Other·September 27, 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 an ABBREVIATED survey to investigate Complaint/Entity Reported Incident (ERI) No: CA00547804 and ERI No: CA00547808. Inspection was limited to the specific complaint and ERI investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyors 37689, HFEN; Surveyor 38489, HFEN; and Surveyor 39199, HFEN. FOR COMPLAINT/ERI No: CA 00547804, THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT/ERI ALLEGATION(S) AND FINDINGS WERE CITED AT F323. FOR ERI No: CA 00547808, THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE ERI ALLEGATION(S) WITH NO REGULATORY VIOLATION. DURING THE INVESTIGATION, THERE WAS A VIOLATION OF REGULATIONS UNRELATED TO THE COMPLAINT AND ERI ALLEGATION(S) AND FINDINGS WERE CITED AT F226. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living CNA - Certified Nursing Assistant CT scan - computerized tomography (a series of x-ray images taken from different angles using computer processing to create crossLABORATORY 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: 2QLG11 Facility ID: CA060000033 If continuation sheet 1 of 15 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 08/23/2017 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 sectional images) ED - emergency department IDT - Interdisciplinary Team LAL mattress - low air loss mattress (air-filled mattress) LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) P&P - policy and procedure RN - Registered Nurse

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

F226 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 abuse, neglect, exploitation, or the misappropriation of resident property FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 2 of 15 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 08/23/2017 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 (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility document review, the facility failed to implement their P&P and investigate an incident for one of two sampled residents (Resident 1) and one of three nonsampled residents (Resident B). * The facility failed to report and investigate an incident involving Resident B who was found lying in bed naked from the waist down with Resident 1 in Resident 1's bedroom. Failure to investigate the allegation of abuse had the potential to place vulnerable residents at increased risk of abuse and all residents not being protected against abuse. Findings: Review of the facility's P&P titled Abuse & Neglect Prohibition, under the section for Investigation showed the facility will timely conduct an investigation of any alleged abuse in accordance with the state law. Under the section for Reporting and Response, the facility will complete an incident/accident report on occurrences of abuse. The facility will report all allegations and substantiated occurrence of abuse in accordance to state law. Review of the form SOC 341 (used to report suspected adult/elder abuse) dated 8/3/17, showed Resident 1's hands were allegedly found inside Resident C's shirt touching her breasts. The SOC 341 dated 8/6/17, showed Resident 1 allegedly hit Resident A. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 3 of 15 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 08/23/2017 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 Medical Record Review for Resident 1 was initiated on 8/11/17. Resident 1 was admitted to the facility on 2/3/16, with a diagnosis of dementia. Review of the History and Physical Examination dated 2/10/17, showed Resident 1 could make his needs known but could not make medical decisions. Review of the MDS dated 5/15/17, showed Resident 1 had severe cognitive impairment. Resident 1 needed limited assistance from one person with bed mobility and transfers. Resident 1 needed supervision to limited assistance from one person with ambulation. On 8/11/17 at 0930 hours, an interview was conducted with CNA 2. CNA 2 was asked if he knew about an incident involving Resident 1. CNA 2 stated two incidents which involved Resident 1 happened on the same day. CNA 2 stated Resident 1 was found by staff with his hand inside Resident C's blouse and about 30 minutes to an hour later, Residents 1 and B were found in Resident 1's room together by themselves. CNA 2 stated he was called by CNA 10 to Resident 1's room for assistance. CNA 2 stated he saw Resident B lying on her back in Resident 1's bed without her pants and incontinence brief. CNA 2 stated Resident 1 was kneeling on the floor on the right side of the bed facing Resident B. CNA 2 stated he asked what happened. Resident B stated, "I asked him to do it." CNA 2 stated Resident B did not respond. CNA 2 stated he did not know what happened between Residents 1 and B when they were alone in the room. Medical Record Review for Resident B was initiated on 8/11/17. Resident B was admitted on 4/6/14, with a diagnosis of dementia. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 4 of 15 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 08/23/2017 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 B's History and Physical Examination dated 9/29/16, showed Resident B did not have the capacity to understand and make decisions. Review of the MDS dated 7/18/17, showed Resident B had severe cognitive impairment, needed extensive assistance from one person for bed mobility and transfers and dressing, and needed assistance to balance during transfers between the wheelchair and bed. Review of Resident B's care plan showed a care plan problem revised 7/31/17, to address the impaired cognitive function. The interventions included to cue, reorient, and supervise as needed. There was no care plan problem to show Resident B had inappropriate sexual behavior prior to the incident. Review of Resident B's Progress Notes showed an entry dated 8/3/17 at 1917 hours, Family Member 1 was made aware of the incident between Resident 1 and Resident B. An entry dated 8/8/17 at 1700 hours, showed a social services note of an IDT meeting conducted with Family Member 1 and addressed the incident between Resident 1 and Resident B. On 8/11/17 at 1030 hours, a concurrent observation and interview was conducted with Resident B. Resident B was observed sitting in her wheelchair in the activity room. When asked if she had time to talk, Resident B stated she would rather talk to someone than watch a movie and asked to be moved to a corner in the activity room. Resident B stated her name. When asked if she knew where she was, she stated this was her home. When asked if she knew what happened between her and Resident 1, Resident B frowned and stated she was upset. Resident B asked to be excused FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 5 of 15 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 08/23/2017 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 went back to watch the movie. On 8/11/17 at 1120 hours, an interview was conducted with LVN 1. LVN 1 stated LVN 6 told her about the incident between Resident 1 and Resident B. When asked if an investigation was initiated regarding the incident, LVN 1 stated it did not require an investigation since Resident B had the behavior of asking male residents to be with her. When asked if Resident 1 and Resident B had a similar incident in the past, LVN 1 stated this was the first time it happened. When asked what type of incident would require an investigation, LVN 1 stated unusual occurrences and incidents not part of routine care would be reported and investigated. When asked if this was a usual occurrence in the facility, LVN 1 stated no. LVN 1 acknowledged the incident should have been investigated. LVN 1 stated Resident 1 was transferred to a room far from Resident B's room and a location monitoring was initiated. An interview was conducted with the Administrator on 8/11/17 at 1415 hours. The Administrator stated he knew about Resident B found lying naked from the waist down in Resident 1's bed with Resident 1 kneeling on the floor at the bedside. When asked if an investigation was initiated regarding the incident, the Administrator stated an investigation was not initiated since nothing happened between Residents 1 and B. When asked how he arrived to the conclusion of nothing happened between Residents 1 and B when an investigation was not initiated, the Administrator stated the time Residents 1 and B were together in the room was too short for something to happen. When asked how he was able to say the time was too short, the Administrator did not respond. When asked if the incident was considered as a routine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 6 of 15 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 08/23/2017 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 occurrence in the facility, the Administrator stated it was not. When asked if the incident was reported as abuse, the Administrator stated Residents 1 and B had dementia. On 8/14/17 at 1540 hours, a telephone interview was conducted with LVN 6 regarding the incident between Resident 1 and Resident B. LVN 6 stated CNA 10 called her to Resident 1's room and she saw Resident 1 kneeling on the floor by the right side of the bed. LVN 6 stated Resident B was lying in Resident 1's bed naked from the waist down. LVN 6 had Resident B's incontinence brief replaced. LVN 6 stated the Administrator and the RN Supervisor were called in to Resident 1's room. When asked if Resident 1 had previous episodes of sexually inappropriate behavior, LVN 6 stated, at about 30 minutes to an hour prior to this incident, Resident 1 was observed in the hallway with his hands inside the blouse of another female resident. When asked if Resident B had previous episodes of sexually inappropriate behavior, LVN 6 stated she was not aware of any. When asked what was done to prevent a similar incident from happening, LVN 6 stated the staff was asked to keep a close watch on Resident B. When asked if this was a usual occurrence in the facility, LVN 6 stated it was not. LVN 6 stated she reported the incident to LVN 1. On 8/15/17 at 1100 hours, a telephone interview was conducted with CNA 10. CNA 10 stated, on 8/3/17, between 1300 hours, she saw Resident 1's room door was closed. CNA 10 stated he opened Resident 1's room and saw Resident 1 kneeling on the floor by the middle bed (Resident 1's bed). CNA 10 stated she saw Resident B lying on Resident 1's bed without her pants and incontinence brief. CNA 10 stated Resident 1 and Resident B were alone in the room. CNA 10 stated she called FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 7 of 15 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 08/23/2017 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 LVN 6 for assistance. CNA 10 stated Resident B's wheelchair was between two beds facing the bedside table. When asked where Resident 1's wheelchair was, CNA 10 stated it was left in the hallway by Resident B's room. When asked if Resident B was able to transfer from the wheelchair to the bed, CNA 10 stated Resident B was able to transfer only with assistance. CNA 10 stated Resident B needed extensive assistance from one person for bed mobility and transfers. When asked if Resident B was able to remove her clothing, CNA 10 stated Resident 1 would need assistance to remove her clothing. When asked if CNA 10 was aware on how much time Resident 1 and Resident B were alone in the room, CNA 10 stated she would not know since she came back from her break and noticed Resident 1's room door was closed. CNA 10 stated she did not see Resident 1 and Resident B go inside the room. When asked when was the last time she saw Resident 1 and Resident B, CNA 10 stated at 1200 hours when she asked Resident 1 to go to the lunch room. When asked if Resident 1 and Resident B had this behavior, CNA 10 stated it was the first time it happened. On 8/17/17 at 1430 hours, an interview was conducted with Family Member 1. Family Member 1 stated she was made aware of the incident where Resident B was found half naked with a male resident. Family Member 1 stated she was told by the facility staff Residents 1 and B were consenting at the time of the incident. Family Member 1 stated she did not agree Resident B gave consent since Resident B had dementia. Family Member 1 stated she had to make decisions for Resident B since the time she was diagnosed with dementia. She stated Resident B was not capable of removing her clothes and transferring to a bed without assistance. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 8 of 15 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 08/23/2017 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

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

F323 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (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 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 interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure adequate supervision was in place to prevent a fall, which resulted in injuries to one of three sampled residents (Resident 2). * Resident 2 fell to the floor while CNA 8 was providing incontinence care, sustaining a skin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 9 of 15 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 08/23/2017 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 tear to the upper lip, right frontal scalp hematoma (abnormal collection of blood outside of a blood vessel), and fracture of the left distal femoral shaft (thigh bone above the knee joint). Findings: According to the Journal of the American Geriatrics Society (June 2005), an air-filled mattress compresses on the side to which a person moves, thus raising the center of the mattress and lowering the side. This may make it easier for a resident to slide off the mattress. Precautions may include following manufacturer equipment alerts and increasing supervision. Medical record review for Resident 2 was initiated on 8/11/17. Resident 2 was admitted to the facility on 10/22/14, with diagnoses including paraplegia and contractures. Review of the History and Physical Note dated 9/28/16, showed Resident 2 did not have the capacity to understand and make decisions. Review of the Fall Risk Assessment dated 7/31/17, showed Resident 2 was assessed to be at high risk for falls. Review of Resident 2's plan of care showed a care plan problem with the initiation date of 9/28/15, to address the risk for falls. A revision to the interventions dated 5/1/17, showed two persons' assistance with transfers, bed mobility, and all ADL care, including incontinence care. Review of Resident 2's MDS dated 7/31/17, showed the resident had severe cognitive impairment and required total assistance of one to two persons for bed mobility, dressing, toilet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 10 of 15 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 08/23/2017 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 use, and personal hygiene. Review of the Order Recap Report for August 2017 showed a physician's order dated 8/4/17, for a LAL mattress for pressure ulcer prevention. Review of the Service Document from the mattress company showed the LAL mattress was ordered and delivered for Resident 2 on 8/4/17. According to the LAL mattress manufacturer's specifications regarding safety information on resident migration, specialty bed products are designed to reduce/redistribute pressure and the shearing/friction forces on the resident's skin. The risk of inadvertent bed exit may be increased due to the nature of these products. Review of the plan of care did not show a care plan problem was developed or revised to address the safety precautions for the use of the LAL mattress. Review of the Incident/Accident Report prepared by RN 1 dated 8/5/17 at 2338 hours, showed CNA 8 was providing incontinence care to Resident 2 who was turned towards her right side. Resident 2 moved her arms, rolled off the mattress, and fell to the floor. Resident 2 sustained a skin tear on her upper lip and was later found to have a bruise on the right side of her face. The form stated the incident was also witnessed by RN 1. Review of the SBAR Communication Form and Progress Note dated 8/5/17, showed RN 1 notified Resident 2's physician at 2140 hours regarding Resident 2's fall. For the entry for functional status changes (compared to baseline), N/A was checked off. The other areas not checked off included falls and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 11 of 15 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 08/23/2017 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 description of symptoms or signs. In the area for assessment by an RN, RN 1 documented the right face and upper lip small skin tears were noted. No other assessments were found. Review of the Skin - Head to Toe Skin Checks dated 8/5/17, showed Resident 2 was noted with bruises to the top of the scalp and the back of the head; and skin tears to the upper lip and face. There were no measurements included in the assessment. Review of the Progress Notes showed the following: - An entry dated 8/6/17 at 0457 hours, by RN 1 showed, "on assessment bruise on forehead & back of the head noted, ice pack with lateral position applied. continue monitoring." - An entry dated 8/6/17 at 0558 hours, by LVN 7 showed a slight bump to the right side of Resident 2's head with purple discoloration was noted. New orders were obtained from the physician for a skull x-ray; - An entry dated 8/6/17 at 1615 hours, by RN 3 showed Resident 2 was noted to be moaning and grimacing during incontinence care. CNA 7 noticed Resident 2's left leg was flaccid, which was not normal for Resident 2. The xrays were ordered and the result showed a fracture of the left distal femur. Resident 2 was transferred to the acute care hospital for further evaluation. Review of the ED record from the acute care hospital showed an x-ray of the left femur was done on 8/6/17. The result showed the following conclusions: comminuted (a break of the bone into more than two fragments), impacted (broken ends of the bone were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 12 of 15 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 08/23/2017 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 jammed together), and displaced (the bone ends were displaced from their original position) fracture of the left distal femoral shaft (thigh bone above the knee joint). Review of the ED record showed a CT scan of the brain was done on 8/6/17. The conclusion included right frontal scalp hematoma. Review of the ED history and physical examination dated 8/6/17, showed a clinical impression of a left distal femur fracture and head contusion (an accumulation of blood under the skin, usually from a blow to the head) likely secondary to fall. Review of the ADL flowsheets from 7/1 to 8/11/17, showed inconsistencies in the number of staff required to provide care for bed mobility, toileting, personal hygiene, dressing, and transfers. On 8/11/17 at 0916 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 2 had required two persons' assistance for all ADL care before the fall. On 8/11/17 at 1020 hours, an interview was conducted with LVN 3. LVN 3 stated before the fall, Resident 2 required total assistance of two persons for her ADL care since she was contracted to the both upper and lower extremities. On 8/11/17 at 1030 hours, an interview was conducted with LVN 1. LVN 1 stated she had been the unit manager on the unit where Resident 2 resided. LVN 1 stated prior to the fall, Resident 2 had required two persons' assistance with care. On 8/11/17 at 1339 hours, an interview was conducted with Resident 2's RP. Resident 2's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 13 of 15 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 08/23/2017 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 RP stated he came to visit Resident 2 every day during lunch and dinner time. Resident 2's RP stated he observed when the staff provided incontinence care, occasionally, two staff members would provide care, at times there would only be one staff person, depending on who the staff were. On 8/11/17 at 1516 hours, an interview was conducted with RN 1. RN 1 stated he witnessed Resident 2's fall on 8/5/17, at approximately 2130 hours. RN 1 also stated he saw Resident 2 roll over from the bed, hitting her left knee on the floor first, then her head hit the feeding pump pole standing next to her bed. RN 2 stated he assessed Resident 2 right away, however, did not try to assess range of motion of bilateral upper and lower extremities due to Resident 2 was contracted. On 8/11/17 at 1534 hours and 8/15/17 at 1606 hours, an interview was conducted with CNA 8. CNA 8 stated he worked the shift from 1500 to 2300 hours and was assigned to Resident 2. CNA 8 stated Resident 2 had always required one person's assistance with ADL care, including incontinence care. CNA 8 stated the only thing different that day was Resident 2's mattress was changed to a LAL from a regular mattress. CNA 8 stated before he provided incontinence care, he raised the bed up to his waist level (measured three and a half feet high) to protect himself from injury. CNA 8 turned Resident 2 to her right side, placed his left hand on Resident 2's left buttock, and wiped the buttocks with his right hand. CNA 2 stated Resident 2 made a sudden jerk, slid off the bed, and fell to the floor. CNA 8 stated he did not receive any in-service regarding the use of the LAL mattress. CNA 8 also stated he thought Resident 2 was not a fall risk because she had not had any prior falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 14 of 15 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 08/23/2017 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 8/15/17 at 1642 hours, a telephone interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she received the order for the LAL mattress on 8/4/17. When asked if the care plan was updated when Resident 2's mattress was changed to a LAL, LVN 1 stated no. LVN 1 also stated there were no new interventions implemented for the risk for falls in reference to the use of the LAL mattress. When asked if she received an in-service regarding the use of LAL mattress, LVN 1 stated no. LVN 1 also acknowledged Resident 2 required two persons' assistance and the care plan was revised on 5/1/17; however, she failed to update the ADL care plan. On 8/17/17 at 1326 hours, a telephone interview and concurrent medical record review was conducted with RN 2. RN 2 verified the inconsistencies in the number of staff support required to provide care for Resident 2 from 7/1/17 to 8/11/17. Resident 2 had required one and two persons' assistance with bed mobility, toileting, personal hygiene, dressing, and transfers. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QLG11 Facility ID: CA060000033 If continuation sheet 15 of 15