Other·March 19, 2019

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 Nos: CA00620666 and CA00623923. Inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 39199, HFEN; Surveyor 36789, HFEN; and Surveyor 34325, HFES. FOR COMPLAINT NO. CA00620666: THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION(S). FOR COMPLAINT NO. CA00623923: THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATION(S). On 2/6/19 at 1106 hours, the Administrator and DON were informed of an Immediate Jeopardy (IJ) regarding the following: * The facility failed to prevent the sexual abuse to Resident 1. Resident 3 was found in Resident 1's room on 12/14/18, with his hand down Resident 1's pants at the perineal area. On other occasions, Resident 3 was observed in the dining room flickering his tongue with two fingers in the "V" shape held at his mouth, directing the gesture to Resident 1, made inappropriate comments to Resident 1, and was observed to take Resident 1's hand and placed it on his crotch. * The facility failed to follow their abuse P&P 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: CT4611 Facility ID: CA060000131 If continuation sheet 1 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 failed to conduct thorough investigations on the four documented incidents of sexual abuse and harassment to Resident 1. * The facility failed to inform Resident 1's responsible party of the incidents, resulting in Resident 1's family encouraging Resident 1 to be friends with Resident 3. * The facility failed to implement measures to separate both residents and ensure Resident 1's safety. * The facility failed to conduct a comprehensive assessment of Resident 1 after the witnessed sexual abuse incident on 12/14/18. On 2/13/19 at 1545 hours, the IJ was abated after the facility had submitted the following plan of correction: * Immediately place Resident 3 on 1:1 (one to one) supervision. * Immediately notify Resident 1's responsible party and family of the four documented abuse incidents. * Immediately in-service all staff on the facility's abuse P&P and reporting requirements. * Conduct a thorough investigation of the four documented abuse incidents to Resident 1. * Conduct a full body assessment and obtain a psychiatric evaluation for Residents 1 and 3. The facility provided documented evidence to show staff, including nursing staff, respiratory therapists, rehabilitation therapists, maintenance, and housekeeping received inservices as they came on duty and prior to providing care to residents. The in-services included the facility's abuse P&P, mandated reporting of abuse, monitoring and documentation of Residents 1 and 3's whereabouts and specific behaviors. Resident 3 continued on 1:1 supervision to ensure Resident 1 and other female residents were protected from abuse. Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 2 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 responsible party and family were informed of the abuse incidents. The Administrator reported to required agencies, including the local police department, and conducted thorough investigations of the four documented abuse incidents to Resident 1. In addition, Residents 1 and 3 were assessed by a psychiatrist. Cross references to F600, F607, and F609. GLOSSARY OF ABBREVIATIONS: CNA - Certified Nursing Assistant DON - Director of Nursing LVN - Licensed vocational Nurse IDT - Interdisciplinary Team MDS - Minimum Data Set (a standardized assessment tool) P&P - policy and procedure RN - Registered Nurse SSD - Social Service Director

F600 SS=J Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 3 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview, medical record review, and facility document review, the facility failed to prevent the sexual abuse against one of two sampled residents (Resident 1). Resident 3 was found in Resident 1's room on 12/14/18, with his hand down Resident 1's pants at the perineal area. On another occasion, Resident 3 was observed to take Resident 1's hand and placed it on his crotch. Resident 1 did not have capacity to make decisions or give informed consent. The facility failed to identify Resident 3's behaviors towards Resident 1 as abuse, and therefore, did not monitor Resident 3's behavior. Resident 3 had no cognitive impairment and could self-propel his wheelchair and move freely around the facility. Resident 1 was dependent on others for mobility in her wheelchair. This placed Resident 1 at risk for further abuse by Resident 3 due to the delay in developing and implementing any interventions to keep Resident 1 safe and away from Resident 3. This delay permitted Resident 3 to display further inappropriate sexual behaviors towards Resident 1, including grabbing Resident 1's hand and placing it on his crotch, making inappropriate comments and flickering his tongue (in a sexual manner) towards Resident 1. The facility's failure to monitor Resident 3's behaviors placed other female residents at risk as potential victims of abuse. On 2/6/19 at 1106 hours, the Administrator and DON were informed of an Immediate Jeopardy (IJ) regarding the following: * The facility failed to prevent the sexual abuse to Resident 1. Resident 3 was found in Resident 1's room on 12/14/18, with his hand down Resident 1's pants at the perineal area. On other occasions, Resident 3 was observed in the dining room flickering his tongue with two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 4 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 fingers in the "V" shape held at his mouth, directing the gesture to Resident 1, made inappropriate comments to Resident 1, and was observed to take Resident 1's hand and placed it on his crotch. * The facility failed to follow their abuse P&P and failed to conduct thorough investigations on the four documented incidents of sexual abuse and harassment to Resident 1. * The facility failed to inform Resident 1's responsible party of the incidents, resulting in Resident 1's family encouraging Resident 1 to be friends with Resident 3. * The facility failed to implement measures to separate both residents and ensure Resident 1's safety. * The facility failed to conduct a comprehensive assessment of Resident 1 after the witnessed sexual abuse incident on 12/14/18. On 2/13/19 at 1545 hours, the IJ was abated after the facility had submitted the following plan of correction: * Immediately place Resident 3 on 1:1 supervision. * Immediately notify Resident 1's responsible party and family of the four documented abuse incidents. * Immediately in-service all staff on the facility's abuse P&P and reporting requirements. * Conduct a thorough investigation of the four documented abuse incidents to Resident 1. * Conduct a full body assessment and obtain a psychiatric evaluation for Residents 1 and 3. Findings: On 1/25/19 at 0813 hours, Resident 1 was observed in her room lying in bed. Resident 1 was asked if she felt safe living at the facility. Resident 1 stated she did not feel safe living at the facility but could not elaborate why. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 5 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 1 stated, "I just don't." Resident 1 was asked if she was touched inappropriately. Resident 1 stated some man touched her "down there" and pointed to her groin area. Resident 1 stated she "did not like it." When asked who had inappropriately touched her, Resident 1 stated the man who came into her room did. a. Medical record review for Resident 1 was initiated on 1/25/19. Resident 1 was readmitted to the facility on 6/21/18, with diagnoses including traumatic brain injury and a functional quadriplegic. Review of Resident 1's History and Physical Examinations dated 6/22, 11/26, and 12/30/18, showed Resident 1 did not have the capacity to understand and was not capable of decision making. Review of Resident 1's MDSs dated 10/3/18 and 1/3/19, showed Resident 1's cognition was moderately impaired. Review of Resident 1's Progress Notes showed a nursing entry by LVN 1 dated 12/14/18, showing the CNA reported Resident 1 "was seen laying in bed with the company of a male resident (Resident 3) at bedside with his hand down her pants and the privacy curtain pulled." The male resident was escorted out of the room. Review of Resident 1's Progress Notes identified an entry by the Activities Director dated 12/20/18 at 1357 hours, showing the Activities Director was approached by Family Member 1 regarding Resident 1 being removed from the group activities. The Activities Director documented Resident 1 was removed from the group activities for safety monitoring due to Resident 1 receiving inappropriate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 6 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 sexual advances from a male resident. The Activities Director documented Family Member 1's response as "I don't have a problem if the male resident comes close to my (Resident 1) if the closeness is for encouragement and motivation, I'm okay with that; but if is sexual inappropriate I'm not okay." Review of Resident 1's Progress Notes showed an entry by the SSD dated 12/20/18 at 1417 hours. The SSD documented they had a discussion with Family Member 1 about Resident 1 being removed from the resident group activities due to a male resident making inappropriate gestures towards Resident 1. The progress notes showed Family Member 1 did not want Resident 1 to be in physical contact with the male resident and was not okay with the male resident being inappropriate. Review of Resident 1's plan of care failed to show a care plan problem was developed to address Resident 1 receiving inappropriate sexual behavior from a male resident until 12/20/18, after further incidents had occurred. The care plan problem showed Resident 1 had limited ability to follow redirection and required multiple cues, prompts, and separation from male resident. There were no interventions on how the staff was to monitor or keep Resident 1 safe from the male resident's sexual advances and gestures. On 1/25/19 at 0930 hours, an interview was conducted with CNA 2. CNA 2 stated the facility's Abuse Coordinator was the Administrator. CNA 2 stated any allegation or suspicion of abuse were supposed to be reported to the Administrator immediately. CNA 2 stated about a week ago (approximately one month after the 12/14/18 incident), she witnessed Resident 3 in Resident 1's room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 7 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 CNA 2 stated Resident 3 left Resident 1's room after being seen by her. CNA 2 stated she reported the incident to the RN Supervisor for that shift because male residents were not supposed to be in the female residents' rooms. On 1/25/19 at 0947 hours, an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 1 and was sometimes assigned to care for Resident 1. CNA 3 stated she was not aware of the incident on 12/14/18, where Resident 3 was found in Resident 1's room behind closed curtains with his hands down her pants. CNA 3 stated she was not aware of any interventions to keep Resident 1 safe and was not notified by any supervisors or managers to keep an eye out for potential abuse against Resident 1 by Resident 3. On 1/25/19 at 1001 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she was familiar with Resident 1. LVN 2 stated Resident 1 was alert and oriented to her name, but was otherwise confused. LVN 2 stated Resident 1 did not have the capacity to make her own decisions. LVN 2 stated she was not aware of the incident on 12/14/18. LVN 2 was asked what was considered sexual abuse. LVN 2 stated sexual abuse could be inappropriate touching without the consent of the person being touched. On 2/6/19 at 0855 hours, an interview was conducted with CNA 1. CNA 1 stated on 12/14/18, she found Resident 3 in Resident 1's room with the curtain drawn, sitting next to Resident 1's bed with his entire hand inside Resident 1's pants. CNA 1 stated she said, "what are you doing" and Resident 3 removed his hand right away and left the room. CNA 1 stated she transferred Resident 1 to her wheelchair and left her by the nurses' station FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 8 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 reported the incident to LVN 1. CNA 1 verified she was not asked to put Resident 1 back to bed to be examined by the nurse. CNA 1 stated Resident 3 could move around by himself and CNA 1 was scared it would happen again. b. Medical record review for Resident 3 was initiated on 1/25/19. Resident 3 was readmitted to the facility on 10/26/18. Review of Resident 3's History and Physical Examination dated 10/29/18, showed Resident 3 had the capacity to understand and make medical decisions and was independent and capable of decision making. Review of Resident 3's MDSs dated 3/30 and 12/31/18, showed Resident 3 was alert, oriented, and had no cognitive impairment. He was independent with his mobility using a wheelchair. Review of Resident 3's Progress Notes showed an entry by the DON on 12/14/18 at 1357 hours, showing the DON had a discussion with Resident 3 regarding his behavior with another resident. The Progress Notes showed the other resident (Resident 1) was not capable of consenting to a relationship. Resident 3 had been observed in the other resident's (Resident 1) room with the privacy curtains closed earlier that morning, then in the dining room making sexually suggestive motions with his tongue at this other resident (Resident 1). Additional review of Resident 3's Progress Notes showed the following entries: * On 12/14/18 at 1444 hours, Resident 3 was observed in Resident 1's room behind the closed privacy curtain with his hand down Resident 1's pants. In addition, the treatment nurse reported Resident 3 was observed in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 9 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 dining room sticking out his tongue in a sexual manner directed at Resident 1. * On 12/20/18 at 1046 hours, Resident 3 was witnessed by the Activities Assistant making inappropriate comments to another resident (Resident 1), and when Resident 3 was told to stop, he became verbally abusive to the Activities Assistant. * On 12/20/18 at 1248 hours, Resident 3 was in the dining room, approached Resident 1 and began to hold Resident 1's hand. * On 12/20/18 at 1408 hours, RN 1 documented Resident 3 was noted touching a female resident sexually. The physician was notified. * On 12/20/18 at 1627 hours, there was an entry showing the Activities Director and the Administrator met with Resident 3 to discuss Resident 3's inappropriate sexual behavior towards a female resident. * On 12/20/18 at 1637 hours, there was an entry showing the IDT, including the Administrator and DON met with Resident 3 due to the noted inappropriate sexual behavior with the female resident (Resident 1) who did not have the capacity to give proper consent. * On 1/15/19, a nurse's note showed Resident 3 was found in Resident 1's room. Review of Resident 3's plan of care showed a care plan problem dated 12/4/18, which addressed Resident 3 found holding hands with a female resident, sitting close to her, and appearing very attentive to her, no sexual overtones; however, the female resident was married. Resident 3 was "...deemed competent to make decisions, other residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 10 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 may not be." Review of the the care plan problem showed a revision date of 12/14/18, to address Resident 3 was found making inappropriate gestures towards a female resident (Resident 1) and being in the room with the privacy curtain pulled close. The goal was for Resident 3 to understand the inappropriateness of physical contact with another resident not capable of making a consensual decision. The interventions included to approach the resident if observed holding hands or other personal attention to female resident, explain again that some behaviors were not acceptable within the facility, encourage the resident to keep a reasonable distance from female residents in the hallway and dining room, and remind the resident as needed that not all residents here were able to give consents for physical touching or involvement. A care plan problem dated 12/20/18, addressed Resident 3 displaying inappropriate sexual gestures towards a female resident: flickering his tongue at females, grabbing the female resident's hand and placing it on his crotch, and placing his hand up the female resident's panties. The interventions included to monitor inappropriate behavior every shift, remind Resident 3 not to take advantage of other residents who did not or might not have the mental competence to consent to sexual advances, remove the resident from female resident area when inappropriate sexual behaviors were present, and report any behaviors to the charge nurse and administrative staff. On 1/25/19 at 1223 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 was asked about the Progress Notes entry dated 12/20/18. RN 1 was asked who the female FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 11 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 referred to in the Progress Notes was. RN 1 stated this was referring to Resident 1. RN 1 stated a CNA approached her and RN 2 to inform them the CNA had witnessed Resident 3 touching Resident 1 in a sexual manner. RN 1 stated she did not recall how Resident 3 touched Resident 1 in a sexual manner. RN 1 verified Resident 1 did not have the capacity to make decisions. RN 1 was asked if the incident between Resident 3 and Resident 1 could be considered sexual abuse. RN 1 stated yes, in hindsight because Resident 1 did not have the capacity to consent. On 1/25/19 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 1 did not have the capacity to consent and "she is definitely impaired." The DON stated prior to the incident on 12/14/18, Residents 1 and 3's relationship started out as innocent hand holding and progressively escalated to inappropriate behavior. The DON was asked if Residents 1 and 3 were assessed to have the capacity to consent to be in a relationship or to engage in sexual activity. The DON replied no and stated Resident 1 did not have the capacity to consent or the capacity to make decisions. The DON verified a care plan problem was not developed to address how staff were to keep Resident 1 safe until 12/20/18, which was six days later. The DON was asked if she considered this incident to be sexual abuse. The DON stated no, because Resident 3's hand was just under the covers. The DON stated she was not aware of the documented incident on 12/20/18, where Resident 3 was noted touching a female resident sexually. On 1/28/19 at 0846 hours, a telephone interview was conducted with the Long-Term Care Ombudsman. The Ombudsman stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 12 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she was familiar with Resident 1 and Resident 3. The Ombudsman stated she noticed Resident 1 and Resident 3 were really touchy with each other. The Ombudsman stated she did not believe Resident 1 had the capacity to consent because Resident 1 was like an infant. The Ombudsman stated no reports of sexual abuse allegations were reported to her in December 2018. On 1/30/19 at 0818 hours, a telephone interview was conducted with the MDS Coordinator. The MDS Coordinator stated she was asked by the Administrator to create a care plan problem for Resident 3 to address Resident 3 showing inappropriate sexual behavior towards a female resident (Resident 1). The MDS Coordinator stated Resident 3 was observed flickering his tongue at Resident 1 by an LVN in the dining room and was observed grabbing Resident 1's hand and placing it on his crotch by another staff member but could not recall who the staff member was. The MDS Coordinator stated the incident where Resident 3 grabbed Resident 1's hand and placed it on his crotch was a separate incident than the incident on 12/14/18, but could not recall the date. On 1/30/19 at 0828 hours, a telephone interview was conducted with LVN 3. LVN 3 stated sometime between 12/14/18, and 12/20/18, she witnessed Resident 3 in the dining room flickering his tongue with two fingers in the "V" shape held at his mouth. LVN 3 stated Resident 3 directed this gesture at Resident 1. LVN 3 stated she was appalled at Resident 3's behavior considering the dining room was full of people. She said she asked Resident 3 to stop. LVN 3 stated during a lunch meal on 12/20/18, in the dining room, Resident 3 approached Resident 1 and held Resident 1's hands. LVN 3 stated she believed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 13 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 3 was "testing the waters" because he had been warned to stay away from Resident 1. On 1/31/19, at 1334 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 3 was sent to the general acute care hospital this morning for a scheduled surgery and was not coming back for approximately three days. On 1/31/19 at 1350 hours, a follow-up interview was conducted with Resident 1. Resident 1 was observed lying in her bed. When asked if she felt safe living at the facility, Resident 1 replied no. Resident 1 was asked if she was touched inappropriately. Resident 1 replied yes and pointed to and touched her perineal area and simulated a rubbing motion with her hand at the perineal area. Resident 1 stated she did not like it. Resident 1 was asked who touched her. Resident 1 stated a man who lived at the facility touched her and stated it happened more than once. On 1/31/18 at 1423 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified Resident 3 had a physician's order dated 12/20/18, to monitor Resident 3 for inappropriate behavior. When asked what behavior was being monitored, RN 3 stated he did not know and acknowledged the order was not specific enough. After review of the Progress Notes dated 12/20/18, RN 3 verified the physician's order to monitor Resident 3 for inappropriate behavior was related to Resident 3 being noted to have touched a female resident in a sexual manner. RN 3 stated any behavior monitoring should be documented in the Medication Administration Record. Review of Resident 3's Medication Administration Record for December 2018 and January 2019 failed to show Resident 3 was being monitored for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 14 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 inappropriate behavior related to touching a female resident in a sexual manner. RN 3 verified the findings. On 2/6/19 at 0640 hours, an interview was conducted with RN 4. RN 4 stated Resident 3 was moved to a new room when he returned from the acute care hospital two days earlier because his old room was under construction. The old room was located in a different hallway than Resident 1's room. On 2/6/19 at 0720 hours, Resident 3 was observed lying in bed in a room three rooms away from Resident 1's room and was in the same hallway. Resident 1's room was not visible to the staff at the nurses' station. On 2/6/19 at 0833 hours, an interview was conducted with CNA 10. CNA 10 stated she was assigned to care for Resident 3 today (day shift 0700 to 1500 hours). CNA 10 stated she had not received any instructions about Resident 3 from the licensed nurses. CNA 10 stated she was not familiar with Resident 3 as she worked for a registry agency and was not employed by the facility. When asked if she was to monitor Resident 3's whereabouts or any special monitoring, CNA 10 said she was not aware if there was any monitoring in place for Resident 3. On 2/6/19 at 0924 hours, an interview was conducted with RN 3. RN 3 stated he wanted to relay "new information" about Resident 3. RN 3 stated Resident 3 informed a CNA that Resident 1 and her family had visited him (Resident 3) while he was at the hospital recovering from his recent surgery. On 2/6/19 at 0915 hours, an interview was attempted with Resident 3 inside his room. A moment later, Resident 1 was observed being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 15 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 wheeled in her wheelchair into Resident 3's room by her family (Family Member 1). Resident 1 was observed to attempt to give Resident 3 a hug, but Family Member 1 stated no. On 2/6/19 at 0933 hours, an interview was conducted with Family Member 1. Family Member 1 stated she could not understand why the facility was now not allowing Resident 1 to be friends with Resident 3. Family Member 1 stated she believed Resident 3 protected, encouraged, and motivated Resident 1. Family Member 1 stated they had taken Resident 1 to visit Resident 3 while Resident 3 was at the hospital last Sunday. Family Member 1 stated she felt the facility was "keeping a secret" and was not telling her everything. Family Member 1 stated they did not mind if Residents 1 and 3 were in the same room because Resident 3 was looking out for Resident 1. On 2/6/19 at 1000 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated he was Resident 1's designated decision maker. Family Member 2 stated Resident 1 had no short-term memory; he had to re-introduce family members to Resident 1 every time they visited her. Family Member 2 stated the facility's DON had called him three weeks or maybe a month ago regarding an incident where a male resident was found in Resident 1's room. Family Member 2 stated there were no other details given to Family Member 2 except the two residents had been seen holding hands and their legs were touching when seated next to one another in their perspective wheelchairs. Family Member 2 stated he made sure the facility understood these behaviors were not okay with him. The facility assured Family Member 2 they would take care of the situation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 16 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 2/6/19 at 1103 hours, an interview was conducted with the Administrator and DON. When asked about notification of Resident 1's responsible party regarding the sexual abuse, the DON stated she had informed Family Member 2 but not Family Member 1 because Family Member 1 was not the responsible party. The DON stated Family Member 2 was made aware a male resident was in Resident 1's room with his hand under the covers. The DON stated she was surprised Family Member 2 was so calm and did not react. The DON stated she did not ask Family Member 2 if he understood what she was telling him. Cross references to F607 and F609.

F607 SS=J Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 17 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 implement their abuse P&P and failed to ensure the staff identified abuse and immediately reported all suspicions of abuse to the Administrator, state agency, and all other required agencies for two of four sampled residents (Residents 1 and 4). * Resident 3 was found with his hand down Resident 1's pants at the perineal area. Resident 1 did not have the capacity for decision making or giving consent. CNA 1, LVN 1, and the DON all had knowledge of the incident between Residents 1 and 3 but failed to initiate an investigation or immediately report the abuse incident to the Administrator who was the facility's Abuse Coordinator. In addition, the Administrator failed to identify the potential sexual abuse and conduct a thorough investigation. These failures placed Resident 1 and other residents at risk for further abuse by Resident 3 due to a delay in developing and implementing interventions to keep Resident 1 safe as well as identify other potential victims of abuse. This permitted Resident 3 to perpetrate further incidents where he displayed inappropriate sexual behaviors towards Resident 1 including grabbing Resident 1's hand and placing it on his crotch and flickering his tongue (in a sexual manner) at Resident 1. * On 2/8/19, Resident 4 reported a licensed nurse was verbally abusive to her. The Administrator was immediately informed, however, failed to follow their abuse P&P in reporting, investigating the abuse allegation, and protecting the resident from the alleged abuser. Resident 4 was assigned to the same nurse the day after she reported the alleged verbal abuse. On 2/13/19 at 1545 hours, the Administrator and the DON were informed the Immediate Jeopardy was abated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 18 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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: Review of the facility's P&P titled Abuse Prevention Program revised 12/16 showed the residents have the right to be free from abuse including, but not limited to sexual abuse. As part of the resident abuse prevention, the administration will identify and assess all possible incidents of abuse and investigate and report any allegations of abuse within timeframes as required by federal requirements. Review of the facility's P&P titled Abuse Investigation and Reporting revised 7/17 showed all reports of resident abuse shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the facility's management. Findings of abuse investigations will also be reported. The Administrator will ensure any further potential abuse is prevented. The individual conducting the investigation will, at a minimum, obtain the following in writing: - Interview the person(s) reporting the incident, - Interview any witnesses to the incident, - Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition, - Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, - Interview the resident's roommate, family members, visitors, and - Interview other residents. Review of the facility's P&P titled Abusive Investigation and Reporting Procedures (undated) showed all staff members and others are responsible for reporting any alleged or witnessed abuse (mental, physical, sexual, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 19 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 seclusion, verbal, or fiduciary). Do not assume that someone has reported the incident. 1. According to an anonymous report received on 1/16/19, Resident 1 was observed being sexually abused by a male resident at Resident 1's bedside with his hand down Resident 1's pants, with the privacy curtain pulled. The report showed the DON did not report this incident and did not notify Resident 1's responsible party of the incident. On 1/25/19 at 0813 hours, Resident 1 was observed in her room lying in bed. Resident 1 was asked if she felt safe living at the facility. Resident 1 stated she did not feel safe living at the facility but could not elaborate why. Resident 1 was asked if she was touched inappropriately. Resident 1 stated some man touched her "down there" and pointed to her groin area. Resident 1 stated she "did not like it." When asked who had inappropriately touched her, Resident 1 stated the man who came into her room did. On 2/6/19 at 0855 hours, an interview was conducted with CNA 1. CNA 1 stated on 12/14/18, she found Resident 3 in Resident 1's room with the curtain drawn, sitting next to Resident 1's bed with his entire hand inside Resident 1's pants. CNA 1 stated she said "what are you doing" and Resident 3 removed his hand right away and left the room. CNA 1 stated she transferred Resident 1 to her wheelchair and left her by the nurses ' station and reported the incident to LVN 1. Medical record review for Resident 1 was initiated on 1/25/19. Resident 1 was readmitted to the facility on 6/21/18. Review of Resident 1's History and Physical Examinations dated 6/22, 11/26, and 12/30/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 20 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE showed Resident 1 did not have the capacity to understand and was not capable of decision making. Review of Resident 1's MDSs dated 10/3/18 and 1/3/19, showed Resident 1's cognition was moderately impaired. On 1/25/19 at 0930 hours, an interview was conducted with CNA 2. CNA 2 stated the facility's Abuse Coordinator was the Administrator. CNA 2 stated about a week ago (approximately one month after the 12/14/18 incident), she witnessed Resident 3 in Resident 1's room. CNA 2 stated Resident 3 left Resident 1's room after being seen by her. CNA 2 stated she reported the incident to the RN Supervisor for that shift because male residents were not supposed to be in the female residents' rooms. On 1/25/19 at 1223 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 stated a CNA approached her and RN 2 to inform them the CNA had witnessed Resident 3 touching Resident 1 in a sexual manner on 12/14/18. RN 1 stated she did not report the incident to the DON or to the Administrator because she thought reporting to the physician was enough. When asked who the facility's Abuse Coordinator was, RN 1 stated she did not know. RN 1 was asked if the incident between Resident 3 and Resident 1 could be considered sexual abuse. RN 1 stated yes, in hindsight, because Resident 3 did not have the capacity to consent. On 1/25/19 at 1244 hours, a telephone interview was conducted with RN 2. RN 2 was asked about the Progress Notes entry dated 12/20/18. RN 2 stated she remembered a CNA reporting Resident 3 was observed touching FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 21 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 1 in a sexual manner. RN 2 stated she did not ask the CNA for more details regarding the incident and she did not interview the residents involved. When asked why she did not ask the CNA for further details, RN 2 stated she did not remember. When asked why she did not interview Residents 1 and 3, RN 2 stated she did not remember. RN 2 stated the incident was only reported to the physician. On 1/25/19 at 1412 hours, an interview and concurrent facility document and medical record review was conducted with the Administrator. The Administrator stated she was not aware of the incident that occurred on 12/14/18, where Resident 3 was found with his hand down Resident 1's pants until six days later, on 12/20/18, when she was notified by the Case Manager. The Administrator stated CNA 1, LVN 1, and the DON did not immediately notify her of the incident. The Administrator stated she was the Abuse Coordinator and needed to know about the incidents so she could keep the residents safe by putting measures into place. The Administrator was asked to provide any documentation for the investigation related to the incident between Residents 1 and 3 on 12/14/18. The Administrator provided a onesided document titled Administrator Progress Notes dated 12/20/19 [sic]. The document showed the Administrator was notified of Resident 1 and Resident 3 engaging in a developing relationship where Resident 1 and Resident 3 have been found holding hands several times including in activities and the staff had concerns due to Resident 1 being married. The document showed the IDT discussed the residents' right to have private relationships with anyone of their choice and both residents were alert and oriented and able to express their wants and needs. The Administrator was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 22 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 asked why an abuse investigation was not conducted. The Administrator stated Resident 1 and Resident 3 had the right to be in a relationship, therefore she did not constitute it as abuse. The Administrator was asked if Resident 1 had the capacity to consent. The Administrator stated Resident 1 had the capacity to consent based on the nurses' documentation showing Resident 1 was alert and oriented. When asked what Resident 1 was alert and oriented to, the Administrator stated she did not know. The Administrator reviewed Resident 1's History and Physical Examinations dated 6/22, 11/26, and 12/30/18, which all showed Resident 1 did not have the capacity to understand and make medical decisions and was not capable of decision making. The Administrator stated Resident 3 agreed to boundaries via a written contract dated 12/24/1/8, which prohibited Resident 3 from entering female residents' rooms and keeping an arm's length distance from female residents while in group. The Administrator was asked why she had boundaries in place if she believed the relationship between Resident 1 and Resident 3 was consensual. The Administrator replied because Resident 1 and Resident 3 each had spouses. The Administrator was asked if Resident 1 and Resident 3 were assessed to have the capacity to consent to a relationship. The Administrator replied no. The Administrator verified her investigation did not include documentation to show interviews with any witnesses to the incident (CNA 1 and LVN 1), interview with the resident's attending physician to determine the resident's current level of cognitive function and medical condition, interviews with other staff members on all shifts who have had contact with these residents, interviews with Resident 1's roommate, or other residents to identify other potential victims of Resident 3. When asked why these interviews were not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 23 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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, the Administrator replied because she "did not constitute it as abuse" because the residents have a right to be in a relationship. The Administrator was asked what sexual abuse was. The Administrator stated any nonconsensual inappropriate touching would constitute as sexual abuse. On 1/25/19 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated she was notified of the incident between Resident 1 and Resident 3 on 12/14/18, when CNA 1 discovered Resident 3 in Resident 1's room and Resident 3 had his hand under the covers and below Resident 1's waist level. The DON stated Resident 1 did not have the capacity to consent and "she is definitely impaired." The DON stated prior to the incident on 12/14/18, Resident 1 and Resident 3's relationship started out as innocent hand holding and progressively escalated to inappropriate behavior. The DON stated both Resident 1 and Resident 3 had spouses and children. The DON was asked if Resident 1 was interviewed after the incident on 12/14/18 (a Friday). The DON stated no, no one spoke to Resident 1 after the incident because it was not appropriate to do so because Resident 1 did not have capacity. The DON was asked if she reported the incident to the Administrator. The DON stated no, but stated the Administrator knew about the incident because everyone knew about it and the incident was discussed during the next daily standup meeting (the following Monday) and the Administrator and the other department heads were present. The DON was asked if Resident 1 and Resident 3 were assessed to have the capacity to consent to be in a relationship or to engage in sexual activity. The DON replied no and stated Resident 1 did not have the capacity to consent or the capacity to make decisions. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 24 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was asked if she considered this incident to be sexual abuse. The DON stated no, because Resident 3's hand was just under the covers. The DON was asked why sexual abuse was not suspected since Resident 1 did not have the capacity to consent and she was inappropriately touched by Resident 3. The DON stated Resident 3 considered the relationship with Resident 1 to be consensual. The DON stated she was not aware of the documented incident on 12/20/18, where Resident 3 was noted touching a female resident sexually. On 1/25/19 at 1553 hours, an interview was conducted with Resident 1's attending physician, Physician 1. Physician 1 stated the facility did not report any incidents of Resident 1 being inappropriately touched by another resident. On 1/28/19 at 0846 hours, a telephone interview was conducted with the Ombudsman. The Ombudsman stated she was familiar with Resident 1 and Resident 3. The Ombudsman stated she noticed Resident 1 and Resident 3 were really touchy with each other. The Ombudsman stated she did not believe Resident 1 had the capacity to consent because Resident 1 was like an infant. The Ombudsman stated no report(s) of sexual abuse allegations were reported to her in December 2018. On 1/28/19 at 1148 hours, a telephone interview was conducted with CNA 1. CNA 1 stated, while making rounds on 12/14/18, she observed Resident 3 in Resident 1's room behind the closed privacy curtain touching Resident 1. When asked where Resident 3 was touching Resident 1, CNA 1 stated Resident 3 was touching Resident 1 in the private area with his hand inside Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 25 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 pants. CNA 1 stated Resident 3 got scared and left Resident's 1's room when CNA 1 found him. CNA 1 stated she immediately reported the incident to LVN 1. CNA 1 stated she did not report the incident to the Administrator or anyone else because she reported the incident to LVN 1. On 1/28/19 at 1205 hours, a telephone interview was conducted with LVN 1. LVN 1 stated she was informed by CNA 1 Resident 1 was in bed and Resident 3 was in his wheelchair in Resident 1's room behind the privacy curtain and Resident 3 had his hand down Resident 1's pants. LVN 1 stated Resident 1 had confusion and could not make her own decisions. LVN 1 stated she did not report the incident to the Administrator. On 2/6/19 at 0855 hours, a follow-up interview was conducted with CNA 1. CNA 1 stated, after witnessing the incident between Resident 1 by Resident 3, she immediately reported the incident to the nurse supervisor because she thought this was sexual abuse. CNA 1 stated as of today, the Administrator nor the DON asked her about the incident she had witnessed on 12/14/18. On 2/26/19 at 1000 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated he was Resident 1's designated decision maker. Family Member 2 stated the facility's DON called him three weeks or maybe a month ago regading an incident where a male resident was found in Resident 1's room. Family Member 2 stated there were no other details given to Family Member 2 except the two residents had been seen holding hands and their legs were touching when seated next to one another in their perspective wheelchairs. Family Member 2 stated he made sure the facility understood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 26 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 these behaviors were no okay with him. The facility assured Family Member 2 they would take care of the situation. On 2/7/19 an SOC-341 (a form used to report elderly/adult dependent abuse) dated 2/7/19, filled out by the Administrator, showed a report of the following resident to resident allegation of sexual abuse dated: *12/14/18, Resident 3 was observed in Resident 1's room with the privacy curtain pulled, and Resident 3's hand was under resident 1's sheets; *12/14/18, Resident 3 made inappropriate gestures with his hands and tongue towards Resident 1; *12/20/18, Resident 3 made inappropriate comments and held Resident 1's hands while in activities; *12/20/18, Resident 3 allegedly placed Resident 1's hand in his crotch area. On 2/11/19 at 1239 hours, CDPH L&C received a five-day follow up letter from the Administrator regarding the abuse investigations. The Administrator SUBSTANTIATED sexual abuse occurred with the two incidents on 12/14/18. Cross references to F600 and F609. 2. On 2/8/19 at 1252 hours, an interview was conducted with Resident 4. Resident 4 stated there was a nurse during the 2300 to 0700 hours shift who got "verbally abusive" to her. Resident 4 stated she did not like the way the nurse talked to her, and the nurse made her feel it was her fault to be dependent on staff for all care. On 2/8/19 at 1350 hours, the allegation of "verbal abuse" made by Resident 4 was reported to the Administrator who was also the facility's Abuse Coordinator. The Administrator stated she would investigate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 27 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Medical record review for Resident 4 was initiated on 2/12/19. Resident 4 was admitted to the facility on 1/3/19. Review of the History and Physical Examination dated 1/4/19, showed Resident 4 had the capacity to understand and make decisions. On 2/12/19 at 1207 hours, an interview was conducted with Resident 4. Resident 4 stated the verbal abuse she felt from the nurse (LVN 9) had "...progressed way beyond." When asked why, Resident 4 stated, after reporting the verbal abuse last Friday (2/8/19), LVN 9 was assigned to take care of her on Saturday on the 2300 to 0700 hours shift. Resident 4 stated at around 0130 hours, she informed LVN 9 her indwelling urinary drainage catheter was not draining and needed to be irrigated. Resident 4 stated she had to wait for approximately two hours and ended up calling 911 to get assistance because LVN 9 did not come return to irrigate her catheter. Resident 4 stated whenever she had LVN 9 as her nurse, she was full of dread and was worried about her health and safety. Review of the Emergency Department report dated 2/10/19 at 0444 hours, showed Resident 4 had urinary retention, the indwelling urinary catheter was not draining and was replaced. Resident 4 was also found to have a urinary tract infection. On 2/12/19 at 1239 hours, an interview was conducted with the Administrator. The Administrator stated the verbal abuse allegation reported to her on 2/8/19, was not investigated and reported according to the facility's abuse P&P because the Administrator did not think it was verbal abuse. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 28 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 Administrator was asked how she came to the conclusion the allegation was not verbal abuse since she did not investigate the allegation. The Administrator stated she determined it was not verbal abuse after talking to Resident 4. The Administrator stated Resident 4 told her "...the charge nurse was kind of rude every time she asked for help," and Resident 4 felt the nurse always reminded her of her situation. The Administrator stated she instructed the DON not to assign LVN 9 to take care of Resident 4. The Administrator stated she felt, after talking to Resident 4, there was no verbal abuse. Review of the Staff Interview Form dated 2/8/19, showed the SSD conducted an interview with Resident 4 regarding her concern with one of the nurses taking care of her. Resident 4 named LVN 9 as the nurse she was referring to during the 2300 to 0700 hours shift on 2/7/19. The interview showed Resident 4 was repositioned by her CNA around 0330 to 0400 hours; however, the CNA forgot to apply her ankle boots. Resident 4 pushed her call light and LVN 9 answered through the intercom. Resident 4 told LVN 9 she needed her CNA back to apply the ankle boots. LVN 9 responded "...she was already there for a long time, more than 15 minutes. Why are you taking so long? There are residents out here who are waiting 10 minutes because of you." Resident 4 further stated "...she kept saying I was making it harder for other residents. I felt like I was being chastised." Review of the staff assignment dated 2/9/19, showed LVN 9 was assigned to take care of Resident 4 during the 2300 to 0700 hours shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 29 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F609 Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, facility document review, and facility P&P FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 30 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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, the facility failed to ensure all allegations or suspicions of abuse were reported no later than two hours to the facility's Administrator, CDPH, and local law enforcement when Resident 3 was observed on more than one occasion exhibiting nonconsensual sexual behaviors towards Resident 1 who did not have the capacity to consent to being touched. This failure resulted in the sexual abuse to go unreported and uninvestigated. * On 12/14/18, Resident 3 was observed in Resident 1's room behind the closed privacy curtain with his hand inside Resident 1's pants. The DON acknowledged the incident but failed to immediately report the incident to the Administrator (the facility's Abuse Coordinator), state agency, Long-Term Ombudsman, and local law enforcement. In a separate incident that occurred on 12/20/18, six days later, Resident 3 was observed by staff touching Resident 1 in a sexual manner, RNs 1 and 2 who had knowledge of the incident failed to immediately report the incident to the Administrator and other proper authorities. Findings: Review of the facility's P&P titled Abuse Investigation and Reported revised 7/17 showed under Reporting, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator or his/her designee to the following persons or agencies: - The State Licensing/Certification agency (CDPH) responsible for surveying/licensing the facility, - The local Long-Term Ombudsman, - Adult Protective Services (where state law provides jurisdiction in long-term care), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 31 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 - Law enforcement officials, - The resident's attending physician, and - The facility's Medical Director The policy also showed an alleged violation of abuse will be reported immediately, but not later than two hours if the alleged violation involves abuse. The Administrator or designee will provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident. Review of the facility's P&P titled Abusive Investigation and Reporting Procedures (undated) showed all staff members and others are responsible for reporting any alleged or witnessed abuse (mental, physical, sexual, seclusion, verbal, or fiduciary) and to not assume that someone has reported the incident. According to an anonymous report received on 1/16/19, Resident 1 was observed being sexually abused by a male resident at Resident 1's bedside with his hand down Resident 1's pants, with the privacy curtain pulled. The report showed the DON did not report this incident and did not notify Resident 1's responsible party of the incident. Medical record review for Resident 1 was initiated on 1/25/19. Resident 1 was readmitted to the facility on 6/21/18. Review of Resident 1's History and Physical Examinations dated 6/22, 11/26, and 12/30/18, showed Resident 1 did not have the capacity to understand and make medical decisions and was not capable of decision making. Review of Resident 1's Progress Notes showed a nursing note written by LVN 1 dated 12/14/18, which showed CNA 1 reported she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 32 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 had found Resident 1 lying in bed with Resident 3 at Resident 1's bedside with his hand down Resident 1's pants. Resident 1's privacy curtains had been pulled closed to prevent visualization of Resident 1 from the hallway. On 1/25/19 at 1412 hours, an interview and concurrent facility document and medical record review for Resident 1 was conducted with the Administrator. The Administrator stated she was not aware of the abuse incident that occurred on 12/14/18, where Resident 3 was found with his hand down Resident 1's pants until six days later, on 12/20/18, when she was notified by the Case Manager. The Administrator stated CNA 1, LVN 1, and the DON did not immediately notify her of the incident. The Administrator was asked what the staff was supposed to do if they suspected abuse. The Administrator stated if the staff suspected abuse they were required to report it to her immediately and report to the state agency, Ombudsman, and local law enforcement. The Administrator was asked if by reporting suspicion of abuse to the Administrator, it negated the staff's responsibility to report to the authorities. The Administrator stated no, everyone was a mandated reporter and should report to the proper authorities. On 1/25/19 at 1500 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated she was notified on 12/14/18, of the incident between Residents 1 and 3 when CNA 1 discovered Resident 3 in Resident 1's room behind the closed privacy curtain with his hand under the covers below Resident 1's waist level. The DON stated Resident 1 did not have the capacity to consent and "she is definitely impaired." The DON was asked if she reported FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 33 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 incident to the Administrator. The DON replied no, but said the Administrator knew about it because everyone knew about it and it was discussed in the next daily standup meeting with the Administrator and the other department heads present. The DON was asked if she reported the incident to the state agency, Ombudsman, and local law enforcement. The DON replied no, because it was the Administrator's responsibility to conduct the investigation and report the incident. On 1/28/19 at 0846 hours, a telephone interview was conducted with the Ombudsman. The Ombudsman stated the facility did not report any allegations of abuse related to Residents 1 or 3 during December 2018. On 1/28/19 at 1148 hours, a telephone interview was conducted with CNA 1. CNA 1 stated she reported the incident to LVN 1. CNA 1 stated she did not report the incident to the Administrator or anyone else because she reported the incident to LVN 1. On 1/28/19 at 1205 hours, a telephone interview was conducted with LVN 1 regarding the sexual abuse incident between Residents 1 and 3 reported to her on 12/14/18. When asked if she reported the abuse to the Administrator, LVN 1 stated she did not report the incident to the Administrator. On 1/25/19 at 1223 hours, an interview and concurrent medical record review was conducted with RN 1 regarding the sexual abuse by Resident 3 to Resident 1. When asked if she reported the sexual abuse to anyone, RN 1 stated she reported the incident to the physician and obtained an order to monitor Resident 3's behavior. RN 1 stated she did not report the incident to the DON or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 34 of 35 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: _______________ 555751 (X3) DATE SURVEY COMPLETED 02/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (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 Administrator because she thought reporting to the physician was enough. On 1/25/19 at 1244 hours, a telephone interview was conducted with RN 2 regarding the sexual abuse by Resident 3 to Resident 1. RN 2 was asked to whom she had reported the abuse. RN 2 stated the incident was only reported to the physician. Cross references to F600 and F607, example #1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CT4611 Facility ID: CA060000131 If continuation sheet 35 of 35