Other·December 19, 2017

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for COMPLAINT No: CA00555023. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 34325, HFEN; Surveyor 36872, HFEN; and Surveyor 38661, HFEN. THE DEPARTMENT SUBSTANTIATED THE COMPLAINT ALLEGATION(S) AND FINDINGS WERE CITED AT F323. Glossary of Abbreviations and Brief Definitions: CNA - Certified Nursing Assistant DON - Director of Nursing DSD - Director of Staff Development ED - Emergency Department Functional quadriplegia - inability to move due to severe disability or frailty caused by another condition without physical injury or damage to the brain or spinal cord. LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) SBAR - Situation, Background, Appearance, Review

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

F323 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: N5WB11 Facility ID: CA060000042 If continuation sheet 1 of 6 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: _______________ 056110 (X3) DATE SURVEY COMPLETED 11/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (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 CFR(s): 483.25(d)(1)(2)(n)(1)-(3) (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure adequate assistance was in place to prevent a fall for one of two sampled residents (Resident 1). Resident 1 had been assessed as needing two persons for bed mobility. CNA 1 had not cared for Resident 1 before and was not aware Resident 1 needed to have two staff in attendance during bed mobility. Resident 1 fell off the bed onto the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N5WB11 Facility ID: CA060000042 If continuation sheet 2 of 6 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: _______________ 056110 (X3) DATE SURVEY COMPLETED 11/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (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 floor while CNA 1 was providing incontinence care with no other staff in assistance. As a result, Resident 1 sustained lacerations to the upper lip, right forehead, and right knee, requiring a transfer to the acute care hospital ED by 911 and sutures. Findings: On 10/11/17 at 1210 hours, Resident 1 was observed lying on an air-filled mattress. Resident 1 had yellowish discoloration under her eyes and light purple discoloration on the right side of her forehead. Medical record review for Resident 1 was initiated on 10/11/17. Resident 1 was admitted to the facility on 8/19/14, and readmitted on 9/23/17, with diagnoses including functional quadriplegia and dementia. Review of the SBAR Communication Form and Progress Note dated 9/22/17 at 2015 hours, showed Resident 1 sustained a fall from bed onto the floor while being receiving incontinent care. Resident 1 was transferred to the acute care hospital ED by 911. Review of the acute care hospital Physical Exam and Procedures report dated 9/22/17, showed Resident 1 arrived at the ED at 2116 hours. Resident 1 was assessed to have the following injuries: a laceration to the anterior of her right knee and swelling to the left elbow, a full thickness laceration to her right forehead (measuring 3 cm) and a full thickness laceration to the upper lip (measuring 2 cm), both requiring sutures. On 10/11/17 at 0912 hours, an interview was conducted with Resident 1's responsible party. Resident 1's responsible party stated Resident 1 was totally bed bound and could not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N5WB11 Facility ID: CA060000042 If continuation sheet 3 of 6 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: _______________ 056110 (X3) DATE SURVEY COMPLETED 11/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (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 understand how she could have fallen. The responsible party stated the night nurse had informed her she made sure Resident 1 always had two staff assisting to change Resident 1, which clearly did not happen at the time the resident fell. Review of the MDSs dated 6/8 and 9/5/17, showed Resident 1 had severe cognitive impairment and required extensive assistance of two persons for bed mobility and total assistance of two persons for transfers. Review of Resident 1's plan of care showed a care plan problem dated 8/14/17, to address Resident 1's claim she had fallen out of bed. One of the interventions dated 8/15/17, showed two persons' assistance with bed mobility and transfers. On 10/11/17 at 1420 hours and again on 10/12/17 at 1445 hours, the interviews were conducted with LVN 1. LVN 1 stated he considered Resident 1 to need one person's assistance for bed mobility before the fall on 9/22/17. LVN 1 stated he was not aware of any documentation showing Resident 1 needed two persons to assist with bed mobility. On 1/12/17 at 1503 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 was a one person assist before the fall on 9/22/17. On 10/12/17 at 1130 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the MDS dated 6/8/17, identified Resident 1 as needing two persons for bed mobility and the care plan problem was updated on 8/15/17, to reflect the need of two persons's assistance with bed mobility and transfers. The MDS Coordinator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N5WB11 Facility ID: CA060000042 If continuation sheet 4 of 6 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: _______________ 056110 (X3) DATE SURVEY COMPLETED 11/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE verified the Documentation Survey Report form for the task of bed mobility from June through September 2017 showed inconsistencies in the number of staff required to provide bed mobility assistance for Resident 1. On 10/12/17 at 1340 hours, an interview was conducted with the DSD. The DSD stated when a CNA from a nursing registry (business which provides CNAs as needed) was working, it was up to the licensed nurse to inform them of their assignments and give them the reports on the residents they were assigned to care for. On 10/20/17 at 1500 hours, a telephone interview was conducted with CNA 1. CNA 1 was assigned to care for Resident 1 on 9/22/17, when the fall occurred. CNA 1 verified she was employed by a nursing registry agency. CNA 1 stated she never received any report regarding Resident 1's care needs and was never informed Resident 1 needed two persons' assistance for bed mobility and transfers. CNA 1 stated she was cleaning and changing Resident 1 at the time of the accident. CNA 1 stated Resident 1 was trying to help by turning to her side, but she accidentally rolled too far and fell off the bed onto the floor. On 11/13/17 at 1420 hours, an interview was conducted with LVN 1. LVN 1 was the licensed nurse assigned to Resident 1 on 9/22/17, when the fall occurred. LVN 1 stated he did not give a report regarding Resident 1 to CNA 1. LVN 1 stated he told the other CNAs to answer whatever questions CNA 1 might have. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N5WB11 Facility ID: CA060000042 If continuation sheet 5 of 6 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: _______________ 056110 (X3) DATE SURVEY COMPLETED 11/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: N5WB11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA060000042 (X5) COMPLETE DATE If continuation sheet 6 of 6