Other·May 20, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ** AMENDED ** The following reflects the findings of the California Department of Public Health during the concurrent RECERTIFICATION, RELICENSING, and ABBREVIATED surveys to investigate COMPLAINT No. CA00632468 and ERI No. CA00631139. Representing the California Department of Public Health: Surveyor 37689, HFEN; Surveyor 37726, HFEN; Surveyor 39683, HFEN; Surveyor 40431, HFEN; Surveyor 40483, HFEN; and Surveyor 35346, HFEN. FOR COMPLAINT NO. CA00632468: THE DEPARTMENT WAS UNABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION(S). FOR ERI NO. CA00631139: THE DEPARTMENT WAS UNABLE TO SUBSTANTIATE THE ERI ALLEGATION(S) AND FOUND NO VIOLATION TO THE REGULATIONS. The surveyors entered the facility on 4/7/19 at 0730 hours. The census was 119. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: bpm - beat per minute CAI - community acquired infection CDC - Centers for Disease Control and Prevention CNA - Certified Nursing Assistant cm - centimeter(s) DON - Director of Nursing DSD - Director of Staff Development HAI - healthcare associated infection 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: IKNF11 Facility ID: CA060000033 If continuation sheet 1 of 60 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 04/15/2019 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 IDT - Interdisciplinary Team IV - intravenous (administration of medications/fluids through the vein) LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) mmHg - millimeter(s) of mercury mg - milligram(s) P&P - policy and procedure PICC - peripherally inserted central catheter (used for prolonged intravenous access) PRN - as needed PT - Physical Therapy/Therapist RD - Registered Dietitian RN - Registered Nurse SSA - Social Services Assistant UTI - urinary tract infection

F550 SS=E Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 05/30/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity 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. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 2 of 60 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 04/15/2019 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 policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide care in a manner to enhance dignity for six of 24 final sampled residents (Residents 9, 38, 39, 40, 43, and 111) and three of 12 nonsampled residents (Residents 13, 46, and 51) when the staff did not respond to call lights in a timely manner. * Residents 9, 13, 38, and 46 stated they had to wait for hours to have their soiled incontinence briefs changed. * Resident 39 stated she had to sit in her wheelchair in soiled incontinence briefs and the staff would not clean her wheelchair when she asked them. * Resident 43 had to wait in the dining room for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 3 of 60 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 04/15/2019 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 his lunch tray, but staff had delivered the lunch tray to his room. * Resident 51 stated she had to wait over two hours to have her call light answered. When she complained about it to the staff, nothing was done. * Resident 111 was not provided assistance to eat her meal at the time her lunch tray was delivered to her room, while her roommate was eating his meal. * Resident 40 had to wait 45 minutes for someone to reposition him to relieve his pain in his back and hips. These failures had the potential to negatively impact the residents' feelings of self-worth and well-being. Findings: The Resident Council Meeting Minutes for 1/22, 2/19, and 3/18/19 were reviewed. The minutes showed the residents repeatedly voiced concerns with their call lights not being answered timely and staff turning off the call lights without addressing the resident's needs for three months. 1. On 4/8/19 at 0845 hours, nurses' call light system showed Resident 38's light started chiming at Station 3. At 0930 hours, Resident 38's call light was still chiming at the nurses' station. Upon entering Resident 38's room, the resident was asked if she needed anything. Resident 38 stated she needed to have her tray removed and her diaper changed. CNA 5 entered the room at this time, took the tray and asked Resident 38 what she needed. Resident 38 stated she needed her diaper changed. CNA 5 told the resident she had to take the tray FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 4 of 60 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 04/15/2019 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 get Resident 38's nurse to come and change her diaper. On 4/8/19 at 0949 hours, an interview was conducted with CNA 5 concerning the call light chiming for nearly 45 minutes . CNA 5 stated, yeah, but it was not her resident. After CNA 5 left the room, Resident 38 was asked if she had experienced a delay in call lights being answered when she needed assistance in the past. Resident 38 stated, about two days ago, when she called for assistance to change her soiled and wet diaper, CNA 1 told her she had to go and collect all the food trays first before she could come and change the resident. When asked how she was able to determine the time it took for CNA 1 to return to assist her, Resident 38 pointed at the large clock on the wall in front of her bed. When asked how this made her feel, Resident 38 stated, "Well how would anyone feel sitting in their own mess for hours at a time?" Resident 38 stated it never feels good to have to wait for someone to come and help you. On 4/8/19 at 0927 hours, an interview was conducted with CNA 6. CNA 6 confirmed Resident 38's call light had been on for over 40 minutes, because she was giving care to another resident whose room was right in front of Station 3. 2. On 4/7/19 at 0816 hours, Resident 39 was observed awake in bed. Resident 39 stated she was not doing well. When asked why she felt she was not doing well, Resident 39 stated her wheelchair was dirty. Resident 39 stated she had to ask the staff a lot of times to come and clean her wheelchair, but they don't. Resident 39 stated her family was coming to visit her today and she wanted her wheelchair FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 5 of 60 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 04/15/2019 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 be cleaned Resident 39 stated the nurses leave her in wet and soiled diapers for a long time. 3. On 4/7/19 at 0835 hours, an interview was conducted with Resident 13. Resident 13 stated her food was always cold by the time she got it and they were always late. Resident 13 stated the staff was always late about everything. Resident 13 stated the nurses did not answer the call lights and she had been left in soiled diapers during most of the nights and changed in the early mornings. Resident 13 stated it happened to her during the early morning today. Resident 13 stated she knew it was messy and time consuming to clean her up, and she knew it was a lot of work for the nurses, but it should not take them that long to come and clean her up. Resident 13 stated it always took over two to four hours waiting for the nurses to come and clean her. When asked how this made her feel, Resident 13 stated it made her very upset. Resident 13 stated this morning she was really upset with the charge nurse's response when she complained to her about the CNAs not cleaning her and answering her call light timely. Resident 13 stated the charge nurse acted as though she was not pleased with her for saying what she had. Resident 13 stated, "I don't know why, because why should I have to go through that? The nurses are supposed to be here to help take care of us." Resident 13 stated it made her feel like the staff did not care about her or the other residents because it happened a lot and no one was doing anything to solve the problem. 4. On 4/7/19 at 0906 hours, an interview was conducted with Resident 9. Resident 9 stated the nurses did not even come to turn the call lights off and did not answer them. Resident 9 stated she had been at the facility for about six FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 6 of 60 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 04/15/2019 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 months. When asked about timeliness of answering the call light, Resident 9 stated, "Are you kidding me!" Resident 9 stated it was always more than 2 hours. Resident 9 stated she was left in soiled diapers all the time, and it was always between 45 minutes to 2 hours. Resident 9 stated the clock on the wall in front of her bed was her time keeper. 5. On 4/7/19 at 1249 hours, Resident 43 was observed sitting at table 2 asking for his food in Spanish. On 4/7/19 at 1255 hours, Resident 43's tray was observed in his room. The dining room staff was asked why Resident 43 was in the dining room while his tray had been left in his room. Resident 43 was observed in the dining room for about 30 minutes before being taken back to his room for lunch. 6. On 4/7/19 at 0906 hours, Resident 51 stated she had told a social service staff member about the call light and the timeliness of the nurses answering the call lights. Resident 51 stated the social services staff member told her she would call the Ombudsman. Resident 51 stated she had not heard back from anyone. On 4/9/19 at 1220 hours, Resident 51 stated she had to wait for over two hours to have her call light answered. Resident 51 stated, "Why do they treat us like we are dirt?" On 4/9/19 at 1219 hours, an interview was conducted with the SSA. The SSA verified she had spoken with Resident 51 concerning the call lights not being answered timely. The SSA stated she had also contacted the Ombudsman. The SSA stated she had informed Resident 51 that the Ombudsman was on vacation. 7. Medical record review for Resident 111 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 7 of 60 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 04/15/2019 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 4/7/19. Resident 111 was admitted to the facility on 8/30/18. Review of the quarterly MDS dated 3/18/19, showed Resident 111 required total assistance from one person for eating. On 4/7/19 at 1219 hours, a lunch observation was conducted in Resident 111's room. Resident 111's lunch tray was observed covered on top of the over bed table next to her bed. Resident 111's roommate (Resident 2, a family member) also had his lunch tray and was observed feeding himself while laying in bed. Resident 111 was looking in Resident 2's direction and was saying "aaahhh....aaahhh..." Resident 2 stated it meant Resident 111 was hungry but had to wait for facility staff to come feed her. Resident 2 stated Resident 111 always got fed late. On 4/7/19 at 1235 hours, Resident 111's tray was still sitting on the overbed table, covered and untouched. Resident 2 was already done eating his lunch. Resident 2 stated by the time the staff got here to feed her, Resident 111 would not want to eat anymore. It had been like this all the time. On 4/7/19 at 1252 hours, CNA 1 was observed entering Resident 111's room. CNA 1 stated she had to attend to another resident so she was not able to feed Resident 111 right away. CNA 1 verified Resident 111's tray was passed more than thirty minutes ago. 8. On 4/8/19 at 0937 hours, an interview was conducted with Resident 40. Resident 40 stated on 4/6/19, he turned on his call light at 0445 hours and was not helped until 0525 hours. Resident 40 stated he was aware of the time as he had both a clock in the room and a watch. He recorded the time on a sheet of paper when he pressed the call button and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 8 of 60 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 04/15/2019 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 time in which help arrived. Resident 40 stated he needed to be repositioned, as he was in pain. He had both pain in his lower back and buttocks. He needed to be repositioned so he could get relief from the pain and return to sleep. Resident 40 stated waiting for 45 minutes while in pain for someone to answer his call light made him feel both frustrated and angry. 9. Review of Resident 46's MDS dated 1/23/19, showed the resident was cognitively intact. On 4/8/19 at 1005 hours, a resident group interview was conducted. Resident 46 stated it took 85 minutes for staff to respond to her call light. On 4/9/19 at 1604 hours, a follow-up interview was conducted with Resident 46. Resident 46 stated the other night, the resident was up in their wheelchair in soiled briefs, and wanted assistance to get back to bed and cleaned up. The resident stated she waited 85 minutes, per the resident's cell phone clock, before staff responded to the call light. The resident stated they hated sitting in soiled briefs and felt helpless.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 05/30/2019 §483.10(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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 9 of 60 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 04/15/2019 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 and interview, the facility failed to accommodate the needs of one of 24 final sampled residents (Resident 9). * The facility failed to evaluate and provide devices to assist Resident 9 with bed mobility. This failure resulted in a delay of care provided to the resident as well as the potential for the resident to feel unworthy and unimportant. Findings: On 4/7/19 at 0906 hours, Resident 9 stated she was frustrated because she had asked for side rails to help her move about in bed, but the staff did not listen. On 4/8/19 at 1225 hours, an interview was conducted with the PT. When asked if he had been to evaluate Resident 9 for an assistive device to help her turn in the bed by herself, the PT stated Resident 9 was not evaluated for an assistive device to the bed because he had not been sent an order to do so. On 4/10/19 at 0841 hours, Resident 9 was observed awake in bed. When asked if she had an opportunity to speak with someone concerning the assistive rails for turning in the bed, Resident 9 stated she did about two days ago. Resident 9 stated two men came to talk to her about assistive bed rails. Resident 9 stated she would like to have them so she could turn herself in bed sometimes.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 05/30/2019 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 10 of 60 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 04/15/2019 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; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 11 of 60 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 04/15/2019 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 policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to notify the physician timely of an injury for one of 12 nonsampled residents (Resident 46). This had the potential to delay assessment, monitoring and treatment of the resident's injury. Findings: Review of the facility's P&P titled Incident/Accident Reporting for Residents dated February 2017 showed all incidents, accidents, and unusual occurrences involving a resident are investigated, documented and reported in accordance with Federal and State law. Definitions of incidents, accidents, and unusual occurrences include any event not consistent with routine resident care, any event involving a resident with a negative result or outcome. The Administrator, DON, or designee will notify the physician and family or the resident's legal representative of incidents as required. Review of Resident 46's medical record was initiated on 4/7/19. Resident 46 was admitted to the facility on 10/19/18. On 4/8/19 at 1002 hours, during a resident group interview, Resident 46 was observed with multiple red discolorations to her right lateral arm. Resident 46 stated she was trying to get out of bed and hit her arm on her O-ring (circular attachment on each side the bed to aid with mobility and repositioning). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 12 of 60 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 04/15/2019 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 an SBAR (Situation, Background, Assessment, and Recommendation) Communication Form and Progress Note dated 4/9/19, showed Resident 46 had a skin discoloration to the right elbow area. The note showed the Nurse Practitioner (on call for the physician) was notified on 4/9/19 at 2120 hours. Review of the Skin- Head to Toe Skin Checks form dated 4/10/19, showed the resident had multiple scattered, irregularly shaped skin discolorations to the right anterior elbow. It showed the largest discoloration was approximately 3 cm x 0.75 cm. On 4/9/19 at 1604 hours, a follow-up interview was conducted with Resident 46. Resident 46 stated when she noticed the bruises, she notified her CNA. Resident 46 stated she notified PT 1 the next day. On 4/10/19 at 0912 hours, an interview was conducted with PT 1. PT 1 stated he saw Resident 46 in passing in the hallway and observed her skin discolorations to her right arm. PT 1 stated the resident said the injury occurred when she was getting out of bed and hit her arm on the O-ring. When asked when PT 1 saw the discolorations, he stated last week, but could not recall the date. PT 1 stated it was not in his documentation as it was not observed during a treatment. When PT 1 was asked if he notified anyone regarding the resident's discolorations, PT 1 stated he did not because the resident informed him she had already told their nurse. On 4/10/19 at 1101 hours, a follow-up interview was conducted with PT 1. PT 1 stated they reviewed their notes, and based on the dates he treated the resident, he observed Resident 46's discolorations on 4/4/19, while briefly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 13 of 60 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 04/15/2019 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 speaking with Resident 46 in the hallway. On 4/11/19 at 0907 hours, the DON stated facility staff should notify a resident's nurse of any injury, regardless if the resident stated they already notified someone. Staff should verify with the nurse to ensure they were informed. The DON stated it was better to overcommunicate. The DON stated she was not aware Resident 46 had notified the staff of her injury prior to 4/9/19.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 05/30/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure the MDSs were accurate for two of 24 final sampled residents (Residents 111 and 43) and one of five unnecessary medication sampled residents (Resident 4). * The facility failed accurately code Resident 111's fall in the facility. * The facility failed to accurately code the number of falls sustained by Resident 43 in the facility. * The facility failed to accurately code antipsychotic medication use on two of Resident 4's MDS assessments. These failures posed the risk of the residents not receiving individualized plans of care based on their specific needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 14 of 60 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 04/15/2019 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. Medical record review for Resident 111 was initiated on 4/7/19. Resident 111 was admitted to the facility on 8/30/18. Review of the plan of care showed a care plan problem was developed to address Resident 111's actual fall from bed with a skin tear to the right elbow on 9/14/18. Review of Resident 111's quarterly MDS dated 12/13/18, showed Section J1700 (fall history on admission or reentry) was coded zero (showing the resident did not have any falls since reentry or the prior assessment). On 4/10/19 at 1248 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator reviewed Resident 111's medical record and verified Resident 111 had a fall on 9/14/18. The MDS Coordinator stated the fall should have been coded in the quarterly MDS dated 12/13/18. 2. Medical record review for Resident 43 was initiated on 4/7/19. Resident 43 was admitted to the facility on 4/18/18, and was readmitted on 10/27/18. Review of the Interdisciplinary Post Fall Reviews dated 11/13, 11/23, and 12/6/18, showed Resident 43 had three falls. Review of the quarterly MDS dated 2/3/19, showed Section J1900 (number of falls since reentry or prior assessment) was coded one on Subsection A (showing the resident had one fall with no evidence of injury since reentry or prior assessment). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 15 of 60 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 04/15/2019 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 4/15/19 at 1634 hours, an interview was conducted with the MDS Director. The MDS Director was informed and verified the above findings. 3. Medical record review for Resident 4 was initiated on 4/15/19. Resident 4 was readmitted to the facility on 6/22/19. Review of Resident 4's Order Summary Report showed a physician's order dated 5/26/18, for Rexulti (an antipsychotic medication). a. Review of Resident 4's MDS dated 3/16/19, showed under the section, Medication Received, showed Resident 4 did not receive any antipsychotic medications during the seven day look back period (3/10/19-3/16/19). Under the section Antipsychotic Medication Review, did the resident received any antipsychotic medications since the prior assessment, the section was coded to show Resident 4 did not receive any antipsychotic medication. Review of the resident's Medication Administration Record for March 2019 showed the resident received all scheduled daily doses of Rexulti, including the seven days of the look back period. On 4/15/19 at 0959 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator reviewed Resident 4's Medication Administration Record for March 2019 and verified the MDS was coded incorrectly. b. Review of Resident 4's MDS dated 12/14/18, showed, under the section for Medication Received showed Resident 4 received antispychotic medication all seven days of the seven day look back period (12/8/19-12/14/19). Under the section, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 16 of 60 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 04/15/2019 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 Antipsychotic Medication Review, did the resident receive antipsychotic medications since admission/entry or reentry or the prior assessment, the section was coded to show the resident did not receive antipsychotic medication. Review of Resident 4's Medication Administration Record for December 2018 showed the resident received all scheduled daily doses of Rexulti. On 4/15/19 at 0959 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator reviewed Resident 4's Medication Administration Record for December 2018 and verified the MDS was coded incorrectly.

F684 SS=D Quality of Care CFR(s): 483.25

F684 05/30/2019 § 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 of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure appropriate services was provided to one of 24 final sampled residents (Resident 111). * The facility failed to follow the physician's order in the administration of Resident 111's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 17 of 60 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 04/15/2019 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 anithypertensive medication. The medication was held even though the blood pressure was within the parameters prescribed by the physician. This had the potential for Resident 111's blood pressure to be out of range. Findings: Medical record review for Resident 111 was initiated on 4/7/19. Resident 111 was admitted to the facility on 8/30/18. Review of the Order Summary Report showed a physician's order dated 8/31/18, to administer metoprolol tartrate (blood pressure medication) 25 mg, give one tablet by mouth two times a day for hypertension and hold for SBP (systolic blood pressure, the upper reading of the blood pressure) below 100 mmHg or pulse less than 55 bpm. Review of the Medication Administration Record for April 2019 showed metoprolol was scheduled to be given daily at 0900 and 1700 hours and the following was identified: - On 4/4/19 at 0900 hours, Resident 111's SBP was 103 mmHg and the pulse was 58 bpm; however, the metoprolol was not given. - On 4/5/19 at 1700 hours, Resident 111's SBP was 106 mmHg and the pulse was 62 bpm; however, the metoprolol was not given. - On 4/6/19 at 0900 hours, Resident 111's SBP was 106 mmHg and the pulse was 62 bpm; however, the metoprolol was not given. The documentation showed the metoprolol was not given because the vital signs were outside administration parameters. On 4/10/19 at 1054 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified the metoprolol should have been given because FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 18 of 60 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 04/15/2019 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 111's SBP and pulse were within the parameters prescribed by the physician.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/30/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 24 final sampled residents (Resident 84) was free from accident hazards. * The front wheel of Resident 84's wheelchair slid into an uncovered drain on the smoking patio while she was self-propelling towards the covered area of the smoking patio. As a result, Resident 84 fell onto the ground and sustained a fracture to the left proximal femur (the thigh bone above the knee joint) and underwent a surgical procedure to repair the fracture. Findings: On 4/7/19 at 0844 hours, an interview was conducted with Resident 84. Resident 84 stated she sustained a fall and fracture while in the facility. Resident 84 stated she went out to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 19 of 60 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 04/15/2019 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 smoking patio to smoke when the front wheel of her wheelchair got caught in a drainage hole that was not covered. Resident 84 stated her wheelchair tipped over and she fell out of the wheelchair. She sustained a fracture to her left hip and had surgery to fix it. Medical record review for Resident 84 was initiated on 4/7/19. Resident 84 was admitted to the facility on 11/9/18, and was readmitted on 2/15/19. Review of the Significant Change MDS dated 2/22/19, showed Resident 84 was cognitively intact. Review of the Fall Risk Assessment dated 12/10/18, showed Resident 84 was a high risk for falls. Review of the Safe Smoking Evaluation dated 11/15/18, showed Resident 8 was determined a safe smoker and did not require supervision while smoking. Review of the Documentation Survey Report v2 (CNA's ADL flowsheet) for the month of January 2019 showed inconsistencies in the assistance provided and number of person(s) required to assist Resident 84 with locomotion off the unit (how the resident moved to and returned from off-unit locations). However, on 2/1 and 2/2/19, for the 0700 to 1500 hours shift, documentation showed Resident 84 was totally dependent on one person's physical assistance for locomotion off the unit. Review of the Maintenance Issues log for Station 2 from January 2019 to present failed to show any maintenance issues reported regarding the smoking patio. Review of the SBAR Communication Form and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 20 of 60 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 04/15/2019 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 Progress Note dated 2/2/19, showed LVN 1 notified Resident 84's physician at 1220 hours regarding Resident 84's fall and complaint of left hip pain. Resident 84 was found lying on her left side on the smoking patio with her wheelchair beside her. Review of the Progress Notes showed an entry dated 2/2/19 at 1230 hours, by LVN 2, at approximately 1150 hours, showed Resident 84 went out to the smoking patio while it was raining. Resident 84 stated she was "...going toward the wall furthest from entrance to smoking patio to be away from rain." Resident 84's wheelchair slid into the drain and fell to the side. Resident 84 was found lying on her left side next to her wheelchair. Resident 84 complained of left hip pain 8 out of 10 (on a pain scale of 0 to 10 with 0 = no pain and 10 = severe pain). Review of the Radiology Report showed an xray of the left hip was done on 2/2/19. The result showed a non-displaced fracture (alignment of the fractured bone) of the left proximal femur. Review of the Pain Evaluation on 2/2/19 at 1245 hours, showed Resident 84 experienced sharp, aching pain 7 out of 10 (severe pain) to the left hip almost constantly due to the fracture of the left hip status post fall. Review of the Medication Administration Record dated 2/2/19, showed Resident 84 was administered the following PRN (as needed) pain medications due to left hip pain: - At 1200 hours, Percocet (a narcotic pain medication) 10-325 mg one tablet by mouth for pain 8 out of 10. - At 1230 hours, tramadol hydrochloride (a narcotic pain medication) 50 mg one tablet by mouth for pain 8 out of 10. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 21 of 60 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 04/15/2019 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 - At 1600 hours, Percocet 10-325 mg one tablet by mouth for pain 6 out of 10. Further review of the Progress Notes showed the following: - An entry dated 2/2/19 at 1700 hours, by LVN 1 showed Resident 84 was transferred to the general acute care hospital. Resident 84 complained of pain 6 out of 10 to the left hip at 1600 hours and was given PRN Percocet "...with little relief noted." - An entry dated 2/4/19 at 1849 hours, by RN 3 showed Resident 84 was readmitted back to the facility from the general acute care hospital status post left hip ORIF (open reduction internal fixation - a type of surgery to fix broken bones where bones are held together with hardware like metal pins, plates, rods, or screws). Review of the Medication Administration Record for February 2019 showed on 2/5/19, Resident 84 was administered PRN Percocet 10-325 mg one tablet for breakthrough pain of 7-8 out of 10 at 0144, 0700, 1103, 1609, and 2300 hours. On 4/8/19 at 1230 hours, an observation and concurrent interview were conducted with Residents 84 and 40. Both residents were observed sitting in their wheelchairs on the smoking patio. There was no staff member present. Resident 40 stated he witnessed Resident 84's fall on 2/2/19, and screamed for help. Resident 40 stated at the time of the fall, it was starting to drizzle. He and another resident (Resident 106) were on the smoking patio by the left side under the overhang. Resident 40 saw Resident 84 wheeling herself towards the right side of the smoking patio under the overhang (covered area), heading FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 22 of 60 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 04/15/2019 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 towards the umbrella located at the middle back portion of the smoking patio. Resident 84 stated by the time she got under the umbrella, the front wheel of her wheelchair got caught in the drainage hole, tipped over, and she fell out of her wheelchair. Residents 40 and 84 stated there were no warning signs nor any precautions regarding the uncovered drain hole. On 4/8/19 at 1547 hours and 4/9/19 at 0806 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the drain on the smoking patio was covered by a metal drain cover (grate). The metal cover was heavy and one had to intentionally pick it up in order to remove it. The metal cover was heavy enough not to move by itself. The Maintenance Supervisor measured the uncovered drain as 7.5 inches in diameter and 29 inches deep. The width of the overhang surrounding the patio was 36 inches. The size of the smoking patio was 19 feet x 24 feet. The Maintenance Supervisor stated when it rained, the residents had to go under the overhang in order to get to the umbrella, which was the residents' only protection from the rain on the smoking patio. The drain was located beneath the umbrella. The Maintenance Supervisor stated he was not aware the drain on the smoking patio was not covered on 2/2/19, and nobody informed him about this. On 4/9/19 at 0806 hours, an interview was conducted with the Case Manager. The Case Manager stated she was the Manager On Duty (MOD) on 2/2/19. When she learned of Resident 84's fall, the Case Manager stated she interviewed the Maintenance Assistant and was told he removed the drain cover earlier that morning because there was debris and stuff inside the drain, to prevent flooding since they were expecting rain that day. The Case FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 23 of 60 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 04/15/2019 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 Manager stated there were no precaution signs placed near the uncovered drain to alert the residents. On 4/9/19 at 0824 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 84's routine was to get out of bed to her wheelchair at around 1130 hours every day. Resident 84 then self-propelled to the smoking patio to smoke. "...all the time, that's her routine." CNA 1 stated Resident 84 went out to smoke by herself as she normally did on 2/2/19; the only difference was, it was raining that day. However, Resident 84 had been smoking outside when it was raining, that was not the first time Resident 84 went out to smoke when it was raining. On 4/9/19 at 0859 hours, an interview was conducted with the Maintenance Assistant. The Maintenance Assistant stated the facility had issues with flooding when it rained. However, on 2/2/19, the Maintenance Assistant stated he went to the smoking patio in the morning around 0755 hours, but did not check the drain. The last time he checked the drain was on Friday (2/1/19) and it was covered. The Maintenance Assistant stated he went out to the smoking patio again after he learned Resident 84 had a fall and found the drain uncovered; the metal cover was sitting on top of the trash can by the door. The Maintenance Assistant acknowledged there were no precautions nor warning signs provided to alert the residents of the uncovered drain and the drain was located under the umbrella used to protect the residents from the rain. The Maintenance Assistant stated he was supposed to check all the drains in the facility because they were expecting rain, but he only checked the drains outside. The Maintenance Assistant measured the front wheel of Resident 84's wheelchair at 7 inches in diameter. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 24 of 60 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 04/15/2019 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 4/9/19 at 0923 hours, an interview was conducted with CNA 2. CNA 2 stated when Resident 84 fell on 2/2/19, it was raining "...but not too hard." CNA 2 stated there were no instructions provided to the CNAs nor the residents not to smoke on the smoking patio when it rained. On 4/9/19 at 0935 hours, an interview was conducted with Resident 106. Resident 106 stated he and Resident 40 were on the smoking patio when Resident 84 fell on 2/2/19. Resident 106 stated there were no instructions from facility staff not to go out to the smoking patio when it rained. On 4/9/19 at 0957 hours, a telephone interview was conducted with LVN 1. LVN 1 stated she was at her medication cart when she saw Resident 84 propelling in her wheelchair on 2/2/19. LVN 1 stated she did not say anything to Resident 84. LVN 1 stated she knew where Resident 84 was going. Resident 84 was going out to smoke, which she did every day. When it was raining in the past, the residents went out to the smoking patio to smoke. The smoking patio was the only designated smoking area in the facility. LVN 1 stated the maintenance staff did not inform the nursing staff the drain was not covered, so no precautions or warnings were given to the residents. On 4/9/19 at 1150 hours, an interview was conducted with LVN 7. LVN 7 stated a few minutes prior to Resident 84's fall, she saw Resident 84 wheeling herself out to the smoking patio. It was not raining at that time, it was starting to drizzle. LVN 7 stated there were no instructions not to let residents out because it was raining. When asked if they checked the smoking patio to ensure the residents safety, LVN 7 stated she never went FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 25 of 60 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 04/15/2019 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 outside to the smoking patio to check. On 4/9/19 at 1401 hours, an interview and concurrent facility document review was conducted with LVN 8. LVN 8 stated each nurses' station had a maintenance binder where they logged any maintenance issues. LVN 8 reviewed the log and verified there were no maintenance issues concerning the smoking patio in the log from January 2019 to present. On 4/9/19 at 1604 hours, an interview was conducted with RN 5. RN 5 stated there were no routine safety checks conducted on the smoking patio even when it rained. The residents went in and out of the patio unsupervised. RN 5 stated the smoking patio could get flooded when it rained. On 4/10/19 at 0807 hours, an interview was conducted with the OT. The OT stated he evaluated Resident 84 on 2/5/19, and provided therapy until 2/12/19. The OT stated Resident 84 was functionally the same; however, Resident 84 was very lethargic and was in a lot of pain. When asked if the fall and fracture had affected Resident 84's therapy, the OT stated it did affect Resident 84's overall drive and motivation. On 4/11/19 at 0920 hours, an interview was conducted with LVN 9. LVN 9 stated they did not conduct routine checks of the smoking patio and she would assume the Maintenance Department was responsible for checking. On 4/11/19 at 0954 hours, an interview was conducted with LVN 3. LVN 3 stated residents smoked on the smoking patio even when it rained. LVN 3 stated the smoking patio could get flooded when it rained. LVN 3 stated they did not conduct safety checks of the smoking patio on a routine basis, even when it rained. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 26 of 60 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 04/15/2019 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 3 stated she had not seen Resident 84 attend group activities. Resident 84 socialized with other residents when smoking. On 4/11/19 at 1358 hours, a follow-up interview was conducted with Resident 84. Resident 84 stated the day she fell, there were no instructions from the staff not to smoke on the smoking patio. There were no warning signs nor precautions to avoid the uncovered drain. When asked how the fall and the fracture affected her, Resident 84 stated, before the fall, she experienced generalized muscle pain, now, she experienced dull and throbbing pain to her left thigh. "...I did not have this pain before." Resident 84 stated her fall could have been avoided if the facility staff were working on something they could have placed a "...yellow tape" to alert the residents. Resident 84 stated they were under the impression that everything was fixed after the flood. Resident 84 stated her activity and only form of socialization in this place was smoking.

F694 SS=D Parenteral/IV Fluids CFR(s): 483.25(h)

F694 06/30/2019 § 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to properly maintain and assess the midline catheters (PICC) for two of two residents with midline catheters (Residents 6 and 82). This had the potential to put the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 27 of 60 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 04/15/2019 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 at an increased risk of infection and to cause a delay in identifying signs of a catheter acquired venous thrombosis (a blood clot formed in a vein). Findings: Review of the facility's P&P titled Midline Catheter Dressing Change revised 7/1/12, provided by the pharmacy, showed sterile dressing changes are to be completed 24 hours post-insertion or upon admission and at least weekly. The length of the external catheter is obtained 24 hours post insertion or upon admission and during dressing changes. The arm circumference 10 cm above he antecubital fossa (bend in the elbow) is to be obtained upon admission if no insertion measurement is available, then weekly. Compare the baseline measurement to detect possible catheter-associated venous thrombosis; a 3 cm increase in arm circumference and edema were associated with upper-arm deep vein thrombosis. 1. Medical record review for Resident 82 was initiated on 4/7/19. Resident 82 was readmitted to the facility 3/5/19. Review of the Nursing Admission Data Collection dated 3/5/19, showed Resident 82 had a midline (used for intravenous access)/PICC to the right upper extremity. Review of Resident 82's Order Summary Report dated 4/8/19, showed a physician's order dated 4/7/19, to change the midline dressing every Sunday and as needed. On 4/7/19 at 1121 hours, resident 82 was observed in bed with a dressing dated 3/30/19, covering a vascular access device on the right bicep area. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 28 of 60 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 04/15/2019 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 4/7/19 at 1131 hours, an interview and observation was conducted with RN 4. RN 4 verified Resident 82's midline catheter dressing was dated 3/30/19. RN 4 stated dressing changes were completed every Sunday. When informed 3/30/19, was a Saturday, RN 4 verified the dressing should have been changed on 4/6/19. On 4/9/19 at 1419 hours, and interview and concurrent medical record review was conducted with RN 6. RN 6 was unable to find any documentation in Resident 82's medical record to show the facility took measurements of the resident's right upper arm circumference and/or the midline catheter external length. RN 6 was unable to find any documentation to show the midline dressing was changed prior to 4/7/19. 2. Medical record review for Resident 6 was initiated on 4/7/19. Resident 6 was readmitted to the facility on 4/1/19. Review of Resident 6's Nursing Admission Data Collection dated 4/1/19, showed Resident 6 had a midline/PICC catheter to the left upper extremity. Review of Resident 6's Order Summary Report dated 4/8/19, showed a physician's order dated 4/7/19, to change the midline dressing every Sunday and as needed. On 4/7/19 at 0831 hours, an interview and concurrent observation of Resident 6 was conducted with RN 4. RN 4 stated midline dressing changes were completed once a week, usually on a Sunday. RN 4 stated he did not look at Resident 6's dressing yesterday, since he worked the 3-11 shift. RN 4 looked at Resident 6's midline dressing, and stated it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 29 of 60 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 04/15/2019 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 type of catheter which required a dressing change every 30 days. On 4/7/19 at 1131 hours, a follow up interview was conducted with RN 4. RN stated he was incorrect in the earlier interview; Resident 6's midline dressing was to be changed every 7 days. On 4/9/19 at 1400 hours, an interview and concurrent medical record review was conducted with RN 6. RN 6 stated midline catheter dressing changes were to be completed within 24 hours of admission, then every 7 days and as needed. RN 6 was unable to find any documentation in Resident 6's medical record to show the facility took measurements of Resident 6's right upper arm circumference and/or the midline catheter external length. RN 6 stated the arm circumference and external catheter length should have been completed every dressing change and documented in the Progress Notes. RN 6 was unable to find any documentation to show midline dressing changes prior to 4/7/19. RN 6 verified she was unable to find documentation to show any arm circumference and/or external catheter length measurements were completed. RN 6 stated, until she was inserviced on 4/3/19, she thought the protocol was to change the dressing every Sunday, and was not aware measurements were required.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 06/30/2019 §483.25(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' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 30 of 60 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 04/15/2019 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 goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to provide appropriate pain management for two of 24 final sampled residents (Residents 84 and 43). * The facility failed to ensure Resident 84 had PRN pain medication to manage moderate pain. As a result, the licensed nurses administered pain medication prescribed to treat severe pain to manage moderate pain. * The facility failed to ensure there was a parameter when to administer the PRN Norco (a narcotic pain medication) to Resident 43. These failures had the potential to cause the residents unnecessary pain and the risk for the residents to receive unnecessary pain medication. Findings: 1. Medical record review for Resident 84 was initiated on 4/7/19. Resident 84 was admitted to the facility on 11/9/18, and was readmitted on 2/15/19. Review of the Order Summary Report showed the following physician orders dated 2/15/19: - tramadol hydrochloride (a narcotic pain medication) one tablet by mouth every six hours as needed for mild pain (1-3) on a pain scale of 0 to 10 with 0 = no pain and 10 = severe pain; and - Percocet (a narcotic pain medication) 10-325 mg one tablet by mouth every four hours as needed for severe pain (6-10). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 31 of 60 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 04/15/2019 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 There was no pain management for moderate pain or pain level of 4-5. Review of the Medication Administration Record for March 2019 showed Resident 84 was administered the PRN Percocet for a pain level of 5. For example, on 3/23/19 at 2247 hours, and 3/24/19 at 2230 hours, Resident 84 was administered the Percocet tablet for a pain level of 5. On 4/11/19 at 0920 hours, an interview and concurrent medical record review was conducted with LVN 9. When asked what to administer if Resident 84 complained of pain on the scale of 4-5 out of 10, LVN 9 stated she would administer the PRN Percocet. LVN 9 reviewed the Medication Administration Record for the months of February and March 2019 and verified the above findings. LVN 9 stated the order should have been clarified with the physician. On 4/11/19 at 0940 hours, an interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant verified there was no PRN pain medication ordered to manage Resident 84's moderate pain. The Pharmacy Consultant stated this needed to be clarified with the physician. 2. Medical record review for Resident 43 was initiated on 4/7/19. Resident 43 was admitted to the facility on 10/27/18. Review of the Order Summary Report showed a physician's order dated 3/26/19, for Norco tablet 5-325 mg one tablet by mouth every 12 hours as needed for pain. There was no parameter for what pain level to administer the Norco. On 4/15/19 at 0816 hours, an interview and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 32 of 60 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 04/15/2019 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 concurrent medical record review was conducted with LVN 3. LVN 3 verified above findings and stated the order needed to be clarified with the physician.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 06/30/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(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. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 33 of 60 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 04/15/2019 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 Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide pharmacy services for two of 12 nonsampled residents (Residents 23 and 62). * The facility failed to administer Resident 23's medications after returning from the hospital. * The facility failed to remove Resident 62's discontinued controlled medication per policy. Findings: Review of the facility's P&P titled Medication Administration revised dated June 2008 showed to administer medications within 60 minutes of the scheduled time. The facility P&P titled Disposal/Destruction of Expired or Discontinued Medications revised date 7/18/17, showed, once a medication is discontinued, facility staff should remove the medication from the resident's medication supply. All discontinued medications should be placed in a designated secure location which is solely for discontinued medications. 1. Review of the facility's Record of Product Destruction dated 4/8/19, showed Resident 23's medications were destroyed, including: - carvedilol (a medication used to treat high blood pressure and heart failure) 12.5 mg tablets; - trazadone (an antidepressant) 50 mg tablets; and - gabapentin (a medication for nerve pain). Medical record review for Resident 23 was initiated on 4/8/19. Resident 23 was admitted to the facility on 3/31/17. A physician's order dated 4/7/19, showed an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 34 of 60 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 04/15/2019 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 order for Resident 23 to be transferred to the acute care hospital ED. Review of the History & Physical examination from the acute care hospital showed Resident 23 was admitted to the acute care hospital on 4/7/19, with the diagnoses of UTI and sepsis. On 4/10/19 at 1636 hours, Resident 23 was observed in her room, laying back on a transport gurney. The resident's family members and facility staff were talking in the hallway. Review of Resident 23's Progress Notes showed an entry dated 4/10/19 at 1834 hours, showing Resident 23 returned to the facility at 1700 hours. Review of Resident 23's Order Summary Report dated 4/11/19, showed the following medication orders dated 4/10/19: - cephalexin (an antibiotic) 500 mg two times a day for four days - carvedilol 12.5 mg two times a day. - trazadone 50 mg, one tablet at bedtime. - gabapentin 100 mg two times a day. Review of the Medication Administration Record for April 2019 showed the cephalexin, carvedilol, and gabapentin were scheduled to be administered at 1700 hours, and the trazadone was scheduled to be administered at 2100 hours. However, the Medication Administration Record showed Resident 23 was not administered the medications on 4/10/1/9. On 4/11/19 at 1346 hours, an interview and observation was conducted with LVN 9. LVN 9 stated the process for discontinued medications was to remove the medications from the cart and place in the locked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 35 of 60 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 04/15/2019 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 discontinued medication cabinet in the medication room until they are destroyed. LVN 9 stated Resident 23's medications were delivered in the morning and were not available to administer last night. LVN 9 removed the Emergency Medication Supply kits from the medication room cabinet and verified the cephalexin was available in the kit. On 4/11/19 at 1517 hours, in interview was conducted with LVN 5. LVN verified she was the medication nurse when Resident 23 returned to the facility. LVN 5 stated she did not administer any medications to Resident 23 on 4/10/19, and they were not available from the pharmacy. When asked if she administered the resident's antibiotic, LVN 5 stated she wasn't aware there was an antibiotic order. On 4/11/19 at 1524 hours, an interview and facility record review was conducted with the DON. The DON stated, when a resident is transferred to the hospital, and is expected to return, the medications are rubber banded together and left in the medication cart, to be available when the resident returns. If the resident has not returned after seven days, the medications are placed in the discontinued medication cabinet to be destroyed. The DON verified Resident 23's medications were destroyed on 4/8/19, resulting in the medications not being available to administer when the resident returned to the facility on 4/10/19. 2. Medical record review for Resident 62 was initiated on 4/10/19. Resident 62 was admitted to the facility on 2/8/18. Review of the Order Summary Report dated 4/10/19, did not show an active order for Ativan (a controlled medication used to treat anxiety). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 36 of 60 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 04/15/2019 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 Audit Report dated 4/10/19, showed a completed order for Ativan 0.5 mg dated 3/9/19, with a duration of 14 days (to stop after 3/22/19). Review of the Controlled or Antibiotic Drug Record for the Ativan 0.5 mg tablets showed the following: - On 3/24/19 at 0100 hours, a dose was documented as removed from the bubble pack and co-signed as wasted. - On 3/30/19 at 2200 hours, a dose was documented as removed from the bubble pack. - On 4/5/19 at 1600 hours, a dose was documented as removed from the bubble pack. - On 4/6/19 at 0900 hours, a dose was documented as removed from the bubble pack. On 4/10/19 at 1115 hours, an observation of Medication Cart 2 was conducted with LVN 6. Inside the controlled medication drawer was a bubble pack with nine tablets labeled as Resident 62's Ativan 0.5 mg. On 4/10/19 at 1137 hours, a follow-up interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated Resident 62's Ativan order was completed on 3/22/19, and the medication should not have been in the medication cart. On 4/10/19 at 1149 hours, an interview was conducted with the DON. The DON stated when the controlled medication orders were complete or discontinued, the process was for the licensed nurse to bring the medications to the DON, count the medications together, and secure the medications in the DON's office until they were destroyed with the Pharmacy Consultant. The DON stated the Ativan should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 37 of 60 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 04/15/2019 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 not have been in the medication cart without an active physician's order.

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 06/30/2019 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of 24 final sampled residents (Resident 48) was free from a significant medication error. The facility failed to ensure Resident 48 was administered intravenous ertapenem (an antibiotic) every 24 hours as ordered by the physician. This had the potential to prolong the treatment for Resident 48's urinary tract infection. Findings: Current and closed medical record review for Resident 48 was initiated on 4/10/19. Resident 48 was originally admitted to the facility on 3/27/12, with numerous readmissions from the acute care hospital. Medical record reviews of Resident 48's documents entitled SBAR Communication Form and Progress Notes dated 1/12/16, 1/16/19, and 3/31/19, showed Resident 48 had multiple diagnoses of UTIs. Review of Resident 48's Medication Administration Record dated 1/1 - 1/31/19, showed IV ertapenem was administered 30 hours after the initial dose was started. On 4/15/19 at 1040 hours, an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 38 of 60 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 04/15/2019 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 RN 6. RN 6 confirmed the IV ertapenem was not given by LVN 11 as ordered. RN 6 stated, even if LVN 11 gave the medication on time and did not document the time she administered it, then LVN 11 should have documented in the progress notes to show the medication was given on time. Review of the Medication Administration Record showed ertapenem sodium solution was to be administered every 24 hours for UTI for 6 days beginning on 1/16/19 at 1804 hours. Further review of the Medication Administration Record showed the first dose of IV ertapenem sodium solution was administered at 0853 hours on 1/17/19. The second dose of IV ertapenem sodium solution was given at 1457 hours on 1/18/19, by LVN 11. RN 6 attempted to find documentation to show whether or not the dose was given prior to 1457 hours. The Medication Administration Record showed on 1/19/19, a third dose of IV ertapenem sodium solution was given at 0903 hours, and the fourth dose was given at 0932 hours on 1/20/19. The Medication Administration Record showed LVN 11 administered the fifth dose of IV ertapenem on 1/21/19 at 1512 hours. RN 6 was not able to provide documentation or explanation for the late administration of the IV ertapenem on 1/21/19. On 4/15/19 at 1125 hours and 1145 hours, the telephone interviews were conducted with the Pharmacy Consultant. When asked if IV ertapenem sodium solution had parameters and what the standard of practice was for giving IV ertapenem at specific times, the Pharmacy Consultant stated IV ertapenem sodium solution had to be given within a specific timeframe due to its concentration levels. The Pharmacy Consultant stated 30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 39 of 60 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 04/15/2019 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 minutes after administering the medication, the drug loses its concentration and potency. After 12 hours of administration, the concentration of the drug dropped from 155 down to a concentration level of 9 and, within 24 hours, it is nearly completed at the level of 1. Therefore, administering the medication outside of the timeframe specified was like starting the administration process all over again. LVN 11 gave the IV ertapenem sodium solution six hours after the 24 hour period had expired.

F802 SS=E Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 05/30/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(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. §483.60(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 interview and facility document review, the facility failed to ensure the kitchen staff had adequate staffing to safely and effectively carry out all the functions of the food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 40 of 60 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 04/15/2019 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 nutrition service department. This failure had the potential for unsafe food practices which might lead to foodborne illnesses in a highly susceptible population who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/8/19, showed 106 of the 119 residents residing in the facility received food prepared in the kitchen. On 4/7/19, during the initial tour of the facility, three residents (Residents 34, 56 and 96) verbalized their lunch and dinner meals on 4/6/19, had been served in Styrofoam boxes. The residents expressed dissatisfaction with receiving their lunch and dinner in Styrofoam boxes, rather than the normal heated china plates. Resident 34 stated he was a diabetic and needed the food for his medical condition. He stated the Styrofoam food was not good. It was cold and made him not want to eat. Resident 56 stated the Styrofoam boxed food had condensation on it and arrived cold, and unpalatable. Resident 96 stated he received cold pizza and some cold watery vegetables in a Styrofoam box. The Styrofoam didn't keep it hot and the resident stated he did not want to eat cold food. On 4/7/19 at 1556 hours, an interview was conducted with Cook 3 and Dietary Aide 4. Dietary Aide 4 stated the meals were served in Styrofoam boxes due to short staffing. Cook 3 and Dietary Aide 4 verified the lunch and dinner meals on 4/6/19, had been served in Styrofoam boxes due to staffing issues. Cook 3 and Dietary Aide 4 stated they could not feed the residents and did all the dishes for the day with only two staff members, a dietary aide and a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 41 of 60 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 04/15/2019 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 cook. Cook 3 stated they decided to use the take out boxes due to a staffing issue so they would not have to do the dishes. On 4/7/19 at 1600 hours, an interview was conducted with the Dietary District Manager. The Dietary District Manager confirmed two staff members were not sufficient to provide both the meal service and dishes for Saturday 4/6/19. The Dietary District Manager stated food prepared from the kitchen was not to be served in Styrofoam boxes, but on china plates. The Dietary District Manager stated the staff did not have approval to make a unilateral decision to deviate from serving the hot food on the china plates. The Dietary District Manager stated the staff needed to get approval from the Dietary Manager or the RD. Styrofoam boxes were only to be used during an emergency, and lack of staffing did not constitute an emergency. On 4/8/19 at 847 hours, an interview was also conducted with the RD. The RD stated he was unaware of the use of Styrofoam boxes and also concurred that china plates should have been used. The RD stated he was part-time and his role was more clinical than kitchen. He left the supervision of the kitchen to the Dietary Manager. He stated his job was to follow up with the residents. The Dietary Manager did their job and he informed them of his role as the RD and the responsibility. The RD stated the current Dietary Manager was out on leave and the Dietary District Manager was filling in for the position.

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 05/30/2019 §483.60(c) Menus and nutritional adequacy. Menus mustFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 42 of 60 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 04/15/2019 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 §483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed ensure the residents received meals based upon nutritional needs, allergies, and personal preferences. * The facility failed to follow the recipes for the puree regular and fortified mashed potatoes during the puree preparation process. * The facility failed to follow the vegetarian menu or notify residents of substitutions. * The facility failed to ensure a lactoseintolerant resident did not receive ice cream. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 43 of 60 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 04/15/2019 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 follow resident item requests as printed on their menu for two sampled residents (Residents 56 and 2). These failures posed the risk of not providing nutritional and special dietary needs for the residents. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/8/19, showed 106 of the 119 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's document titles Production Counts Day 4: Wk 1 -Wednesday 4/10/19, showed a total of 11 servings of fortified mashed potatoes for puree diets and a total of seven servings of regular mashed potatoes for the puree diets. Review of the facility's documents titled Corporate Recipe Number: 1821 Fortified Potatoes, mashed (mix) showed mashed potatoes mix, water, creamer, half and half bulk, margarine and salt were to be used. Review of the facility's document titled Corporate Recipe - number: 4164 Potatoes, Mashed (mix) showed mash potatoes mix, boiling water and margarine were to be used. On 4/10/19 at 1015 hours, a concurrent observation and interview was conducted with Cook 1. Cook 1 stated she was preparing 20 servings of puree mashed potatoes. Cook 1 brought out a pitcher of milk from the refrigerator, poured a half-gallon of milk into a measuring pitcher and placed it in the microwave. Cook 1 was asked about the mashed potatoes recipe, which required boiling water, if it was okay to substitute the milk for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 44 of 60 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 04/15/2019 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 boiling water. The cook replied it was an okay substitution for the 20 servings of fortified mashed potatoes. The recipe for fortified mashed potatoes was reviewed with Cook 1. Cook 1 once again stated it was okay to substitute milk for what the recipe called for. Cook 1 was asked how many portions of each type of mashed potatoes were to be prepared. Cook 1 stated 11 servings of fortified and seven of regular. Cook 1 stated there were more residents requiring fortified mashed potatoes and she just prepared one batch of fortified potatoes with milk for everyone on puree tray line today. On 4/10/19 at 1053 hours, a concurrent interview and facility document review was conducted with the District Manager. The District Manager stated the cook was to make both types of potatoes as the production sheet called for both to be served to residents. The cook was not to make and serve only the fortified mashed potatoes to all residents on puree diets. On 4/10/19 at 1104 hours, a concurrent interview and facility document review was conducted with the RD. The RD stated corporate recipes must be followed and not altered unless approved by the RD. The RD stated milk instead of water in mashed potatoes could alter the calorie content, the nutritional content, and affect those with milk allergies such as someone with lactoseintolerance. The RD stated it was not an approved substitution. The cooks should not be making unilateral decisions for recipe substitution and did not have the same training and knowledge as an RD to make the decision to substitute an ingredient in a recipe. 2. On 4/7/19 at 0909 hours, an observation and concurrent interview was conducted with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 45 of 60 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 04/15/2019 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 56. Resident 56 stated he followed a vegetarian diet and often received the wrong foods from the kitchen. Resident 56 stated the food provided on the meal tray rarely matched the meal ticket. Resident 56 stated the kitchen provided a plate full of wet, not drained vegetables, slimy tofu dripping with oil, and mashed potatoes. Resident 56 stated he kept a record of everything from the kitchen by recording it on the meal tickets. Resident 56 state it made him feel unhappy and he could enjoy eating. Resident 56 stated it was frustrating not getting the right foods. Resident 56 stated food, especially foods which follow a vegetarian diet, are very important. Resident 56 stated he felt like the kitchen staff was just in too much of a hurry and did not read the menus like they should. Review of the facility document Week-at-aglance week 1 menu showed the vegetarian menu was to provide on (Sunday) 4/7/19, a seasoned veggie Chicken patty for lunch. On the menu for 4/8/19, (Monday) the kitchen was to provide vegetarians with a 3-grain veggie patty for lunch. On 4/9/19 at 1020 hours, a concurrent interview and facility document review was conducted with Cook 1. Cook 1 stated Monday lunch for the residents following a vegetarian diet was a 3-grain veggie patty. Cook 1 stated the kitchen did not have the veggie beef patty for Monday. A substitution of quesadillas, tofu or mac and cheese was made. Cook 1 stated the kitchen didn't receive the veggie patties in their order and the kitchen was short the veggie burgers. On 4/9/19 at 1025 hours, an interview was conducted with the Dietary District Manager, who verified the kitchen did not have enough veggie patties on hand to meet the demand. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 46 of 60 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 04/15/2019 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 Dietary District Manager verified no one informed the vegetarian residents of the lack of veggie patties or of the substitution. On 4/9/19 at 1201 hours, an interview was conducted with Resident 56. According to Resident 56, no seasoned veggie chicken patty was provided for Sunday lunch and no veggie burger was provided for Monday lunch. Resident stated no one told her about the substitutions to the menu. On 4/10/19 at 935 hours, a subsequent interview was conducted with Cook 1. Cook 1 stated on Sunday the kitchen was also out of the veggie chicken patty. Vegetarian residents received a substitution. 3. On 4/10/19 at 1130 hours, an observation of tray line was conducted. During tray line, a low sugar ice cream was placed on a resident's tray with a meal ticket showing lactose intolerant, no milk, no cheese. As Dietary Aide 2 placed the tray in the cart to leave, Dietary aide 2 was asked if it was lactose free ice cream. Dietary Aide 2 stated no it was low sugar. Dietary Aide 2 was asked if lactose intolerant people can have low sugar ice cream. Dietary Aide 2 stated no and replaced the ice cream with sherbet. Dietary Aide 2 stated the resident was to get sherbet instead. 4. On 4/8/19 at 1319 hours, an observation and concurrent interview was conducted with Resident 56. A plate arrived with food that did not match the meal ticket. The tray also had peaches on it, when the meal ticket showed no peaches. Resident 56 sighed and stated they just gave him all the vegetables. There's no real vegetarian diet. The meal ticket and contents of the plate were verified with CNA 10. CNA 10 acknowledged the tray did not match the meal ticket and the resident received an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 47 of 60 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 04/15/2019 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 item (peaches) which was not to be given based on Resident 56's meal ticket preferences. On 4/9/19 at 0847 hours, an interview was conducted with the RD. The RD stated it was the tray line staff's and the cook's responsibility to read and follow the meal tickets. The cook was to follow anything that is added to the tray ticket. Tray line staff was to put the correct cold food on the tray based on the tray ticket and the cook was to place the correct hot food on the tray as shown on the meal ticket. The staff was to follow the meal ticket. 5. On 4/7/19 at 1255 hours, Resident 2 was observed for lunch in his room. Review of Resident 2's meal ticket showed Resident 2 was supposed to get a dinner roll or bread. However, observation of Resident 2's meal tray did not show a dinner roll or bread. The Dietary District Manager was called to the room and verified the finding. On 4/8/19 at 1251 hours, Resident 2 was observed for lunch in his room. Resident 2 stated "...I did not get the dinner roll again." Review of Resident 2's meal ticket showed Resident 2 was supposed to get a dinner roll or bread. However, observation of Resident 2's meal tray did not show a dinner roll or bread. The Dietary District Manager was called to the room and verified the finding.

F804 SS=D Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 05/30/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 48 of 60 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 04/15/2019 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 appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to ensure the food items served to the residents were attractive and at a palatable temperature. Three of 24 final sampled residents (Residents 34, 56, and 96) and one of 12 nonsampled residents (Resident 51) verbalized the lunch and dinner meals on 4/6/19, were served in Styrofoam boxes and arrived wet, slimy, and cold. This failure resulted in the residents not enjoying their meals. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/8/19, showed 106 of the 119 residents residing in the facility received food prepared in the kitchen. On 4/7/19, during the initial tour of the facility, Residents 34, 56 and 96 stated their lunch and dinner meals on 4/6/19, had been served in Styrofoam boxes. The residents verbalized dissatisfaction with receiving their lunch and dinner in Styrofoam boxes, rather than the normal heated china plates. 1. Resident 34 stated he was a diabetic and needed the food for his medical condition. Resident 34 stated he did not get lots of things and was on a fluid restriction, but the food served in Styrofoam boxes was not good; it was cold and made him not want to eat. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 49 of 60 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 04/15/2019 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. Resident 56 stated the Styrofoam boxed food had condensation on it and arrived wet, wilted, cold, and unpalatable. The cheese quesadilla, (which the meal ticket showed no quesadillas) arrived sopping wet. 3. Resident 96 stated he received cold pizza and some cold watery vegetables in a Styrofoam box. Resident 96 stated the Styrofoam didn't keep the food hot and the resident did not want to eat cold food. Review of the facility's document titled WeekAt-A- Glance for 4/6/19, showed braised pork tips were served for the lunch meal and thin crust cheese pizza was served for the dinner meal. Review of the facility's P&P titled Oral Nutrition and Hydration dated April 2005, revised date August 2017 showed residents should receive food in the appropriate form and content as prescribed by their physician to support treatment and plan of care. On 4/7/19 at 1556 hours, Cook 3 and Dietary Aide 4 verified the lunch and dinner meals on 4/6/19, had been served in Styrofoam boxes due to staffing issues. The District Manager stated food was not to be served in Styrofoam, but on china plates. 4. On 4/7/19 at 0906 hours, Resident 51 stated this place was a mess. Resident stated did you know there were only two people in the kitchen yesterday and we had to have lunch and dinner from the outside. Resident 51 stated the food was served on Styrofoam plates and the food was not good. Resident 51 stated the food was cold. On 4/9/19 at 1204 hours, an interview was conducted with Resident 51 regarding food satisfaction. Resident 51 stated most of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 50 of 60 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 04/15/2019 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 time the food was cold. Resident 51 stated she had asked the cook why her food could not be brought to her hot. Resident 51 stated the cook told her it was because the hot plate in the kitchen was broke. Resident 51 stated she asked the cook if the facility only had one hot plate, but all the cook would say was, the hot plate was broke.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 05/30/2019 §483.60(i) Food safety requirements. The facility must §483.60(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. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation and interview, and facility P&P review, the facility failed to follow proper sanitation, food handling, and storage practices. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 51 of 60 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 04/15/2019 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 * Dietary staff failed to use proper hand hygiene. * Soiled cooking pots were stored with clean cook ware. * A food blender was towel dried instead of being allowed to air dry. * Fresh vegetables were observed on the counter top next to soiled dishes. * Dented cans were observed stored amongst the non-dented cans. * Cooking pots and pans were not maintained in sanitary and safe condition. * The facility failed to ensure food stored in resident designated refrigerators was properly labeled for two of three refrigerators. These had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/8/19, showed 106 of the 119 residents residing in the facility received food prepared in the kitchen. 1. On 4/7/19 beginning at 0742 hours, an initial tour of the kitchen was conducted with assistance from Cook 2 and Dietary Aide 3. During the tour, a container of peaches with two different dates was found in the walk in. The container was shown to Cook 2. Cook 2 stated the container should only have one date on it. Cook 2 verified the finding. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 52 of 60 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 04/15/2019 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 According to the Federal Food Code (2017), refrigerated foods that are kept longer than 24 hours are to have a date to identify when it is to be used or discarded. 2. During the initial tour, Dietary Aide 3 was observed not removing gloves when walking away from the prep area. Dietary Aide 3 was observed using a gloved hand on the walk in refrigerator handle to open the door, brought out a carton of eggs and returned to the steam table. Dietary Aide 3 was also observed not washing hands in between glove changes. Dietary Aide 3 verified both observations. Dietary Aide 3 stated gloves are to be removed when leaving the production area and hands are to be washed after removal of the gloves and prior to applying new gloves. 3. Observation of a dirty stock pot was noted in the clean dishes area. Dietary Aide 3 stated the pot was dirty and had chocolate drips on the side. Dietary Aide 3 stated the pot should not be placed with the clean dishes on the upper rack and removed the pot to the dish machine. Dietary Aide 3 verified the finding. 4. In the dry storage area, two dented, number 10 food cans were found with the regular cans. Cook 2 stated the cans should have been removed and placed in the dented can area. Cook 2 verified the finding. 5. In the area with the 2 compartment sink, a pan of freshly cut vegetables was found on the sink top next to the dirty dishes. Cook 2 stated the freshly cut vegetables should not have been placed on the sink top with dirty dishes; the freshly chopped food belonged in the production section. Cook 2 verified this finding. 6. On 4/10/19 at 1015 hours, Cook 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 53 of 60 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 04/15/2019 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 observed cleaning the blender with a towel instead of allowing it to air dry. Cook 2 was asked what the procedure was for drying the blender in between use. Cook 2 stated the procedure is to air dry, not to dry with a towel. Cook 2 verified the findings. According to the Federal Food Code (2017) after cleaning and sanitizing, equipment and utensils are to be air dried before contact with food, not cloth dried. 7. Review of the facility's P&P titled Oral Nutrition and Hydration revised 8/17 showed food brought in to the facility by residents or others for the resident's use, will be labeled with the resident's name and the date the food was brought to the facility. Food items stored in the refrigerator greater than seven days are to be discarded. On 4/7/19 at 0745 hours, an observation and concurrent interview was conducted with LVN 1. A refrigerator used to store resident food was observed in Station A. The following items were observed inside of the refrigerator: (1) A plastic bag labeled with Resident 96's name which contained five microwaveable burritos (neither the bag containing the burritos or the burritos were labeled with the date received, or an expiration date). (2) An unlabeled sprite soda can. LVN 1 verified the findings. LVN 1 stated the facility policy for storing resident food was to label food items with the resident's name and the date received, in order to determine who the food belonged to and when to discard the food. On 4/7/19 at 0800 hours, an observation and concurrent interview was conducted with RN 1. A refrigerator used to store resident food was observed in Station B. The following items were observed inside of the freezer section of the refrigerator: (1) An unlabeled container of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 54 of 60 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 04/15/2019 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 frozen fruit and granola (2) A carton of expired ice cream labeled with Resident 21's name dated 12/18/18. RN 1 verified the findings and stated the facility's policy for storing resident food was to label food items with the resident's name and the date the food item was received. 8. On 4/15/19 at 0820 hours, concurrent observation and interview was conducted with the District Manager. The District Manager verified one 16 inch pan had a black substance on its inner surface and one 16 inch pan had scratches and a black substance on its inner perimeter. The District Manager verified the bottom surfaces of two stock pots were warped.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 05/30/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(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: §483.80(a)(1) A system for preventing, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 55 of 60 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 04/15/2019 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 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; §483.80(a)(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 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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 56 of 60 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 04/15/2019 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 §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(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 help prevent the development and transmission of diseases and infections. The facility failed to conduct accurate surveillance of infection as per the McGeer's Criteria. This posed the risk of the facility not accurately investigating and preventing new infections from developing and an outbreak going unrecognized within the facility. Findings: According to the facility's P&P titled Surveillance of Infections revised 2/2018, in conducting surveillance, infections should be attributed to the long term care facility when the onset of clinical manifestation occurs more than two calendar days after admission. On 4/15/19 at 0942 hours, an interview and concurrent review of the facility's infection control program was conducted with the DSD. The DSD stated she was responsible for the facility's Infection Control and Antibiotic Stewardship Programs. The DSD stated the Infection Control Committee met on a monthly basis and the facility initiated an Antibiotic Stewardship Program last month (March 2019) and will be meeting on a quarterly basis. The DSD stated the facility utilized the McGeer's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 57 of 60 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 04/15/2019 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 Criteria to define infection surveillance activities and an infection was considered a HAI if the onset of clinical manifestation occurred more than three days after admission. Review of the Infection Control surveillance, line listings, and monthly report summaries from July 2018 to March 2019 showed inaccuracies in the summary of infections reported to the monthly Infection Control Committee Meetings. For example, review of Healthcare Associated Infection Summary report By Resident Days for March 2019 showed a total of 13 HAIs were reported to the Infection Control Committee meeting. However, review of the Line Listing of Resident Infections for March 2019 showed there were 17 HAIs. Further review of the Infection Control surveillance, line listings, and monthly report summaries from July 2018 to March 2019 showed inaccuracies in the classification of HAIs and CAIs. For example, review of the surveillance forms for March 2019 showed Residents 21's and 96's clinical manifestations did not meet the McGeer's criteria for UTI. However, review of the Line Listing of Resident Infections for March 2019 showed Residents 21's and 96's infections were checked off as HAIs. In addition, Resident 113, who was admitted to the facility on 2/18/19, was identified with the onset of clinical manifestation for UTI on 3/20/19; however, the infection was classified as a CAI. The DSD verified the above findings. (Cross reference to F881)

F881 SS=E Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 05/30/2019 §483.80(a) Infection prevention and control FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 58 of 60 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 04/15/2019 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 program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview and facility record review, the facility failed to implement an Antibiotic Stewardship Program to reduce the risk of unnecessary or inappropriate antibiotic use. The facility failed to ensure the use of antibiotics for residents whose symptoms did not meet the McGeer's Criteria were tracked and reported to the Infection Control Committee meetings. As a result, there were no action plans developed to address the inappropriate use of antibiotics in the facility. Findings: According to the CDC, unnecessary antibiotic use promotes development of antibioticresistant 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. On 4/15/19 at 0942 hours, an interview and concurrent review of the facility's infection control program was conducted with the DSD. The DSD stated she was responsible for the facility's Infection Control and Antibiotic Stewardship Programs. The DSD stated the Infection Control Committee met on a monthly basis and the facility initiated an Antibiotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 59 of 60 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 04/15/2019 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 Stewardship Program last month (March 2019) and will be meeting on a quarterly basis. Review of the Infection Control Summary Reports and Healthcare Associated Infection Summary Report by Resident Days from July 2018 to March 2019 showed antibiotic use for symptoms not meeting the McGeer's Criteria were not reported to the Infection Control Committee meetings from September 2018 to March 2019, and was not addressed during the Antibiotic Stewardship Program meeting in March 2019. There was no tracking and trending, and no action plan developed to address the inappropriate use of antibiotics. The DSD verified the above findings. (Cross reference to F880) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IKNF11 Facility ID: CA060000033 If continuation sheet 60 of 60