was admitted with a Stage IV pressure ulcer. Review of Resident T's urine culture results dated 8/1/16, showed it was positive for a urinary tract infection and showed 100,000 colonies of Proteus mirabilis (a bacteria commonly found in urinary tract infections). Review of Resident T's wound culture dated 8/18/16, showed positive growth of the same bacteria found in Resident T's urine culture dated 8/1/16. Review of Resident T's urine culture dated 10/17/16, showed it was positive for a urinary tract infection and showed the same strain of bacteria as the culture dated 8/1/16. Review of Resident T's wound culture dated 10/5/16, showed moderate growth of the same bacteria as the urine culture dated 10/17/16. Review of Resident T's care plan showed a care plan problem dated 7/16/16, addressing the indwelling urinary catheter for urinary retention and pressure ulcer management. The care plan intervention showed to monitor urinary output every shift, change the catheter monthly, position the bag below the level of the bladder, hand hygiene during care, observe for signs and symptoms of infection and perineal care as indicated. On 12/13/16, multiple observations were made of Resident T between 0500 and 1330 hours. CNA 15 stated she initially changed Resident T between 0100 and 0200 hours on 12/13/16, and was subsequently not changed again until 0620 hours by CNA 15. Resident T's next pericare and incontinence brief change did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 51 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE occur until 1000 hours on 12/13/15, by CNA 15. Cross reference to F314. Review of the Treatment Administration Record Log for the months of August through December 2016 showed to perform catheter care every shift. Multiple dates in each month of August, September, October, November and December 2016 showed the absence of documentation of indwelling urinary catheter care. A telephone interview and concurrent clinical record review for Resident T was conducted with RN 1 on 12/14/16 at 1430 hours. RN 1 verified the care plan for indwelling catheter care did not specify interventions for daily care. RN 1 also verified the absence of documentation of indwelling catheter care on multiple days from August 1st through December 14, 2016.

F318 SS=D INCREASE/PREVENT DECREASE IN RANGE F318 OF MOTION CFR(s): 483.25(c)(2)(3) 03/10/2017 (c) Mobility. (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on interview and clinical record review, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 52 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the facility failed to show range of motion services were being provided for one of 24 sampled residents (Resident 10). This had the potential for the resident not receiving his therapy as ordered. Findings: Clinical record review for Resident 10 was initiated on 11/30/16. Resident 10 was admitted to the facility with diagnoses including osteoarthritis. Review of Resident 10's MDS showed he had impairment to both lower extremities. Review of the MDSs dated 7/9 and 10/9/16, showed Resident 10 had limited range of motion to the upper and lower extremities. Review of Resident 10's November 2016 Order Summary Report showed an order dated 5/7/14, for passive range of motion to the bilateral lower extremities three times per week as tolerated to be done by RNA. During an interview with Resident 10 on 12/8/16 at 1135 hours, Resident 10 stated the last time he received RNA services for range of motion was over six months ago. The resident stated he felt the contractures to his extremities have increased. On 12/5/16 at 1511 hours, an interview with RNA 1 was conducted. When asked when Resident 10 last received RNA services, RNA 1 stated Resident 10 was not on the list of residents to receive RNA services. RNA 1 stated she remembered Resident 10 had been receiving RNA services prior to going to the hospital. During an interview with Medical Records Clerk 1 on 12/5/16 at 1600 hours, Medical Records FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 53 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Clerk 1 provided Resident 10's Rehabilitation/Restorative Service Delivery Record for the month of January 2016. When asked if there were any other 2016 Rehabilitation/Restorative Service Delivery Records for Resident 10, Medical Records Clerk 1 stated no other 2016 Rehabilitation/Restorative Service Delivery Records for Resident 10 were found in his clinical record. On 12/8/16 at 1135 hours, an interview with Resident 10 was conducted. When asked when he last received RNA services, Resident 10 stated it had been more than six months since he had received therapy.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 04/28/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 54 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, clinical record review, and facility P&P review, the facility failed to ensure the residents remained free from accident hazards and appropriate assistive devices were in place to prevent accidents for four of 24 sampled residents (Residents 3, 9, 10, and 12). * Resident 10 suffered a fall with injury while being transferred using a Hoyer lift (a mechanical lift to transfer residents to and from the bed or chair). Resident 10 fell from the Hoyer lift sling, resulting in fractured ribs and hospitalization. In addition, Resident 10 was scratched by Resident S's dog and suffered from a skin tear on the right forearm. * Resident 12 got up from the bed and ambulated unassisted. He had dementia and an unsteady gait, had four falls within two weeks, and was then transferred to a room away from the nurses' station where he was not visible from the hallway. This had the potential for Resident 12 to sustain unwitnessed falls with possible injury. * Resident 3 sustained a fall with a right hip pain and fracture. The resident had six more fall incidents which were not investigated thoroughly in an attempt to prevent further falls. * The facility failed to place a pad alarm in Resident 9's wheelchair as ordered by the physician. This had the potential of Resident 9 getting up unassisted, falling, and sustaining injuries. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 55 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE * Two television sets in two different resident rooms were not secured and a portable air conditioner with wheels on the bottom was observed on top of table with a blue paper tape securing the air conditioner. These posed potential hazards in the event of an earthquake for residents, staff, and visitors. Findings: 1. Clinical record review for Resident 10 was initiated on 11/30/16. Resident 10 was initially admitted to the facility on 6/22/12, and readmitted on 7/2/16, with diagnoses including osteoarthritis. a. Review of Resident 10's MDS dated 7/9/16, showed he needed two persons' assistance for transfers. Resident 10 was assessed to need a Hoyer lift for transfers. Further review of Resident 10's clinical record showed a hospital CT scan dated 7/1/16, which showed Resident 10 had rib fractures. On 12/5/16 at 0940 hours, during an interview with Resident 10, Resident 10 stated he fell onto the floor and suffered rib fractures while being transferred via a Hoyer lift. Review of Resident 10's fall investigation showed Resident 10 fell on 7/1/16, while being transferred using a "net" sling (the part of the machine in which the resident is allowed to rest) attached to a Hoyer lift. On 12/6/16 at 1140 hours, an interview regarding Resident 10's fall on 7/1/16, was conducted with the DON. The DON stated Resident 10 had requested a specific sling be used during his transfers with the Hoyer lift. When asked if documentation existed to show FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 56 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 10's sling preference, the DON stated all communication regarding this was done verbally and not documented. On 12/6/16 at 1350 hours, an interview with the OT was conducted. The OT stated she was called to assist CNA 7 with transferring Resident 10 from his bed onto a shower chair using a Hoyer lift on 7/1/16. The OT stated Resident 10 was already on the sling and it was already attached to the Hoyer lift. When asked what type of sling Resident 10 had underneath him during the transfer, the OT stated the sling was made of sturdy mesh material. When asked what the condition of the sling was on 7/1/16, the OT was unable to state; the OT just remembered the sling snapped and Resident 10 fell onto the ground. On 12/7/16 at 1130 hours, an interview with CNA 7 was conducted. When asked about Resident 10's fall on 7/1/16, CNA 7 stated she and the OT were in the room assisting Resident 10 to transfer him via a Hoyer lift onto a shower chair. When asked about the sling used to transfer Resident 10, CNA 7 stated she used a sling she had been informed Resident 10 preferred. CNA 7 stated it was a blue clothlike material which extended from Resident 10's mid back area to Resident 10's back of the shoulder area. CNA 7 stated the cloth area of the sling then continued underneath Resident 7's legs, which CNA 7 stated she criss-crossed in between his legs and then attached onto the Hoyer lift. CNA 7 stated Resident 10 was to one side of his bed, approximately four feet above the ground when three of the slings straps snapped and Resident 7 fell onto the ground. CNA 7 stated two of the sling's straps snapped at the seam area where the straight edge and looped area of the straps met, and the third strap snapped about midway down. CNA 7 stated she saw drops of blood coming FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 57 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE out of the left side of Resident 10's head. CNA 7 stated Resident 10 was transported to the acute care hospital afterwards. On 12/8/16 at 1135 hours, an interview with Resident 10 was conducted. When asked what type of sling was used on 7/1/16, during his transfer and subsequent fall from the Hoyer lift, Resident 10 stated a blue mesh sling was placed underneath him. Resident 10 stated while he was suspended in the air, he felt the back "cord" against his back break and his back hit the floor. When asked if he had expressed a preference of the type of sling to be used on him for transfers with the Hoyer lift, Resident 10 stated he did not request any specific sling; staff chose which sling to use for his transfers. On 12/8/16 at 1426 hours, an interview with the DON was conducted. When asked if she looked at the sling used on Resident 10 on 7/1/16, after Resident 10 fell, the DON stated she did not look at the sling but was focused on caring for Resident 10 after he fell. The DON stated the mechanical lift used on Resident 10 on 7/1/16, was called a Joerns Hoyer Presence 500; however, the sling used with this lift on 7/1/16, was a toileting sling designed to be used with the Invacare mechanical lift, not the sling for the Joerns Hoyer Presence 500. Review of the Joerns Hoyer Presence User Instruction Manual showed to not use a sling unless it is recommended for use with this lift. b. Review of the facility's P&P titled Animals in the Long Term Care Facility revised 9/2015 showed animal-assisted activities and resident animal programs - animals that are fully vaccinated for zoonotic diseases (infectious diseases that can be transmitted from animals to humans) and that are healthy, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 58 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE clean, well-groomed, and negative for enteric parasites (parasites that can infect the gastrointestinal tract of humans and other animals) or otherwise have completed recent anthelmintic treatment (used to destroy parasitic worms) under the regular care of a veterinarian will be used in the program. During an observation on 11/30/16 at 1600 hours, Resident 10 was observed to have two white dressings on the right hand and forearm. A two inch by two inch white dressing was placed on Resident 10's right hand and a two inch by six inch white dressing was on Resident 10's right forearm. During an interview with LVN 5 on 11/30/16 at 1610 hours, LVN 5 stated Resident 10 was trying to pet Resident S's dog and the dog scratched him. LVN 5 stated Resident 10 acquired a skin tear from the dog's scratch and was getting treatment with normal saline. During an interview with the DON on 12/5/16 at 1440 hours, the DON stated she did not have Resident S's dog's immunization record. The DON stated the Activity Manager was contacting Resident S's husband to bring in the immunization record. 2. Clinical record review for Resident 12 was initiated on 11/30/16. Resident 12 was readmitted to the facility on 10/27/16, with diagnoses including advanced Parkinson's disease and dementia. On 11/30/16 at 1650 hours, Resident 12 was observed walking without assistance in Room H with the bed alarm sounding. Resident 12 walked with an unsteady gait to the opposite side of the room, then back to his bed, and sat down, which then stopped the bed alarm from sounding. Room H was shaped like an "L." Bed A was visible from the hallway, but in order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 59 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to see Beds B and C, the staff had to walk into the room and turn to the left. Resident 12's bed was the furthest from the door (Bed C) and not visible from the hallway. Further impeding the view were the privacy curtains, which were drawn between the three beds. LVN 9 verified the above. On 12/1/16 at 0650 hours, Resident 12 was observed sleeping in his bed with both legs hanging over the side of the bed touching the floor; the privacy curtains were drawn between the beds. On 12/1/16 at 0700 hours, an interview was conducted with LVN 8. LVN 8 stated at night, Resident 12 went to the bathroom by himself, but the staff listened for the alarm and went to assist him. LVN 8 stated sometimes Resident 12 needed help to lift his legs onto the bed. Review of the MDS dated 11/10/16, showed Resident 12 had severe cognitive impairment and needed extensive assistance with transfers, walking, and toileting. Resident 12's balance was not steady, only able to stabilize with human assistance when moving from a seated to a standing position, walking, turning around, and surface-to-surface transfers. Review of the Incident/Accident Report dated 10/31/16 at 2200 hours, showed Resident 12 attempted to get out of bed unassisted and had an unwitnessed fall with no apparent injury. Review of Resident 12's physician's order dated 10/31/16, showed to move Resident 12 closer to the nurses' station. Review of the Incident/Accident Report dated 11/1/16 at 1530 hours, showed Resident 12 had an unwitnessed fall near his bed, resulting in a head laceration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 60 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 12's physician's order dated 11/1/16, showed to apply a pad alarm to the bed and wheelchair to remind the resident not to get up unassisted. Review of the SBAR Communication Form and Progress Note dated 11/8/16, showed Resident 12 had an unwitnessed fall near the bathroom of the resident's room. Resident 12 had no apparent injury. Review of the Incident/Accident Report dated 11/8/16 at 1800 hours, showed Resident 12 was found standing in his bathroom with a laceration to the left eyebrow. The facility did not determine how it had occurred. Review of the SBAR Communication Form and Progress Note dated 12/6/16 at 0317 hours, showed Resident 12 had an unwitnessed fall in his bathroom, resulting in a left elbow wound, measuring 2 cm (length) x 3 cm (width). On 12/6/16 at 0900 hours, an interview and concurrent clinical record review was conducted with the DON. The DON was unaware Resident 12 had a fall in the morning. The DON verified Resident 12 had four falls from 10/27 to 11/8/16. The DON verified Resident 12 was moved to his current room on 11/10/16, and the reason was not documented. The DON verified Resident 12 got up and walked without assistance. Resident 12 was observed in his room on the bed. Two straps, holding the mattress to the bed frame, were observed laying on the floor where Resident 12 stood up. The DON verified it was a fall hazard. The DON verified Resident 12 could not be seen from the doorway and the view was further impeded by the curtain being drawn between the beds. The DON verified Resident 12's room was not near the nurses' station as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 61 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE per the physician's order. 3. Review of the facility's P&P titled Incident Investigation dated March 2008 showed all employee reports of incidents must be thoroughly investigated at the time the incident is reported. The incident investigation process is designed to determine the root cause of the incident. Clinical record review for Resident 3 was initiated on 11/30/16. Review of the Admission Record showed Resident 3 was initially admitted to the facility on 12/26/15, and readmitted on 8/18/16. Review of the MDS dated 5/9/16, showed Resident 3 had severe cognitive impairment and was not able to be interviewed. In addition, Resident 3 required supervision for eating and extensive assistance for dressing, bathing, and daily hygiene care. Review of the Fall risk assessments for Resident 3 dated 4/4, 5/2, 5/31, 6/21, 7/7, 8/9, 10/18, 10/21, and 10/25/16, showed Resident 3 was at a high risk for falls. Review of History and Physical Examination form dated 5/3/16, showed the diagnosis of fall with right hip fracture status post ORIF. Review of the history and physical examination from the acute care hospital dated 4/23/16, showed "Yesterday she went to bathroom and lost balance, so fell on the floor. She had severe right hip pain. X ray showed intertrochanteric (upper part of the thigh bone) and proximal fracture at the right hip." Review of Resident 3's care plan showed a care plan problem dated 4/22/16, to address the resident's fall to the floor when attempting to get back to bed from the bathroom. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 62 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interventions included to continue safety whenever ambulating, make sure the bed alarm was in place, have staff respond promptly, monitor the resident while in bed, place pads on the floor, offer assistance to the restroom, provide area for safe ambulation, and use of bed and wheelchair alarm. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 4/25/16, showed the section for witnessed or unwitnessed was blank. The section for Injury was blank. The location of the resident prior to the fall was blank, predisposing disease, the footwear or assistive device at time of fall, and the medications that may contribute was documented as none. There was no documentation to identify the circumstances surrounding the fall (i.e. whether the resident was in bed or in a wheelchair when she fell and/or what external factors could have contributed to the resident's fall, etc.). Review of the Incident/Accident Investigation Follow-Up dated 4/23/16, showed Resident 3 was found on the floor complaining of hip pain; she fell when she was trying to get back to bed from the bathroom. Documentation showed the resident was interviewed; however, there was no documented evidence to show the direct care staff and licensed nurse were interviewed. Review of the Interdisciplinary Post Fall Review dated 5/31/16, showed Resident 3 was noted to be sitting on the floor at the bedside complaining of moderate pain to the right hip. The facility interviewed only the OT; however, there was no direct care staff or licensed nurse interviewed. Review of the Incident/Accident Investigation Follow-Up dated 7/2/16, showed Resident 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 63 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was found sitting on the floor in the room at the bedside. The Summary of Investigation (Reasonable Conclusion) showed the resident was trying to get out of bed unassisted. It failed to show if the staff or resident was interviewed and what was the reason the resident wanted to get out of bed. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 7/7/16, showed a resident assisted fall in the hallway in front of the smoking patio by resident care services. The environmental factors and medications that might contribute to the fall were left blank. Review of the Interdisciplinary Post Fall Review dated 9/11/16, showed Resident 3 fell in the front lobby, unassisted transfer from the wheelchair to the sofa. The footwear or assistive devices at the time of the fall were left blank. Review of the Incident/Accident Investigation Follow-Up dated 10/18/16, showed Resident 3 was found sitting on the floor in the front lobby. The Past Interventions Attempted was left blank. The Recommendations/New Interventions showed frequent visual checks. The Summary of Investigation (Reasonable Conclusion) showed when the resident was asked what happened, the resident continuously spoke in her primary language. Review of the Incident/Accident Investigation Follow-Up dated 10/21/16, showed Resident 3 was found sitting on the floor; she stated she was coming out from the toilet and slid. The Past Interventions Attempted were left blank. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 10/21/16, showed the areas to document the injury, vital signs, hypotension on the fall, location of the fall, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 64 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE location of the resident prior to the fall, activity at the time of the fall, predisposing diseases, conditions that might contribute to the fall, footwear or assistive devices at time of fall, environmental factors, and medications that might contribute to the fall were left blank. There was no documentation to identify the circumstances surrounding the fall (i.e. whether Resident 3 was in bed or in a wheelchair when she fell and/or what external factors could have contributed to the resident's fall, etc.). On 12/2/16 at 0915 hours, an interview was conducted with CNA 9. CNA 9 was asked if Resident 3 asked for assistance to the restroom or for toileting, bathing, and dressing. CNA 9 stated Resident 3 could press the call light and asked for assistance to go to the toilet but could not wait long. CNA 9 stated she was very busy helping other residents. Sometimes she helped other residents in the restroom, so she could not go to Resident 3 right away and Resident 3 would get up unassisted to go to the toilet. On 12/6/16 at 1330 hours, an interview and concurrent clinical record review was conducted with the DON and LVN 4. When asked regarding the fall incidents involving Resident 3, LVN 4 stated Resident 3 sustained a right hip fracture after the fall on 4/22/16. Each of the fall incidents was investigated. LVN 4 was asked if the fall incident on 4/22/16, where the location of the resident prior to the fall, predisposing disease, footwear or assistive device, medication, who supervised or monitored the resident and if any staff was interviewed. LVN 4 stated she did not know the location, the predisposing disease should be documented for Parkinson's, hypertension, and dementia, and the medication should be documented for hypertension, and psychoactive. LVN 4 stated she did not know FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 65 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE how the resident transferred herself to the bathroom and if the bed alarm or wheelchair alarm sounded. When asked if she could show any documentation for any information regarding the fall, LVN 4 stated she did not have it. When asked what happened on 9/11/16, LVN 4 stated the volunteer who spoke in Resident 3's language left the resident alone in the lobby; the volunteer should not have left her alone. LVN 4 was asked if the volunteer was interviewed about the fall incident or if the volunteer knew or was made aware Resident 3 was at high risk for falls prior to the fall. LVN 4 stated there was no documentation of an interview with the volunteer. When asked what past interventions were in place for the incident on 10/18/16, LVN 4 stated she did not know the details and was unable to provide any information. When asked about the incomplete investigation dated 10/21/16, and the IDT assessment, LVN 4 confirmed the fall investigation was not conducted thoroughly. LVN 4 stated she depended on staff to keep her informed of any incidents that needed the investigation. LVN 4 acknowledged Resident 3 had six more fall incidents in the facility after the fall incident on 4/22/16. 4. Clinical record review was initiated for Resident 9 on 12/2/16. Resident 9 was admitted to the facility on 5/25/15, and readmitted on 4/9/16. Review of the MDS dated 10/17/16, showed Resident 9 was cognitively intact. Review of the History and Physical Examination form dated 4/11/16, showed Resident 9 had dementia with behavioral disturbances, generalized weakness, and foot drop. Further review of Resident 9's MDS dated 12/2/16, showed Resident 9 required extensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 66 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assistance and one person's physical assistance for transfers from one surface to another. Review of the Order Summary Report for the month of December 2016 showed an order to apply a pad alarm in the chair due to episodes of getting up unassisted and monitor episodes of getting up unassisted from the chair. Review of Resident 9 's care plan showed a care plan problem dated 4/12/16, to address the potential safety fall risk related to disease process and anxiety. The interventions showed to observe for placement and function of devices per the facility's protocols and place the pad alarms in the bed and wheelchair due to episodes of getting up unassisted. Resident 9 was observed on 12/2/16 at 0815 hours, sitting in a wheelchair, eating breakfast, and watching television. No pad alarm was observed on the wheelchair. On 12/2/16 at 1510 hours, Resident 9 was observed sitting in his wheelchair in the doorway of his room watching television. No pad alarm was observed on the wheelchair. On 12/2/16 at 1535 hours, an interview was conducted with CNA 9. When asked how the staff ensured Resident 9 was not getting out of his chair unassisted when the staff were not available to help him when needed, CNA 9 stated she did not know, but the resident let her know when he wanted to get up. CNA 9 was asked if Resident 9 should have a pad alarm in place while up in his wheelchair. CNA 9 stated she did not know, but the resident did not have one in his chair. On 12/2/16 at 1540 hours, an interview and concurrent clinical record review was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 67 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with LVN 2. When asked if Resident 9 should have a pad alarm while in his wheelchair, LVN 2 stated the resident should have one and then verified the physician's order for a pad alarm. LVN 2 verified Resident 9 was sitting in his wheelchair without a pad alarm. 5. On 12/2/16 at 0930 hours, during an environmental tour of the facility, resident Room B was observed. A television in Room B was observed sitting on a night stand adjacent to a resident's bed. The Maintenance Supervisor verified the television was not secured. On 12/1/16 at 0940 hours, a television in resident Room C was observed sitting on a night stand next to the wall adjacent to a resident's bed. The Maintenance Supervisor verified the television was not secured. During initial tour with LVN 5 on 11/30/16 at 1145 hours, a detached portable air conditioner with wheels on the bottom was observed on top of a table in Room D next to the window. The portable air conditioner was secured with a blue paper tape. This finding was verified by LVN 5.

F328 SS=D TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(b)(2)(f)(g)(5)(h)(i)(j)

F328 01/15/2017 (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 68 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to … prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive personcentered care plan, and the resident’s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and 483.65 of this subpart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 69 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, to wear and be able to use the prosthetic device. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and clinical record review, the facility failed to ensure proper administration of continuous oxygen for one nonsampled resident (Resident F). Failure to administer oxygen as ordered had the potential to negatively impact Resident F's medical condition. Findings: During an initial tour on 11/30/16 at 1220 hours, Resident F was observed in a wheelchair with a portable oxygen tank outside room F and a nasal cannula (an oxygen tube with two small prongs which are placed in the nostrils to administer the oxygen) on the floor. The oxygen tank was observed to be empty. Resident F stated to CNA 8 she wanted to be pulled up in the wheelchair. CNA 8 called for help. While waiting for help, CNA 8 picked up the nasal cannula off the floor, pulled the portable oxygen tank into Room F, and wheeled Resident F into Room F. CNA 8 verified the oxygen tank was empty. When asked how long Resident F's oxygen tank had been empty, CNA 8 stated she was not sure. At 1240 hours, RN 1 arrived. CNA 8 informed RN 1 the oxygen tank was empty and the nasal cannula had been on the floor. RN 1 verified the oxygen tank was empty. RN 1 went to get a new oxygen tank and a nasal cannula. Resident F was placed on 2 liters of oxygen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 70 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE RN 1 stated Resident F was on oxygen at 2 liters, and was not sure when the oxygen tank became empty. Clinical record review for Resident F was initiated on 11/30/16. Resident F was admitted to the facility on 11/23/16, with diagnoses including COPD. Resident F had a physician's order to administer continuous oxygen at 2 liters per minute via nasal cannula.

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 03/10/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 71 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on interview and clinical record review, the facility failed to ensure six of 24 sampled residents (Residents 9, 21, 3, 4, 19, and 1) was free from unnecessary drugs. * The facility failed to conduct adequate monitoring of Resident 9 for the use of Nuedexta (a medication used to treat pseudobulbar affect [PBA]), monitor orthostatic blood pressure for the month of October for the use of Zyprexa (antipsychotic medication) and failed to conduct adequate monitoring for the use of Ativan (antianxiety). * The facility failed to conduct adequate monitoring of Resident 21 for the use of Ativan and Trazadone (an anti-depressant that is also used to help with sleep). * Resident 1 had an order for melatonin (a medication used to treat insomnia) without adequate indications for use and without adequate monitoring. * The facility failed to attempt nonpharmacological interventions prior to the administration of an anti-anxiety medication (Ativan) for Resident 3. * The facility failed to attempt nonFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 72 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pharmacological interventions prior to the administration of an anti-anxiety medication (Ativan) and an anti-depressant medication (setraline) for Resident 4. * The facility failed to conduct adequate monitoring for the use of Depakene (an anticonvulsant also used for mood instability) for Resident 19. These failures created a risk of providing unnecessary medication and the potential for developing significant side effects for these residents. Findings: According to Lexi-Comp Online (an online drug resource used by medical professionals) showed, for the medication Nuedexta, under Monitoring Parameters, "periodically reassess the need for treatment (spontaneous improvement of PBA may occur)." Side effects included diarrhea, dizziness, cough, vomiting, weakness, swelling of the feet and ankles, and abnormal liver tests. PBA symptoms are described as frequent uncontrollable outbursts of laughing or crying. The crying or laughing episodes are inappropriate to the situation in which they occur. Sometimes these are spontaneous crying or laughing eruptions that don't reflect the way a person is actually feeling. 1. Clinical record review for Resident 9 was initiated on 12/2/16. The MDS dated 10/17/16, showed Resident 9 was cognitively intact. a. A psychological consultation dated 5/10/16, showed Resident 9 had a diagnosis of dementia, PBA and depression. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 73 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the Order Summary Report for the month of December 2016 showed to administer Nuedexta 20-10 mg one capsule by mouth every 12 hours for PBA. Review of the Medication Administration Record for the month of December 2016 showed to administer Nuedexta every 12 hours for PBA. An interview with CNA 9 was conducted on 12/2/16 at 1530 hours. CNA 9 was asked if Resident 9 had any behaviors including sudden laughing or crying, angry outbursts, or verbal aggression. CNA 9 stated no. CNA 9 stated the only time Resident 9 yelled was when the staff did not answer his call light in time and sometimes he got mad if the staff did not get him up into his chair right away to eat when his food was served. During an interview and concurrent clinical record review conducted with RN 1 on 12/2/16 at 1025 hours, RN 1 was asked why Resident 9 was taking Neudexta. RN 1 stated Neudexta was for PBA, for behaviors like yelling out. After clarifying with an online clinical resource, RN 1 stated Neudexta was used for uncontrollable crying or laughing. When asked if Resident 9 exhibited any of those behaviors, RN 1 stated no. When asked if there was a care plan or behavior log in Resident 9's clinical record for Neudexta, RN 1 could not locate it in Resident 9's clinical record. When asked how they knew if the Neudexta was effective or if the resident was experiencing side effects if there was no care plan or log to document behaviors for Resident 9, RN 1 stated, "we don't." b. Review of the Order Summary Report for September 2016 showed to give Zyprexa 7.5 mg by mouth at bedtime for behavioral and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 74 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychological symptoms of dementia manifested by uncontrollable angry outbursts. Review of the physician's orders dated 10/11/16, showed to discontinue Zyprexa 7.5 mg by mouth at bedtime and administer Zyprexa 5 mg, one tablet by mouth at bedtime for behavioral and psychological symptoms of dementia manifested by uncontrolled angry outburst. Review of the Order Summary Report for December 2016 showed to monitor orthostatic blood pressure (B/P), B/P sitting and B/P lying down one time a day starting on the first of the month and ending on the first of the month for Zyprexa with an order start date of 7/1/16. Review of the monthly weights and vitals summary for the month of October 2016 did not show a documented orthostatic blood pressure readings. An interview and concurrent clinical record review was conducted with LVN 2 on 12/2/16 at 1115 hours. When LVN 2 was asked how often Resident 9 got orthostatic blood pressure readings. LVN 2 stated weekly. LVN 2 verified Resident 9 was taking Zyprexa for the month of October, 2016. LVN 2 also verified the physician's order to take orthostatic blood pressure readings on the first of every month while taking Zyprexa. LVN 2 could not provide documentation an orthostatic blood pressure was taken for the month of October, 2016 for Resident 9. c. Review of Resident 9's Medication Administration Record for the month of November showed an order for Ativan 0.5 mg. Give one tablet by mouth every four hours as needed for anxiety manifested by verbalization FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 75 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of feeling anxious. Resident 9's Medication Administration Record for the month of November, 2016 showed Resident 9 received Ativan on multiple dates, including 11/2, 11/3, 11/4, 11/25, 11/26, and 11/27/16. Review of Resident 9's care plan showed a care plan problem to address anti-anxiety medication for anxiety manifested by verbalization of feeling anxious. The interventions showed to observe/record occurrences for target behavior symptoms like verbalization of feeling anxious, administer antianxiety medications as ordered by the physician and observe for side effects and effectiveness every shift. The behavior log for anxiety for behaviors of verbalization of feeling anxious for the month of November, 2016 showed to specify each behavior; for each shift, document the number of behavior occurrences, identify interventions used and the outcome. On the dates of 11/2, 11/3, 11/4, 11/25, 11/26 and 11/27/16, the number of behaviors occurring on those days were documented as zero. An interview and concurrent clinical record review for Resident 9 was conducted with LVN 9 on 12/2/16 at 1420 hours. When asked why Resident 9 took Ativan, LVN 9 stated for feeling anxious. When asked where they documented the behaviors when Resident 9 felt anxious, LVN 9 stated in the behavior log. When LVN 9 was asked why no events were recorded for behaviors on the dates 11/2, 11/3, 11/4, 11/25, 11/26 and 11/27/16, when Resident 9 received Ativan, LVN 9 stated she did not know. When asked how they knew if the medication was effective if it was not documented, LVN 9 stated they would not know. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 76 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Clinical record review for Resident 21 was initiated on 12/5/16. Resident 21 was readmitted to the facility on 11/3/16. a. Review of the Order Summary Report for the month of November 2016 showed to administer Ativan 1 mg via G-Tube (a tube placed through the abdominal wall into the stomach, used for feeding and or administering medication) every six hours as needed for anxiety manifested by the inability to relax. Review of the Medication Administration Record for the month of November 2016 showed Resident 21 received Ativan 1 mg on 11/3, 11/17 and 11/30/16. Review of the care plan problem dated 11/7/16, to address Ativan for anxiety manifested by the inability to relax showed an intervention to administer anti-anxiety medication as ordered by the physician, observe for side effects and effectiveness every shift. An interview and concurrent clinical record review was conducted with LVN 12 on 12/5/16 at 1100 hours. LVN 12 stated Resident 21 was usually calm throughout the day, especially when her music was playing. At times she would yell out, but she calmed down if reoriented. LVN 12 verified Resident 21 received Ativan on 11/3, 11/17 and 11/30/16. When asked to show the behavior log for Ativan for the month of November, LVN 12 could not provide documentation. When asked how they knew if the Ativan, when given for the inability to relax, was warranted, was effective or if there were any side effects, LVN 12 stated they would not know if it was not documented. b. Review of Resident 21's History and Physical Examination form dated 11/16/16, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 77 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE showed Resident 21 did not have the capacity to understand and make decisions. Review of the Order Summary Report for the month of November 2016 showed to administer Trazadone 50 mg, one tablet via G-tube at bedtime for depression manifested by the inability to sleep. Review of the Medication Administration Record for the month of November 2016 showed Resident 21 received Trazadone for depression manifested by the inability to sleep as prescribed beginning 11/14/16. An interview and concurrent clinical record review was conducted with LVN 13 on 12/6/16 at 0835 hours. LVN 13 verified an incomplete behavior log for Trazadone on 12/2, 12/3, 12/4/16. When asked how the staff knew if a medication used to help with sleep was effective if the behavior logs were incomplete, LVN 13 stated they would not know. LVN 13 verified Resident 21 did not have the capacity to understand and make decisions. LVN 13 was asked how they ensured a resident who did not have the capacity to understand or make decisions was receiving appropriate medication, especially for an indication like trouble sleeping. LVN 13 stated there should have been consistent documentation in the clinical record showing Resident 21 was having trouble sleeping before being placed on a medication to help with sleep. LVN 13 was unable to provide documentation regarding Resident 21's inability to sleep. 3. Clinical record review for Resident 3 was initiated on 11/30/16. Resident 3 was admitted to the facility on 12/26/15, and readmitted on 8/18/16. Review of a physician's order dated 8/16/16, showed Ativan 0.5 mg, one tablet by mouth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 78 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE every six hours as needed for anxiety manifested by inability to relax. Review of Resident 3's Psychoactive Medication Consent for Ativan dated 5/2/16, showed under "The following less restrictive non-drug approaches have proven to be ineffective:, "staff wrote in, "keep clean, dry & comfortable." On 12/6/16 at 0900 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 was asked to show any documentation for nonpharmacological attempts made before staff administered antianxiety medication. LVN 4 stated it was offered to keep Resident 3's skin clean, dry and comfortable. LVN 4 was asked if there were any non-pharmacological interventions offered besides keeping the resident's skin clean, dry and comfortable. LVN 4 stated they should have offered other interventions to Resident 3 prior to the administration of Ativan. LVN 4 verified the findings. 4. Clinical record review for Resident 4 was initiated on 11/30/16. Resident 4 was admitted to the facility on 6/13/15. Review of Resident 4's Psychoactive Medication Consent for Ativan dated 10/14/15, showed the space under "The following less restrictive non-drug approaches have proven to be ineffective:" was blank. Review of Resident 4's Psychoactive Medication Consent for setraline (antidepressant) dated 6/17/15, showed the space under "The following less restrictive nondrug approaches have proven to be ineffective:" was blank. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 79 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of a physician's order dated 8/28/15, showed setraline hydrocholride 1000 mg two tablets by mouth one time a day manifested by angry outbursts. Review of a physician's order dated 11/5/16, showed Ativan 0.5 mg one tablet by mouth every 24 hours as needed for anxiety manifested by pacing in the wheelchair. Review of Medication Administration Record dated November 2016 showed Ativan 0.5 was administered on 11/11/16 at 0229 hours, on 11/13/16 at 2324 hours, on 11/18/16 at 2300 hours, and on 11/25/16 at 0002 hours. Review of Behavior /intervention/outcome for November 2016 showed the intervention sections for the night shifts on 11/11, 11/13, 11/18, and 11/25/16, were documented zero for non-pharmacological interventions. On 12/6/16 at 0900 hours, an interview and concurrent clinical record review was conducted with LVN 4. LVN 4 was asked to show any documentation of nonpharmacological interventions attempted before administering antianxiety and antidepressant medications to Resident 4. LVN 4 stated it was not documented in the consent; it should have been documented in the consent. LVN 4 stated the nurses should have attempted nonpharmacological interventions and documented the results before they administered the medications. 5. Clinical record review was initiated for Resident 19 on 11/30/16. Resident 19 was admitted to the facility on 3/24/16, with a diagnosis of dementia with behavioral disturbance. Review of the Order Summary Report for November 2016 showed a physician's order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 80 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 11/17/16, for Resident 19 to receive Depakene 250 mg by mouth two times a day for mood instability manifested by yelling out to the point of exhaustion. Review of the plan of care showed a care plan problem dated 9/16/16, to address the use of Depakene. The interventions showed to observe for and document the side effects and effectiveness of the medication every shift. Review of the Behavior Monitoring Form for Depakene showed a targeted behavior of yelling out to the point of exhaustion. For the month of November 2016 showed incomplete monitoring on dates 11/3, 11/4, 11/12, 11/13, 11/14, 11/15/16, for the night shift and dates 11/5, 11/6, 11/11, 11/14, 11/15/16, for the evening shift. The number of episodes, interventions, outcome, side effects and initials were left blank. On 12/6/16 at 0825 hours, an interview and concurrent clinical record review was initiated with MDS Coordinator 1. MDS Coordinator 1 verified the behavior monitoring for Depakene was incompletely documented. 6. Clinical record review was initiated for Resident 1 on 11/30/16. Resident 1 was admitted on 8/26/15. Review of the MAR dated 10/1 through 10/31/16, showed an order for melatonin 3 mg by mouth every 24 hours as needed for supplement. The MAR showed LVN 10 administered melatonin on 10/3/16 at 2119 hours, and the medication was ineffective, and on 10/28/16 at 2131 hours, and the medication was effective. On 12/2/16 at 1600 hours, an interview and concurrent clinical record review was conducted with LVN 10. LVN 10 was asked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 81 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE why she administered melatonin to Resident 1 on 10/3/16, and 10/28/16. LVN 10 stated Resident 1 often had visual hallucinations, in which she saw cats outside in the tree, and auditory hallucinations, in which she heard children running in the hallway. LVN 10 stated she administered the melatonin to help Resident 1 sleep. LVN 10 verified the melatonin order did not indicate use for treatment of insomnia or hallucinations. LVN 10 was asked how she determined whether the melatonin was effective or ineffective. LVN 10 stated she determined melatonin's effectiveness based on whether or not Resident 1 exhibited hallucinations and/or insomnia. LVN 10 was asked to provide documentation showing melatonin's effectiveness in treating Resident 1's hallucinations and/or insomnia on 10/3 and 10/28/16. LVN 10 was unable to provide documentation showing melatonin's effectiveness in treating Resident 1's hallucinations and/or insomnia on 10/3/16, or 10/28/16.

F334 SS=D INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS CFR(s): 483.80(d)(1)(2)

F334 01/15/2017 (d) Influenza and pneumococcal immunizations (1) Influenza. The facility must develop policies and procedures to ensure that(i) Before offering the influenza immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 82 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE been immunized during this time period; (iii) The resident or the resident’s representative has the opportunity to refuse immunization; and (iv) The resident’s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident’s representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. (2) Pneumococcal disease. The facility must develop policies and procedures to ensure that(i) Before offering the pneumococcal immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident’s representative has the opportunity to refuse immunization; and (iv) The resident’s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident’s FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 83 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This REQUIREMENT is not met as evidenced by: Based on interview and clinical record review, the facility failed to ensure the flu vaccine (a vaccine which provides immunity to a variety of influenza viruses) was provided to one of 24 sampled residents (Resident 21). This had the potential for putting the resident at risk for acquiring, transmitting or experiencing complications from influenza (an acute contagious viral infection characterized by inflammation of the respiratory tract). Findings: Review of the facility's P&P titled Immunizations: Influenza (flu) Vaccination of Resident and Staff with a revised date 9/2015 showed current and newly admitted residents will be offered the influenza vaccine from October of each year through the end of March of the following year. Clinical record review for Resident 21 was initiated on 12/5/16 at 0800 hours. The MDS dated 10/7/16 showed Resident 21 had severe cognitive impairment. The History and Physical Examination form dated 11/16/16, showed resident 21 did not have the capacity to understand and make decisions. Review of Resident 21's Pneumococcal and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 84 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Influenza Immunization form showed the refusal box was checked for both the pneumonia and influenza vaccinations. There was no signature, date or time on the form. On 12/5/16 at 1227 hours, an interview and concurrent clinical record review was conducted with Social Services Manager for Resident 21. When asked who was the responsible party for Resident 21, the Social Services Manager stated Resident 21 was not able to make decisions for herself and did not have any family. Resident 21 was part of a Bioethics committee that made healthcare decisions for her. The Social Services Manager was unable to verify the annual influenza and pneumonia vaccination record was addressed by the Bioethics committee for the start of this flu season. On 12/5/16 at 1510 hours, a clinical record review and concurrent interview was conducted with LVN 13. When asked when the last time Resident 21 received an influenza vaccination, LVN 13 stated she did not know; usually the dialysis center Resident 21 went to administered the vaccinations. LVN 13 verified the Pneumococcal and Influenza Immunization form in Resident 21's clinical record was incomplete. LVN 13 was unable to provide documentation in Resident 21's clinical record showing she had received the influenza vaccination for this flu season.

F353 SS=F SUFFICIENT 24-HR NURSING STAFF PER CARE PLANS CFR(s): 483.35(a)(1)-(4)

F353 03/10/2017 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 85 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). [As linked to Facility Assessment, §483.70(e), will be implemented beginning November 28, 2017 (Phase 2)] (a) Sufficient Staff. (a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. (a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. (a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. (a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 86 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview, observation, and facility document review, the facility failed to provide sufficient nursing staff throughout the facility to attain and maintain the basic physical and psychosocial needs of each resident. The lack of sufficient staffing was voiced by multiple residents and staff and was evidenced by the workload and inability of staff to provide ADL and incontinence care to the residents in the facility. The lack of care had the potential of continent residents becoming incontinent, the development of skin irritations, pressure ulcers and/or worsening of pressure ulcers, and increasing the risk of accidents due to falls. Cross references to F241, F312, F314, and

F323. Findings: Review of the CMS 672 completed by the DON dated 11/30/16, showed the facility had a census of 157 residents, of which 153 residents needed physical assistance with their ADL and incontinence care. 1. Review of the facility's Daily Nursing Sign-In sheet for the 11-7 shift on 11/30/16, showed five CNA had called off, leaving five CNAs taking care of 157 residents throughout the facility (about 31 residents for each CNA). For the 11-7 shift on 12/10/16, there were 6 CNAs taking care of 153 residents throughout the facility (about 25 residents for each CNA). Cross reference to F312. 2. During the resident group interview on 12/1/16 at 1100 hours, Residents B, C, D, E, and 7 stated the staff did not answer the call lights in a timely manner. Residents B and D had to wait up to 25-30 minutes and had accidents in their beds. Resident C had his light turned off and had to wait over two hours FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 87 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE before he received his pain medication. Residents E and 7 stated staff took a long time to answer the call light and sometimes turned it off without addressing their needs. Cross reference to F241. 3. On 12/2/16 at 0915 hours, CNA 9 stated Resident 3 could press the call light and ask for assistance to go to the toilet but could not wait long. CNA 9 stated she was very busy helping other residents. Sometimes she helped other residents in the restroom, so she could not go to Resident 3 right away. As a result, Resident 3 would get up unassisted to go to the toilet. Cross reference to F323, example #3. 4. On 12/5/16, the 7-3 shift CNAs were assigned to care for 14-16 residents each. Two CNAs from Station C were unable to provide morning ADL and incontinence care to four residents each before 1200 noon. The DON stated the goal for the 7-3 shift was for the CNAs to be assigned 7-8 residents. Cross reference to F312. 5. On 12/12/16, four CNAs had called off for the 11-7 shift and not been replaced, leaving five CNAs assigned to care for 153 residents. Each CNA had from 29-31 residents each. CNA 11 was assigned 31 residents during the 11-7 shift and was only able to provide incontinence care one time to most of her residents. Four residents were observed to have waited over six hours before their incontinence care was provided. CNA 11 worked 7.5 hours and had approximately 25 incontinent residents and six continent residents. One hour was needed to complete the daily charting on 31 residents. CNA 11 stated it took from 10-15 minutes to clean and change most residents; it depended on the residents and what their needs were. CNA 11 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 88 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE spent 45 minutes with one resident and 20 minutes two separate times with another, leaving approximately five hours to change the remaining 23 incontinent residents one time. By taking an average of 10-15 minutes per resident, it would take between four to five hours, leaving no additional time to answer call lights, change a resident a second time, turn and reposition them, assist continent residents, and empty full linen barrels, and restock supplies. This did not take into account time needed if a fall or emergency occurred. Cross reference to F312. 6. On 12/12/16, CNA 12 was assigned to care for 30 residents from Station B during the 11-7 shift. CNA 12 stated the biggest problem was getting to the residents and meeting their needs. Cross reference to F312. 7. Resident W stated the facility was usually short-staffed. The resident stated she tried to keep her fluids down at night so she would not have to be changed very often; she did not want to lay in a wet diaper. The DON stated she did not think working with five CNAs for a census of 153 residents was a problem she needed to be notified about. The DON stated the 11-7 staff were expected to monitor for falls and check the residents every two hours. The DON stated it took five minutes to change a resident and not everyone needed to be changed during the 7.5 hour shift; they just needed to be checked. The DON stated she felt the staff would be able to provide the needed care, but it might not be timely. Cross reference to F312. 8. On 12/12/16, CNA 13 was assigned to care for 31 residents in Station C during the 11-7 shift. Twenty six of the 31 residents were incontinent and required incontinence care. CNA 13 was observed changing four FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 89 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE incontinent residents who required an average of 10 minutes each. CNA 13 stated some residents took much longer than 10 minutes to change, depending on how soiled they were and what their physical condition and cognitive status were. CNA 13 stated one of her residents took over an hour to change, which left her 6.5 hours (factoring 0.5 hours for a break) to change or assist the remaining 30 residents. CNA 13 stated she also had to answer the call lights repeatedly throughout her shift to attend to the needs of alert residents, which took away from the time she had to spend doing rounds on and changing non-alert residents. CNA 13 also had to spend time documenting care given, emptying trash and linen barrels multiple times, and performing other duties such as bathing residents. During her shift, CNA 13 also spent approximately 20 minutes assisting CNA 11 caring for heavily dependent residents. 9. On 12/13/16, CNA 14 was assigned to care for 12 residents during the 7-3 shift. CNA 14 stated today he had 12 residents but often had between 12-14 residents on an average day. CNA 14 stated he was supposed to have the day off but came in upon request. CNA 14 stated his duties included getting residents out of bed and taking them to the dining room, assisting with passing trays, assisting the residents with eating, giving showers and bed baths, and performing incontinence care. 10. On 12/13/16 at 0755 hours, CHHA 1 was observed taking a resident to the shower room. CHHA 1 later stated she worked for the hospice agency but tried to help out with showers for hospice residents more often because she felt badly for the facility's CNAs. CHHA 1 stated sometimes the 7-3 shift CNAs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 90 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were assigned to care for 18 residents. 11. On 12/13/16, CNA 9 was assigned to care for 13 residents in Station B during the 7-3 shift. CNA 9 came into work at 0810 hours because she tried to "call out" due to family problems but was told she could not do so. CNA 9 stated she worked "every day" plus two to three double shifts per week because they were often short-staffed. CNA 9 stated a staff member often called CNA 9 to come in and help when they were short-staffed. CNA 9 stated the only reason she came in extra to work is because she did not like the staff to be stressed. CNA 9 further stated she used to be assigned to care for 8-10 residents during the 7 -3 shift, but now she was assigned up to 15. When asked how long she had had a heavier assignment, she stated they had been shortstaffed for the last year. 12. On 12/13/16 at 0510 hours, the surveyors walked in to the facility. One surveyor proceeded to Station A. LVN 15 was observed checking the medications in the medication cart. LVN 15 was asked how many CNAs were at this station. LVN 15 stated they were shortstaffed and he had one CNA for this station. LVN 15 was asked how many residents in this station. LVN 15 replied 22 residents. On 12/13/16 at 0518 hours, CNA 3 was observed coming out from a resident's room. CNA 3 was asked how many residents were assigned to her. CNA 3 replied they were short-staffed. CNA 3 stated usually there were 11 to 16 residents assigned to her, but today she had all 29 residents in Station A to take care of. CNA 3 stated she had to be fast when caring for the residents. On 12/13/16 at 0521 hours, RN 3 was observed checking the IV cart. RN 3 was asked what the census was. RN 3 replied 153. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 91 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE RN 3 was asked how many CNAs working during the 11-7 shift. RN 3 replied five CNAs and one of the CNAs had been working double shifts (3-11 and 11-7 shifts) already. RN 3 was asked how many LVNs were working during the 11-7 shift. RN 3 replied four LVNs and two of the LVNs had been working double shifts too. During an interview with CNA 3 on 12/13/16 at 0549 hours, CNA 3 was asked how long it took her to change a resident's incontinence brief. CNA 3 stated if the resident was cooperative, it took around 10 minutes, but if not, she needed an extra hand and it took longer. CNA 3 stated the LVN needed to "share his hands." CNA 3 was asked how often she should change the residents' incontinence briefs. CNA 3 replied every two hours. CNA 3 was asked how many residents in Station A were incontinent. CNA 3 looked around the rooms and stated around 11 residents (around 110 minutes or almost two hours to change 11 "cooperative" residents). CNA 3 stated there were residents who went to the bathroom but required assistance to the bathroom. CNA 3 stated there was a resident who had an indwelling catheter that was required to be emptied. CNA 3 stated the call lights did not stop and pointed to a call light in one of the residents' room, "just like that." LVN 15 was observed going in the resident's room, turning the call light off, and telling the resident to wait for the CNA. CNA 3 stated she also had to throw the trash outside of the facility and empty the dirty linen carts in the basement. On 12/13/16 at 0557 hours, CNA 3 was preparing the dirty linen carts when the ambulance technicians came to pick up a resident to be taken to the dialysis center. CNA 3 assisted the ambulance technicians to prepare the resident to go to the dialysis center. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 92 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/13/16 at 0614 hours, CNA 3 was observed wheeling the dirty linen carts to the basement. On 12/13/16 at 0629 hours, CNA 3 was observed coming back to Station A and going in a resident's room with the call light on. On 12/13/16 at 0645 hours, CNA 3 was observed leaving the station and stated she had to find a maintenance staff to adjust the air conditioning thermostat. On 12/13/16 at 0657 hours, CNA 3 was observed coming back to the station with the maintenance staff. CNA 3 was asked if it was the end of her shift. CNA 3 stated she had not charted on the residents. CNA 3 was asked how long it took her to chart on her residents. CNA 3 replied with 29 residents, it was around one hour. During an interview with the DON on 12/13/16 at 1325 hours, she was asked why the 11-7 shift on 12/12/16, had only five CNAs. The DON stated three CNAs had called off sick and one CNA was suspended. The DON was asked if she was informed there were only five CNAs during the 11-7 shift on 12/12/16. The DON stated the evening RN Supervisor was responsible for replacing the CNAs who had called off. The DON was asked if the Supervisor was responsible for informing the DON. The DON replied no, because they should only call her if it was a "crisis." A telephone interview was conducted with RN 5 on 12/15/16 at 0940 hours. RN 5 was asked if she was the evening Supervisor on 12/12/16. RN 5 replied yes. RN 5 was asked why the 11 -7 shift had only five CNAs. RN 5 stated she could not remember why. RN 5 stated the 11-7 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 93 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE shift was always short-staffed because there were CNAs who constantly called off sick. RN 5 stated the other problem was that there were CNAs who were on the schedule but just did not show up and did not even call in. RN 5 stated usually, they only found out around 1115 hours or 1130 hours that there were these many CNAs working for the 11-7 shift. RN 5 stated the 11-7 Supervisor would ask the 3-11 shift staff to work double shift, and if they could not find a replacement, they divided up the residents among the CNAs available on the 117 shift. RN 5 was asked if they had registry staff that they could call. RN 5 stated they used to have a registry agency a long time ago, but currently, they did not have one. RN 5 was asked how many residents the CNAs should have been assigned to care during the 11-7 shift. RN 5 replied, on an average of 15 to 16 residents each. RN 5 was informed on 12/12/16, during the 11-7 shift, the CNAs had around 29 to 30 residents each. RN 5 replied, "that's too much." On 12/15/16 at 1139 hours, during a telephone interview with RN 5, RN 5 stated she now recalled there were two CNAs who had called off sick on 12/12/16, during the 11-7 shift and she had tried to find a replacement. RN 5 stated there were those CNAs who were on the schedule but did not show up again. 13. On 12/12/16, CNA 15 was assigned to care for 30 residents in Station B during the 117 shift. Nine of the 30 residents were incontinent and required incontinence care. CNA 15 was observed changing two residents which took approximately 30 minutes and 40 minutes each. In between changing the two residents, CNA 15 was interrupted by answering the call lights and changing the soiled linen cart. CNA 15 stated they tried to answer the call lights in between changing the residents. CNA 15 also stated it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 94 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE impossible to get to everyone on time. Cross reference to F312. 14. On 12/13/16, CNA 17 was assigned to care for 12 residents in Station B during the 7-3 shift. On 12/13/16, CNA 17 was observed attending to Resident T's pericare for the first time on her shift at 1000 hours. CNA 17 was observed on 12/13/16, between 0700 and 1000 hours doing her initial rounds, helping pass the breakfast trays, answering the call lights, and assisting Resident V with eating breakfast. CNA 17 stated it had been a few years now with staffing problems at this facility. It was hard to keep the new CNAs working here. It seemed like they would go through the training program, work a few days, then quit. 15. On 12/13/16 at 0540 hours, CNA 15 initiated incontinence care for Resident T. CNA 15 was unable to complete the pericare for Resident T until the dressing to the pressure ulcer was changed by LVN 14. CNA 15 continued to her next incontinence resident and returned to Resident T's bedside at 0620 hours to assist LVN 14 with the pressure ulcer dressing change, then to complete the pericare, change the bed linen and soiled gown, which took approximately 40 minutes to complete. An interview was conducted with CNA 15 on 12/13/16 at 0720 hours. CNA 15 was asked how often she checked on her incontinence residents. CNA 15 stated she checked and changed her residents every two hours and turned and repositioned her residents every two hours. CNA 15 stated, "I'm not going to lie, a night like tonight, it is impossible to get to everyone on time." Cross reference to F314, example #3. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 95 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 16. On 12/13/16 at 0720 hours, CNA 15 was observed providing incontinence care for Resident V. Resident V was observed to have a urine soaked incontinence brief with a soiled dressing to the coccyx area. CNA 15 agreed the dressing to the coccyx area was soaked with urine, kept the dressing in place, performed pericare for Resident V, and placed a new incontinence brief on Resident V. CNA 15 stated the dressing would be changed later today by the treatment nurse and stated the last time she checked and changed Resident V was between 0100 and 0200 hours this morning. Cross reference to F314, example #2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 96 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F356 POSTED NURSE STAFFING INFORMATION CFR(s): 483.35(g)(1)-(4)

F356 SS=C PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/15/2017 483.35 (g) Nurse Staffing Information (1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law) (C) Certified nurse aides. (iv) Resident census. (2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. (3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 97 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE community standard. (4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to prominently post the hours worked by the licensed and unlicensed nursing staff in a place which was readily accessible to residents and visitors. This had the potential of not having the information available to determine if enough staff was available to adequately care for the residents. Findings: On 12/2/16 at 0910 hours, an environmental tour of the facility was conducted. The current nurses' staffing information was not found. On 12/2/16 at 1340 hours, an interview was conducted with the DON. The DON stated the facility posted the nurses' staffing information at the entrance to the facility. The DON was subsequently asked to locate the posted nurses' staffing information. Once at the entrance to the facility, the DON verified the nurses' staffing information was not posted.

F362 SS=E SUFFICIENT DIETARY SUPPORT PERSONNEL CFR(s): 483.60(a)(3)(b)

F362 01/15/2017 (a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 98 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to ensure sufficient support personnel were available to carry out timely preparation and delivery of the dietary program. This failure had the potential to negatively affect residents who received meals prepared in the facility's kitchen. Findings: Review of the CMS 672 completed by the DON dated 11/30/16, showed 134 of the 157 residents residing in the facility received food prepared in the kitchen. Review of the facility document titled Meal Delivery Times showed the latest lunch cart was to be delivered at 1245 hours. On 12/1/16 at 1100 hours, a resident group interview was conducted. When asked about the facility's dietary service, five of 10 nonsampled residents (Residents B, J, K, L, and M) stated they were unhappy with the dietary service because their meals were often served late, especially lunch and dinner. Resident M stated he was upset because he sometimes received his lunch as late as 1315 hours. On 12/1/16 at 1200 hours, during lunch tray line observation, the Cook started plating the first food cart. The first food cart was delivered at 1225 hours to Station 1. The last tray was delivered to the resident at 1253 hours. The last food cart was delivered to Station 3 at 1315 hours, and the last tray was delivered to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 99 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident at 1335 hours. Review of the facility's record for Resident Tray Assessment performed by the RD done on 12/2/16 at 1615 hours, showed on 10/26/16, the breakfast cart was delivered to Station 1 at 0746 hours. Trays were passed to the residents starting at 0820 hours. The time the test tray was delivered to the resident was left blank. Further review of the facility's record for Resident Tray Assessment dated 11/29/16, for the dining room performed by the RD, showed the food cart was delivered to the dining room at 0833 hours, the last tray was delivered to the resident at 0846 hours. Review of the meal delivery times of the facility showed breakfast was to be delivered to Station 1 at 0715 hours, and to the dining room at 0745 hours. Lunch was to be delivered to Station 1 at 1145 hours, to Station 3 at 1245 hours, and to the dining room at 1215 hours. On 12/5/16 at 0740 hours, an interview was conducted with Dietary District Manager 2. Dietary District Manager 2 stated the facility did not have a policy for delivering meals to each station and did not have monitoring of what time meals were delivered to each station. Dietary District Manager 2 stated they tried to deliver meal carts no later than five minutes of the time schedule. During an observation on 12/1/16 at 1215 hours, in the dining room, there were 30 residents waiting for lunch. The first food cart arrived at 1255 hours, and the second food cart arrived at 1302 hours. Staff checked the carts and distributed the trays to the residents. There were three to six staff in the dining room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 100 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F371 FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/10/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, record review, and facility's P&P the facility failed to ensure sanitary conditions in the dietary services as evidenced by: * The ice machine drain pipes did not maintain an air gap (space between the water outlet and the flood level of the drain that prevents backflow of waste water from the drain) at the floor drain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 101 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE * The facility failed to ensure labels and dates opened on items being stored in the refrigerator. * The facility failed to follow the cool down procedures for potentially hazardous foods. These failures had the potential to result in foodborne and waterborne illnesses in highly susceptible resident populations. Findings: Review of the CMS 672 completed by the DON dated 11/30/16, showed 134 of the 157 residents residing in the facility received food prepared in the kitchen. 1. According to the Food and Drug Administration 2013 Food Code, for backflow prevention, an air gap between the water supply inlet (pipe inlet) and the flood level rim of the plumbing fixture or equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. The food code showed, if a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the whole system. During an observation of the ice machine located in the hallway adjacent to Station 2 on 12/2/16 at 0910 hours, two pipes draining water from the ice storage portion of the unit were observed to be located in the floor drain, below floor level. There was no air gap maintained between the pipe outlet and the flood level of the floor drain. During an observation of the ice machine located in the kitchen on 12/2/16 at 0915 hours, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 102 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a pipe draining water from the ice storage portion of the unit was observed to be located in the floor drain, below floor level. There was no air gap maintained between the pipe outlet and the flood level of the floor drain. During a concurrent interview with the Maintenance Supervisor, he acknowledged there were no air gaps maintained for the two ice machines. 2. The U.S. Department of Health and Human Services, Food Code 2001, Public Health Service, Food and Drug Administration, defined potentially hazardous foods (PHF) as any natural or synthetic food or food ingredient that supports the rapid growth of infectious or toxigenic microorganisms. The food code identifies older adults as being highly susceptible to experience food borne illness because they are immunocompromised or older adults and in a facility that provides health care or assisted living services such as a hospital or nursing home. During the initial tour of the kitchen on 11/30/16 at 1115 hours, the walk-in refrigerator was inspected with the DSS. A big jar of preserved peaches, a pan of peeled fresh cantaloupe, one large container of sour cream, one jar of sliced pickles, one container of fat free Italian dressing, and one big half and half carton of creamer did not have opened/prepared dates. The DSS was asked about the facility's policy for opened containers in the refrigerator. The DSS stated opened containers should be dated when first opened. 3. On 12/2/16 at 1015 hours, the Food Temperature Cooling Log was reviewed with the DSS and Dietary District Manager 2. Cooling down logs for the month of October and November 2016 showed temperatures on the 2nd hour were higher than 70° F on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 103 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE following days and did not show corrective actions were taken: 10/30/16 - roast turkey - 172° F 11/12/16 - roast pork - 72° F 11/17/16 - roast pork - 74° F 11/20/16 - roast turkey - 72° F 11/26/16 - roast beef - 72° F 11/30/16 - roast pork - 74° F Review of the facility's P&P for Food Handling Guidelines for Cooling (undated) showed "Potentially hazardous food shall be cooled from 135° F to 41° F or lower as measured at the center within 6 hours. First cool food from 135° F to 70° F within two hours." Food Temperature Cooling Log instructions at the bottom of the page showed for hour 2, if the temperature is above 70° F, discard the food or reheat to 165° F for 15 seconds and begin the cooling process again. Write "discard" or "reheat" in the corrective action column if the temperature does not reach 70° F or below by hour 2. When Dietary District Manager 2 was asked about the corrective actions done for the temperatures above 70° F, he verified no corrective actions were identified if taken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 104 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F372 DISPOSE GARBAGE & REFUSE PROPERLY F372 CFR(s): 483.60(i)(4) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/10/2017 (i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in three of four dumpsters. Failure of the facility to keep the garbage covered had the potential to attract pests/rodents that carried diseases. Findings: On 12/1/16 at 1019 hours, during an observation and concurrent interview with the Dietary District Manager, three of four dumpsters located outside the facility adjacent to the kitchen were each observed to have one of two lids propped open by trash bags full of garbage, preventing the lids from fully closing. The Dietary District Manager verified the findings and stated the dumpster lids should be closed at all times.

F425 SS=D PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.45(a)(b)(1)

F425 03/10/2017 (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 105 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provision of pharmacy services in the facility; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility P&P review, the facility failed to implement their P&P on the disposal/destruction of discontinued noncontrolled medications during the inspection of two medication carts (Medication Carts 1 and 2) for two of two nonsampled residents (Residents A and I). This failure had the potential for medication diversion when discontinued medications were not being accounted for. * The facility failed to dispose of Resident A's discontinued non-controlled medications from the medication cart located at Station 3. * The facility failed to dispose of Resident I's discontinued non-controlled medications from the medication cart located at Station 2. Findings: Review of the facility's P&P titled Disposal/Destruction of Expired or Discontinued Medication revised date 7/27/11, showed the following: - Facility staff should destroy and dispose of medications in accordance with facility policy and applicable law. - Once an order to discontinue a medication is received, facility staff should remove this medication from the resident's medication supply. - Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 106 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE destruction. 1. Inspection of Medication Cart 1 was conducted with LVN 3 on 12/5/16 at 0720 hours. A bubble pack (a card where medications are placed in individual clear sealed bubbles) of gabapentin (medication to prevent seizures) 300 mg capsules to give one capsule orally two times a day was found belonging to Resident A. However, the bubble pack of gabapentin showed a discontinued date of 11/28/16. LVN 3 verified the bubble pack of gabapentin 300 mg capsules was discontinued on 11/28/16 , and should have been removed from the medication cart located at Station 3. LVN 3 stated the discontinued medication should have been placed in the locked medication room for pharmacy to pick up. 2. Inspection of Medication Cart 2 was conducted with LVN 12 on 12/5/16 at 1140 hours. Bubble packs of haloperidol (antipsychotic medication) 1 mg one tablet by mouth every six hours as needed for agitation manifested by restlessness, hyoscyamine sulfate (medication for cramps and irritable bowel syndrome) sublingual 0.125 mg one tablet sublingually (underneath the tongue) every four hours as needed for excessive secretions, and prochlorperazine 10 mg, one tablet by mouth every six hours as needed for nausea and vomiting were found in the medication cart for Resident I. LVN 12 verified the medications were for Resident I. LVN 12 stated Resident I passed away on 11/26/16, and the medications should have been removed from Mediation Cart 2 after the resident had expired and placed in the medication room for pharmacy to collect. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 107 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F431 DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/10/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 108 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the proper reconciliation and storage of medications. * A tube of prescription medication was stored in a resident's bathroom which was shared by two residents. This posed the risk of other residents and visitors having access to the medication. * There were discrepancies in the reconciliation of controlled medications for one nonsampled resident (Resident J). This posed the risk for narcotic medication diversion. Findings: 1. Review of the facility's P&P titled Storage and Expiration of Medication, Biologicals, Syringes, and Needles dated 1/1/13, showed all medications and biologicals, including treatment items, should be securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. Bedside medications FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 109 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE should be stored in a locked compartment within the resident's room. Only the appropriate resident and staff should have access to open the locked compartment. Review of the facility's P&P titled Medication Brought to Facility by Resident/Family/Physician/Prescriber dated 9/1/12, showed medications from a resident's personal inventory, not ordered by the facility, should be placed in a secure location and returned to the resident's family. On 11/30/16 at 1110 hours, an initial tour of the facility was conducted with RN 1. A prescription tube of zinc oxide 40% ointment was observed on top of the toilet tank in Room I's bathroom. The prescription label on the ointment showed one of the resident's names residing in Room I, Resident O. When asked about the tube of medication, Resident O stated he received the prescription medication while residing at an acute care facility. Resident O stated he brought the prescription medication with him from the other facility and used the medication at this facility. Room I's bathroom was shared by two residents. RN 1 verified the finding and stated she did not know why the medication was inside the residents' bathroom. RN 1 stated the medication should have been kept locked in the medication cart, a physician from the facility should order the medication, and the facility was responsible to supply the medication to the resident. 2. Review of the facility's P&P titled Controlled Substance Medications revised June 2013 showed controlled substance medications are counted and reconciled at the beginning and end of each shift. Inspection of Medication Cart 1 was conducted with LVN 3 on 12/5/16 at 1225 hours. A bubble pack of hydrocodone-acetaminophen (opioid FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 110 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE analgesic) 10-325 mg for Resident J was observed to have two tablets left in the bubble pack originally containing 30 tablets. However, the dates documented on the Controlled or Antibiotic Drug Record and MAR did not reconcile. Review of Resident J's Controlled or Antibiotic Drug Record for hydrocodone-acetaminophen and the MAR was conducted on 12/5/16, and showed the following dates and times entered: - On 11/30/16 at 0100 and 0400 hours, doses of the medication were documented on the Controlled or antibiotic Drug Record but were not documented as administered on Resident J's MAR daily or PRN section. - On 12/1/16 at 0100 hours, a dose of the medication was documented on the Controlled or antibiotic Drug Record but not documented as administered on Resident J's MAR daily or PRN section. - On 12/2/16 at 0015 hours, a dose of the medication was documented as administered on the MAR, PRN section but was not documented as signed out on Resident J's Controlled or Antibiotic Drug Record. - On 12/5/16 at 0230 hours, a dose of the medication was documented on the Controlled or Antibiotic Drug Record but was not documented as administered on Resident J's MAR daily or PRN. During an interview with LVN 3 on 12/5/16 at 1225 hours, LVN 3 verified the findings.

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 01/15/2017 Facility ID: CA060000033 If continuation sheet 111 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 112 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to establish and maintain an infection control program designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's Criteria (a set of criteria for long-term care facilities to identify true infections). This had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 113 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE * Resident 4's storage cabinet contained unidentified used items. This had the potential for cross contamination. * LVN 1 failed to ensure proper hand washing was performed during wound care treatment after a soiled wound dressing was removed. This had the potential for spread of infections in the facility. Findings: 1. According to the CDC, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria. Review of the facility's P&P titled Infection Control Surveillance showed the McGeer's Criteria will be utilized to define infection surveillance activities. During an interview on 12/2/16 at 1400 hours, the DSD stated she was designated for the infection control program for the facility since October 2016. The DSD stated the facility used McGeer's Criteria for infection control surveillance. The DSD stated she documented on the Surveillance Data Collection form whenever a physician ordered an antibiotic for a resident. The DSD stated she reviewed the resident's clinical record and interviewed the nursing staff to get more information on the residents' demographics and current signs and symptoms. She stated she also reviewed the results of any cultures. Review of the monthly infection surveillance reports from June 2016 to August 2016 showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 114 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the following: - The Infection Prevention and Control Surveillance Log for June 2016 showed there were 21 Residents identified as having HAI, but there was no documented signs/symptoms and culture if the infection met McGeer's criteria. There were nine residents identified as CAI, but the signs and symptoms and cultures showed HAIs. - The Infection Prevention and Control Surveillance Log for July 2016 showed there were 16 residents identified with CAIs, but the signs and symptoms and cultures showed HAIs. There were 15 residents with no documented signs and symptoms, or cultures to show if the infection was HAIs, CAIs, and if their conditions met the McGeer's criteria. There were 19 residents identified as having HAI,s but there was no documented signs/symptoms and cultures if the infection met the McGeer ' s Criteria. - The Infection Prevention and Control Surveillance Log for August 2016 showed there were 18 residents with no documented signs and symptoms, or cultures to show if their conditions were HAIs, CAIs, , and if their conditions met the McGeer's criteria. There were 10 residents identified with CAIs, but the signs and symptoms and cultures showed they were HAIs. On 12/5/16 at 1400 hours, an interview was conducted with the DSD and the DON. The DSD and the DON were asked how many residents had been placed on antibiotics, but their conditions did not meet McGeer's Criteria for June, July, and August 2016. The DSD stated she was new and started working in October 2016. The DON stated the previous DSD represented the infections for HAIs, CAIs, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 115 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and residents in isolation. The DON was asked for the trending information to show the use of antibiotics when the residents' conditions did not meet McGeer' s Criteria. The DON was unable to answer. The DON was asked to show any documentation what the DSD reported to the infection control committee. The DON was unable to show any documentation. The DON was asked if she was aware if the surveillance log was incomplete and inaccurate. The DON stated nobody was aware of it. She did not check the surveillance log. The DSD explained in the October meeting, she only discussed the infection control statistics for September 2016 but not for August 2016 and July 2016. The DSD stated they did not discuss the trends for the use of antibiotics. 2. On 11/30/16 at 1545 hours, the storage cabinet in the room of Resident 4 close to the door was was observed with a used call light, a clean pad, briefs, used clothing, and an extension cord. LVN 7 was asked who the clothes belonged to. LVN 7 stated the clothing belong to an expired resident. On 11/30/16 at 1600 hours, an interview was conducted with CNA 4. CNA 4 was asked if the briefs and pads were used for Resident 4. CNA 4 stated yes. CNA 4 was asked why the used call light and clothing were stored with the resident's personal items. CNA 4 stated the maintenance staff just fixed the call light and put the call light there. The Maintenance Supervisor was asked if he just fixed the call light. The Maintenance Supervisor stated he did not fix anything today in the room and did not know who had put the used call light in there. The Maintenance Supervisor verified the finding. 3. On 12/1/16 at 0951 hours, a dressing change observation for Resident 6 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 116 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with LVN 1. LVN 1 was observed removing an old dressing with gloved hands soiled with pale yellow drainage from Resident 6's right foot. LVN 1 removed her gloves and donned a new pair of gloves without washing her hands. An interview was conducted with LVN 1 on 12/1/16 at 1030 hours. LVN 1 verified the findings and stated she should have washed her hands after she removed the soiled old dressing and before she donned a new pair of gloves. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 117 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F460 BEDROOMS ASSURE FULL VISUAL PRIVACY CFR(s): 483.90(e)(1)(iv)-(v)

F460 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/15/2017 (e)(1)(iv) Be designed or equipped to assure full visual privacy for each resident; (e)(1)(v) In facilities initially certified after March 31, 1992, except in private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure full visual privacy for one nonsampled resident (Resident H). The facility failed to maintain the integrity of the blinds used for Resident H's privacy. This posed the risk of violating the resident's right to privacy. Findings: During initial tour on 11/30/16 at 1110 hours, Room D was noted to have a vertical slat missing from the blinds at the sliding glass door leading to a patio and adjacent to other resident rooms. On 11/30/16 at 1555 hours, a concurrent observation and interview was conducted with LVN 11 in Room D. When the privacy curtain was pulled across the foot of Resident H's bed, the blinds were to be used as a privacy curtain for the left side of Resident H's bed. When LVN 11 was asked how Resident H maintained full visual privacy if there was a vertical slat missing in the blinds, LVN 11 stated the resident's privacy could not be maintained. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 118 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F463 RESIDENT CALL SYSTEM ROOMS/TOILET/BATH CFR(s): 483.90(g)(2)

F463 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/15/2017 (g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area (2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure the call light was accessible in two resident bathrooms in Rooms A and D. This had the potential for residents not being able to summon assistance timely during an emergency. Findings: 1. On 12/2/16 at 0920 hours, during an environmental tour of the facility, the resident bathroom in Room A was observed. The emergency call light cord was wrapped around the grab bar located on the wall adjacent to the toilet. The grab bar was approximately 34 inches from the floor. If a resident fell onto the floor, the resident might not be able to reach the call light cord to summon help. The Maintenance Supervisor verified the emergency call light cord was wrapped around the grab bar. 2. On 11/30/16 at 1100 hours, an initial tour of the facility was conducted. The resident bathroom in Room D was observed to have a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 119 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE short call light string hanging approximately 3 inches from the wall. On 11/30/16 at 1545 hours, LVN 11 verified the call light string was not long enough to hang freely to the ground. LVN 11 was asked if a resident was to fall in the bathroom, how the staff would be able to reach the emergency cord from the floor. LVN 11 acknowledged the resident would not be able to reach the cord to call for help.

F502 SS=D ADMINISTRATION CFR(s): 483.50(a)(1)

F502 01/15/2017 (a) Laboratory Services (1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. This REQUIREMENT is not met as evidenced by: Based on clinical record review and interview, the facility failed to ensure the laboratory results were obtained timely for one of 24 sampled residents (Resident 6). The facility failed to obtain the wound culture results and place them in Resident 6's clinical record for the physician to review. The laboratory study was abnormal. Failure to obtain laboratory results in a timely manner posed a risk for a delay of appropriate treatment, prevention, and care for the resident. Findings: Clinical record review for Resident 6 was initiated on 11/30/16. Resident 6 was admitted to the facility on 2/12/16, and readmitted on 11/28/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 120 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/2/16 at 1500 hours, an interview and concurrent clinical record review was conducted with LVN 12. Review of Resident 6's physician's order dated 11/8/16, showed to obtain a wound culture of the right heel wound. When LVN 12 was asked about the results of the wound culture, LVN 12 stated she would look in the closed clinical record. On 12/2/16 at 1530 hours, a follow-up interview was conducted with LVN 12. LVN 12 verified the results of wound culture test was not in the closed or current clinical records. LVN 12 stated she had called the laboratory to send a copy of the wound culture test results. LVN 12 provided a faxed copy of the wound culture results sent by the laboratory. The wound culture test results dated 11/13/16, showed the resident had an infection with Pseudomonas aerogenosa.

F517 SS=E WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 01/15/2017 The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, facility P&P review, and facility document review, the facility failed to develop a detailed written plan to address an emergency menu to specific resident populations. * The facility failed to add a substitute food for potatoes and bread. * The DSS and Dietary District Manager 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 121 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE failed to provide the information for a renal diet menu. * The facility failed to provide a dinner puree menu on the first day and a menu for the 2nd and 3rd day. These posed the risk of a lack of appropriate food items for all residents in the event of a disaster. Findings: Review of the CMS 672 completed by the DON dated 11/30/16, showed 134 of the 157 residents residing in the facility consumed food prepared in the kitchen. 1. Review of the facility's P&P for Emergency preparedness (undated) showed "It is the policy that dining services department will develop an emergency preparedness plan for providing meals for residents and staff during emergency situations that has disrupted the delivery of routine care and services." During a concurrent interview with the DSS on 12/2/16 at 1015 hours, review of the facility's emergency menu, and inspection of emergency food supply, the DSS stated the facility was allocating emergency food for 267 people, which included 100 staff and 167 residents. Review of the Disaster Diabetic and Renal Menus showed canned potatoes or bread were to be used for the noon meal and optional alternate evening meal. The DSS was asked to locate the canned potatoes and bread for the emergency food supply. The DSS stated they did not have canned potatoes and bread in their stock of emergency food. On 12/2/16 at 1030 hours, a concurrent and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 122 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review of the Disaster Diabetic and Renal menus regarding the use of potatoes and bread for lunch and alternate evening meal was conducted with Dietary District Manager 2. Dietary District Manager 2 stated the facility could use crackers instead of bread or potatoes. However, when asked where in the menu to show crackers could be used as a substitute for bread and potatoes, Dietary District Manager 2 stated they should have written crackers as a substitute for bread and potatoes. 2. Review of the Disaster Renal Menu and 3 day Emergency menu was conducted with with the DSS on 12/2/16 at 1015 hours. The DSS was asked to explain the disaster renal menu. The DSS stated he did not know the disaster menu for the renal diet and would have to ask Dietary District Manager 2. Review of the Disaster Diabetic and Renal Menus and 3 day Emergency Menu was conducted with Dietary District Manager 2 on 12/2/16 at 1025 hours. Dietary District Manager 2 was asked to explain the renal menu. Dietary District Manager 2 stated they could liberalize the diet. However, he was not able to provide the information as to how it related to the 3 day emergency menu. Dietary District Manager 2 stated he would make a menu for renal residents. 3. Review of the facility's P&P (undated) for Emergency Preparedness showed "The plan should include a 3 day menu, including texture modified therapeutic extension, for the provision of meals in the absence of power and utilities." Review of the 3 day Emergency Menu for puree diet was conducted with Dietary District Manager 2 on 12/2/16 at 1030 hours. The 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 123 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE day Emergency Menu for puree showed menus for breakfast, lunch, and evening snacks, but no dinner menu. Dietary District Manager 2 was asked about the puree diet's dinner menu for day 1 and menus for days 2 and 3. Dietary District Manager 2 stated he did not have them written.

F518 SS=D TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS CFR(s): 483.75(m)(2)

F518 01/15/2017 The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to ensure four of eight staff members (CNAs 1 and 6, RN 3, and Activity Manager) interviewed were knowledgeable of the facility's emergency or disaster procedures. This put the residents at risk of not evacuating safely during an emergency or disaster. Findings: 1. Review of the facility's P&P titled Earthquake revised June 2012 showed during a tremor, find the nearest interior wall, tuck your head to your knees, and cover your head with your arms. During an interview with CNA 1 on 12/1/16 at 0815 hours, regarding emergency procedures, CNA 1 was asked what would be the first thing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 124 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she would do if there was an earthquake. CNA 1 stated she would put the residents in a safe place. CNA 1 was asked what would be the first thing she would do while the tremors were ongoing. CNA 1 replied to evacuate the residents. 2. During an interview with RN 3 on 12/1/16 at 0645 hours, regarding the facility's emergency procedures, RN 3 was asked to open the water supply room. RN 3 tried to open a door with multiple keys but was not able to open it. When asked who else had the key on the night shift, RN 3 stated she was the only person who had the keys. At 0715 hours, the Maintenance Assistant was asked to use RN 3's keys to open the door, but he could not open it. The Maintenance Assistant used his key and was able to open the door. The Maintenance Assistant stated he would give RN 3 a new key. 3. During an interview with CNA 6 on 12/2/16 at 1500 hours, regarding the facility's emergency procedures, CNA 6 was asked to locate the emergency water shut-off valve. CNA 6 stated it was located outside, in front of Room 3. When CNA 6 went outside to locate the emergency water shut-off valve and demonstrated how to shut it off, CNA 6 was not able to confirm the location of the emergency water shut-off valve. CNA 6 was then asked to locate the emergency water supply. CNA 6 stated it was in Station 2. CNA was unable to locate the emergency water supply. 4. Review of the facility's P&P titled Water Shut-off Procedure (undated) showed the use of white and blue handle is for a back flow test. During an interview with the Activity Manager on 12/5/16 at 1100 hours, regarding the facility's emergency procedures, the Activity Manager was asked what the purpose of the blue and white handles were. The Activity Manager stated the blue and white handles FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 125 of 126 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055121 (X3) DATE SURVEY COMPLETED 12/15/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PELICAN RIDGE POST ACUTE 466 Flagship Rd Newport Beach, CA 92663 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were used to shut off the water. The Activity Manager demonstrated the blue and white handles were turned towards Room G. When asked what the yellow wrench was for, the Activity Manager stated it was not used to shut off the water. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J5PM11 Facility ID: CA060000033 If continuation sheet 126 of 126