Other·August 20, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the concurrent RECERTIFICATION, RELICENSING, and ABBREVIATED surveys for COMPLAINT No. CA00644515. Representing the California Department of Public Health: Surveyor 38492, HFEN; Surveyor 41310, HFEN; Surveyor 39199, HFEN; Surveyor 38489, HFEN; Surveyor 35346, HFEN; Surveyor 41418, HFEN; Surveyor 37726, HFEN; and Surveyor 34325, HFES. The surveyors entered the facility on 7/9/19 at 0730 hours. The census was 79. FOR COMPLAINT No. CA00644515: THE DEPARTMENT WAS UNABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION(S). GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living bpm - beat per minute CHHA - Certified Home Health Aide cm - centimeter(s) CNA - Certified Nursing Assistant DON - Director of Nursing DSS - Dietary Service Supervisor Friction - the mechanical force exerted on skin that is dragged across any surface GT - gastrostomy tube (a tube inserted through the abdomen into the stomach to administer nutritional formula and/or medications) IDT - Interdisciplinary Team LVN - Licensed Vocational Nurse LPM - liters per minute MDS - Minimum Data Set (A standardized 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: O69U11 Facility ID: CA060000131 If continuation sheet 1 of 83 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 07/15/2019 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 assessment tool) mcg - microgram(s) mg - milligram(s) ml - milliliter(s) mmHg - millimeter(s) of mercury Pressure ulcer - localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. P&P - policy and procedure RD - Registered Dietitian RN - Registered Nurse RT - Respiratory Therapist Shearing - occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage SBP - systolic blood pressure (the top reading of a blood pressure) SSD - Social Service Director

F582 SS=B Medicaid/Medicare Coverage/Liability Notice CFR(s): 483.10(g)(17)(18)(i)-(v)

F582 08/01/2019 §483.10(g)(17) The facility must-(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 2 of 83 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 07/15/2019 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 specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to provide one of three non-sampled residents (Resident 628) with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 3 of 83 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 07/15/2019 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 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. The SNF ABN Form CMS-10055 is used to inform residents of their potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare. This posed the risk of the resident not being allowed to make an informed decision regarding their Medicare services. Findings: On 7/12/19 at 1446 hours, an interview and concurrent facility document review was conducted with the Billing Supervisor. The Billing Supervisor stated Resident 628's Medicare Part A skilled services episode start date was 3/20/19, and the last covered day of Part A service was 4/28/19. Resident 628 was discharged on 5/18/19. The Billing Supervisor was asked to provide the original notice or documentation Resident 628 was provided with the SNF ABN Form CMS-10055. The Billing Supervisor stated Resident 628 was not provided with the SNF ABN Form CMS-10055. She stated, "I have never seen the form and have never given it to any resident."

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 08/15/2019 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 4 of 83 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 07/15/2019 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 §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure the privacy was provided for one of 21 final sampled residents (Resident 10) during care. The facility failed to ensure the visual privacy was provided for Resident 10 during ADL care. This failure violated the resident's right to privacy. Findings: On 7/9/19 at 1257 hours, CNA 4 was observed providing ADL care to Resident 10. Resident 10 was in the bed closest to the door, in a shared room with one other resident. Resident 10 was observed fully undressed and exposed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 5 of 83 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 07/15/2019 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 10's privacy curtain was observed open in between the two beds and open at the foot of the bed, leaving Resident 10 visible when entering the room. CNA 4 stated she was providing ADL care to Resident 10 but was waiting for another staff member to come help her. CNA 4 verified the privacy curtain should have been closed because the resident was undressed and exposed. Medical record review for Resident 10 was initiated on 7/9/19. Resident 10 was readmitted to the facility on 6/19/18. Review of Resident 10's plan of care showed a care plan problem dated 6/21/18, to address Resident 10's altered mobility. The interventions included to provide privacy when giving care.

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 08/15/2019 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 6 of 83 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 07/15/2019 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 §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure a clean, safe, and comfortable environment was maintained for two of 21 final sampled residents (Residents 377 and 49). * The facility failed to ensure Resident 377's bed was placed on a level surface and failed to ensure the oxygen concentrator was clean. * The wall in Room B was observed with stains and door trim had splintered wood which posed the risk of injury to the residents' skin. These failures had the potential to affect the residents' well-being. Findings: 1. On 7/10/19 at 0930 hours, an observation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 7 of 83 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 07/15/2019 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 concurrent interview was conducted with Resident 377. Resident 377 was observed in bed with oxygen being administered via nasal cannula. The oxygen concentrator was covered in dust and a black substance. The bed was observed on an uneven surface due to the downgrade of the floor towards the wall. Resident 377 stated the uneven floor really bothered him and made him feel unsafe. Medical record review for Resident 377 was initiated on 7/10/19. Resident 377 was admitted to the facility on 6/22/18, and readmitted to the facility on 7/3/19. Review of Resident 377's MDS dated 5/2/19, showed Resident 377 was cognitively intact. Review of Resident 377's plan of care showed a care plan problem dated 7/5/19, addressing Resident 377 had shortness of breath related to anxiety, decreased energy and fatigue, and respiratory failure. The care plan interventions included to position the resident with proper body alignment for an optimal breathing pattern. On 7/10/19 at 0942 hours, an observation and concurrent interview was conducted with the Maintenance Director. When asked who was responsible for cleaning the oxygen concentrator, the Maintenance Director stated housekeeping. The Maintenance Director stated each month every room is deep cleaned. When asked what constitutes a deep cleaning, the Maintenance Director stated the cleaning included all resident equipment, including the oxygen concentrator. The Maintenance Director verified the oxygen concentrator was dirty, and stated it should have been cleaned. When asked about the uneven floor, the Maintenance Director stated the floor was unable to be fixed because doing so would FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 8 of 83 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 07/15/2019 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 affect the basement ceiling. The Maintenance Director used a level to show the floor under Resident 377's bed and the bed itself were not on a level surface. Review of the facility document titled Monthly Deep Cleaning Resident Rooms showed Resident 377's room was deep cleaned on 6/17/19. On 7/10/19 at 1052 hours, an interview was conducted with Housekeeper 1. Housekeeper 1 was asked if cleaning the oxygen concentrator was included in the routine cleaning. Housekeeper 1 stated no. On 7/11/19 at 0845 hours, an observation and follow-up interview was conducted with Resident 377. Resident 377 was observed sitting up in bed, slightly leaning to his left towards the wall. Resident 377 stated when they turned him to the left to provide ADL care, he felt like he was going to fall into the wall so he used his hand to stop himself from hitting the wall. Resident 377 stated he did not like to get up and shower because he felt unsafe getting up using the Hoyer lift (a hydraulic lift to transfer residents from the bed and back); therefore he usually requested a bed bath. Resident 377 stated he felt very frustrated they hadn't moved him when he told them multiple times about his concerns. 2. On 7/9/19 at 0932 hours, during the initial tour, the wall in Room B next to the door was observed with brownish stains in several places. The wall had chipped paint and the wall trim was worn out with sharp splinters sticking out. Resident 49 was observed lying in bed. On 7/10/19 at 0804 hours, an interview was conducted with CNA 3. CNA 3 confirmed the brown stains and chipped paint on the wall of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 9 of 83 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 07/15/2019 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 Room B. CNA 3 stated the brown stains might be food particles because Resident 49 threw her food at times when she did not want to eat. CNA 3 stated the chipped paint could be from moving the bed next to the wall and raising and lowering the side rails on Resident 49's bed. On 7/10/19 at 0824 hours, the Maintenance Director and LVN 7 confirmed the wall in Room B next to the door had chipped paint, brownish stains on the wall and the wall trim was worn out with sharp splinters sticking out of some areas.

F604 SS=D Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 09/29/2019 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 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)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 10 of 83 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 07/15/2019 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 that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one nonsampled resident (Resident 54) was free from physical restraints. The facility failed to ensure the least restrictive measures for the least amount of time with documented and the ongoing re-evaluation was performed in regards to the right hand mitten restraint used on Resident 54. This resulted in compromising resident 54' s independence and psychological well-being. Findings: On 7/9/19 at 0835 hours, Resident 54 was observed lying in bed with a soft hand mitten restraint to her right hand. Medical record review for Resident 54 was initiated on 7/9/19. Resident 54 was readmitted to the facility on 11/21/18. Review of Resident 54's Order Summary Report dated 7/10/19, showed a physician's order dated 1/2/19, to apply a hand mitten to the right hand at all times due to pulling out of medical device (GT) and release every two hours for circulation, mobility, and skin assessment. Review of Resident 54's care plan showed a care plan problem dated 2/26/19, addressing the right hand mitten. The interventions included evaluating the resident's use of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 11 of 83 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 07/15/2019 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 right hand mitten, including risk/benefits, alternatives, need for ongoing use and reason for use. Review of the Informed Consent Verification form dated 12/12/18, showed an informed consent was obtained from Resident 54's legal representative by the physician for the use of a right hand mitten to prevent the resident from pulling out the GT. There was no further documentation found in Resident 54's medical record to show any least restrictive alternatives had been attempted by the staff for the least amount of time, or any re-evaluation of the ongoing need for the right hand mitten restraint was completed. On 7/11/19 at 0838 hours, an interview was conducted with RN 1. RN 1 confirmed no least restrictive interventions were attempted with Resident 54 prior to the right hand mitten being placed and no trial reduction was attempted since Resident 54's readmission on 11/21/18.

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

F609 08/15/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 12 of 83 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 07/15/2019 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 (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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure allegations of abuse were reported for one resident (Resident 5), an injury of unknown origin was reported within two hours for one resident (Resident 46), a missappropriation of Resident 59's property and a resident to resident altercation for two residents (Residents 39 and 59). * The facility failed to report Resident 5's allegation of sexual abuse against Resident 41. * Resident 46 sustained a bump on the back of her head from an unknown source. The facility failed to report the incident to the state agency as per the facility's abuse reporting P&P. * The facility failed to report an allegation of misappropriation of property for Resident 59. * The facility failed to report a resident to resident altercation between Residents 59 and 39. These failures put the residents at risk for further abuse and/or injury. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 13 of 83 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 07/15/2019 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 Investigation and Reporting dated 7/17 showed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. 1. On 7/10/19 at 1434 hours, a requested interview was conducted with Resident 5. Resident 5 stated a couple of weeks prior, she was on the smoking patio with Resident 41. Resident 5 stated Resident 41 was unclothed from the waist down and had a towel on his lap. Resident 5 stated Resident 41 often only covered himself with a towel; however, on this day he had moved the towel so his abdomen and penis were exposed. Resident 5 stated Resident 41 was observed by the smoking patio exit "stroking himself." Resident 5 stated it made her very uncomfortable because she was unable to leave the smoking patio without going past Resident 41. Resident 5 stated she informed the SSD. Medical record review for Resident 5 was initiated on 7/10/19. Resident 5 was admitted to the facility on 1/3/19. Review of Resident 5's MDS dated 4/12/19, showed Resident 5 was cognitively intact. On 7/10/19 at 1456 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD was asked if Resident 5 had reported any incidents to her. The SSD stated she remembered an incident when a resident was wearing inappropriate clothing. The SSD verified Resident 5 reported to her on 7/1/19, Resident 41 was wearing only FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 14 of 83 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 07/15/2019 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 a towel and exposed himself and stroked himself in front of her. The SSD stated she filled out a grievance form and gave it to both the DON and Administrator on the same day. The SSD stated she did not know what happened after she handed over the grievance form. Review of the facility's document titled Grievance Report/Concerns & Issues dated 7/1/19, showed Resident 5 reported, another resident came out with nothing but a towel over his crotch area, then he pushed it away from that area and started stroking himself. On 7/10/19 at 1518 hours, an interview was conducted with the DON. The DON was asked if she was aware of the above incident. The DON stated she thought the incident was reported to her on Friday around 1700 hours, but was unsure. When asked what her next actions were, the DON stated, "I didn't do anything." The DON stated she discussed it with the SSD and, because this was the first complaint about Resident 41 touching himself, she thought Resident 5 was exaggerating. When asked for clarification if she did an investigation, the DON stated she did not initiate an investigation. The DON stated Resident 41 had not worn pants for years since he'd been in the facility. The DON stated several staff had complained about Resident 41 not wearing pants. When asked if there were interventions in place for Resident 41's behavior of not wearing pants, the DON stated he was currently not being monitored. When asked if she had interviewed Resident 5 about the incident, the DON stated no. The DON stated she did not speak to Resident 5 because Resident 5 is not her "biggest fan." The DON stated she was informed other residents complained during the Resident Council meeting on 7/8/19, about Resident 41 not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 15 of 83 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 07/15/2019 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 wearing pants. The DON stated the residents were offended. When asked what was done about those complaints, the DON stated the staff member who was in the Resident Council meeting and another staff member "probably would have started following up yesterday" but the surveyors arrived. On 7/10/19 at 1541 hours, an interview and record review was conducted with the Administrator. The Administrator stated he did not remember if he was made aware of the incident on 7/1/19; however, he knew Resident 41 would not do that and stated Resident 5 was nearsighted and could not see anything. (Cross Reference F610, Example 1) 2. Medical record review for Resident 46 was initiated on 7/9/19. Resident 46 was admitted to the facility on 3/27/18, and readmitted on 8/4/18. Review of the MDS dated 5/17/19, showed Resident 46 had severely impaired cognition and was totally dependent on staff for care. Review of a Health Status Note dated 7/2/19, showed Resident 46 sustained a bump to the back of her head, and an investigation was completed. On 7/12/19 at 1451 hours, an interview was conducted with the Administrator. The Administrator stated he was the facility's Abuse Coordinator. The Administrator stated the facility conducted an investigation for a bump Resident 46 sustained on the back of her head identified on 7/2/19. The Administrator stated, at the conclusion of the facility's investigation, he was unable to determine the cause of the bump on Resident 46's head. The Administrator stated the facility failed to report this incident to the state agency. The Administrator verified the incident should have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 16 of 83 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 07/15/2019 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 been reported to the state licensing/certification agency responsible for surveying and licensing the facility. 3. Medical record review for Resident 59 showed the resident had no cognitive impairment. Review of Resident 59's Progress Notes showed an entry dated 6/9/19 at 1400 hours, showing Resident 59 had falsely accused a CNA of taking her clothes and not returning it. The writer documented the incident would never happen, "...This CNA barely takes care of her." Review of the Progress Notes showed an entry dated 6/12/19 at 1411 hours, showing Resident 59 reported her clothes being stolen by another resident or was lent to a staff for an occasion and was not returned. On 7/11/19 at 1423 hours, an interview was conducted with the Administrator. The Administrator stated he was not made aware of Resident 59's allegations of a staff member borrowing clothes and did not return the clothes. The Administrator stated Resident 59 had previous episodes of allegations of people taking her clothes only to find out the clothes were in her cabinet. When asked he were made aware of this allegation, would he have investigated, the Administrator stated possibly. When asked if it needed to be reported to the state, the Administrator stated yes. (Cross Reference F610, example 3a). 4. Review of Resident 59's Progress Notes showed an entry dated 5/15/19 at 1028 hours, showing an activity staff had reported Resident 59's aggressive behavior towards Resident 39. During activities, Resident 59 grabbed the playing cards and threw them at Resident 39's face. Resident 59 called Resident 39 vulgar FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 17 of 83 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 07/15/2019 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 term And Residents 39 and 59 were separated. On 7/11/19 at 1423 hours, an interview was conducted with the Administrator. The Administrator stated a resident to resident altercation may be a disagreement, but is not abuse. When asked if throwing cards at another resident's face and calling that resident a bad name was acceptable, the Administrator stated no but it was just a disagreement, not necessarily an incident of abuse. When asked if the incident was investigated, the Administrator stated no. When asked if it was reported, the Administrator stated no. On 7/15/19 at 0959 hours, a concurrent interview and record review was conducted with the SSD. The SSD stated, since she was not made aware of this incident, an investigation had not been initiated, nor was it reported to the state. (Cross Reference F610, example 3b).

F610 SS=E Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 08/15/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 18 of 83 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 07/15/2019 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 verified appropriate corrective action must be taken. 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 ensure the allegations of abuse were investigated for two of 21 final sampled residents (46 and 59) and two nonsampled residents (Residents 5 and 39) and an injury of unknown origin was investigated for one of 21 final sampled residents (Resident 46). * The facility failed to report Resident 5's allegation of sexual abuse against Resident 41. * Resident 46 sustained a bump on the back of her head from an unknown source. The facility failed to conduct a thorough investigation as evidenced by the failure to conduct interviews with all staff members who might have had contact with Resident 46 during the period of the alleged incident and the failure to document interviews or attempted interviews with Resident 46's roommates as per the facility's P&P for abuse. * The facility failed to investigate Resident 59's allegation of a CNA taking her clothes. * The facility failed to initiate an investigation when Resident 59 threw game cards at Resident 39's face and called her a vulgar name. The failures to conduct thorough investigations put the residents at risk for further abuse and/or injury. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 19 of 83 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 07/15/2019 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 of the facility's P&P titled Abuse Investigation and Reporting dated 7/17 showed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. 1. On 7/10/19 at 1434 hours, a requested interview was conducted with Resident 5. Resident 5 stated a couple of weeks prior she was on the smoking patio with Resident 41. Resident 5 stated Resident 41 was unclothed from the waist down and had a towel on his lap. Resident 5 stated Resident 41 often only covered himself with a towel; however, on this day he had moved the towel so his abdomen and penis were exposed. Resident 5 stated Resident 41 was observed by the smoking patio exit "stroking himself." Resident 5 stated it made her very uncomfortable because she was unable to leave the smoking patio without going past Resident 41. Resident 5 stated she informed the SSD. Medical record review for Resident 5 was initiated on 7/10/19. Resident 5 was admitted to the facility on 1/3/19. Review of Resident 5's MDS dated 4/12/19, showed Resident 5 was cognitively intact. On 7/10/19 at 1456 hours, an interview and concurrent record review was conducted with the SSD. The SSD was asked if Resident 5 had reported any incidents to her. The SSD stated she remembered an incident when a resident was wearing inappropriate clothing. The SSD verified Resident 5 reported to her on 7/1/19, Resident 41 was wearing only a towel and then exposed himself and stroked himself in front of her. The SSD stated she filled out a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 20 of 83 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 07/15/2019 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 grievance form and gave it to both the DON and Administrator on the same day. The SSD stated she did not know what happened after she handed over the grievance form. Review of the facility's document titled Grievance Report/Concerns & Issues dated 7/1/19, showed Resident 5 reported another resident came out with nothing but a towel over his crotch area, then he pushed it away from that area and started stroking himself. On 7/10/19 at 1518 hours, an interview was conducted with the DON. The DON was asked if she was aware of the above incident. The DON stated she thought the incident was reported to her on Friday around 1700 hours, but was unsure. When asked what her next actions were, the DON stated, "I didn't do anything." The DON stated she discussed it with the SSD, and because this was the first complaint about Resident 41 touching himself, she thought Resident 5 was exaggerating. When asked for clarification if she did an investigation, the DON stated she did not initiate an investigation. The DON stated Resident 41 had not worn pants for years since he'd been in the facility. The DON stated several staff had complained about Resident 41 not wearing pants. When asked if there were interventions in place for Resident 41's behavior of not wearing pants, the DON stated he was currently not being monitored. When asked if she had interviewed Resident 5 about the incident, the DON stated no. The DON stated she did not speak to Resident 5 because Resident 5 was not her "biggest fan." The DON stated she was informed other residents complained during the Resident Council meeting on 7/8/19, about Resident 41 not wearing pants. The DON stated the residents were offended. When asked what was done about those complaints, the DON stated two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 21 of 83 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 07/15/2019 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 staff members probably would have started following up on it yesterday, but the surveyors arrived. On 7/10/19 at 1541 hours, a concurrent interview and facility document review was conducted with the Administrator. The Administrator stated he did not remember if he was made aware of the incident on 7/1/19; however, he knew Resident 41 would not do that and stated Resident 5 was nearsighted and could not see anything. On 7/10/19 at 1548 hours, Resident 41 was observed from the hallway in his room. Resident 41's door was open and the privacy curtain was not closed. Resident 41 was observed in bed fully unclothed except for a towel partially covering his penis. On 7/10/19 at 1550 hours, LVN 4 entered Resident 41's room and closed the privacy curtain. LVN 4 verified Resident 41 was naked with the towel not fully covering his penis. LVN 4 stated Resident 41 was often naked and did not like to wear clothes. On 7/10/19 at 1601 hours, an interview was conducted with LVN 4. LVN 4 stated the resident was fully exposed most of the time while in bed. LVN 4 stated she has walked in on him a couple of times while he was masturbating because he refused to close the curtain. LVN 4 stated Resident 41 used to selfpropel his wheelchair in the hallway, naked, but now he usually wore a towel. LVN 4 stated on 7/9/19 after 1700 hours, Resident 41 was fully exposed in bed. LVN 4 stated she reported it to the DON, and the DON got up and told Resident 41 to cover up because it was not appropriate behavior. LVN 4 stated she always had to ask Resident 41 to cover himself before he was given his medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 22 of 83 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 07/15/2019 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 During the above interview, the Maintenance Director walked by and was asked about Resident 41. The Maintenance Director stated he had seen the resident self-propel his wheelchair in the hallway with a towel on. The Maintenance Director stated Resident 41 threw his towel on the ground and pretended it fell off when some people were around. The Maintenance Director stated he informed Resident 41 it was not right to do that. On 7/10/19 at 1605 hours, an interview was conducted with RN 5. RN 5 stated Resident 41 was usually fully exposed when in bed and she had to ask him to cover himself before she gave him medications. Review of Resident 41's plan of care showed a care plan problem dated 11/7/18, addressing Resident 41 traveling in and out of the facility in a wheelchair without proper clothing and having no pants on and covers self with a small towel or blanket. The interventions included to monitor behavior episodes, document the behaviors and potential causes, and intervene as necessary to protect the rights and safety of others. Review of Resident 41's medical record failed to show any other documentation regarding Resident 41's behaviors of not wearing proper clothing. On 7/10/19 at 1649 hours, RN 5 was asked why there was no other documentation regarding Resident 41 being naked or covered with only a towel. RN 5 stated she guessed because it was the norm for the resident. On 7/10/19 at 1710 hours, an interview was conducted with LVN 4. LVN 4 was asked why she did not document regarding Resident 41's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 23 of 83 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 07/15/2019 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 behaviors. LVN 4 stated she did not document because when Resident 41 was in his room she figured it was his business. LVN 4 stated since she started working for the facility one and a half years ago, Resident 41's behaviors had always been the norm for him. On 7/11/19 at 0905 hours, a follow-up interview was conducted with the DON. The DON was asked if an investigation was done regarding Resident 5's allegation. The DON stated no. The DON was asked if she had interviewed Resident 5 and she stated no. The DON stated she did not think Resident 41 was aware he was not fully covered because he was paraplegic, and she did not think he was a voyeur. On 7/11/19 at 0931 hours, a follow-up interview was conducted with Resident 5. Resident 5 was asked again about her allegation regarding Resident 41 on the patio. Resident 5 stated Resident 41 was on the smoking patio in front of the sliding doors, blocking the exit. Resident 5 stated she was on the other side of the patio near the ashtray. Resident 5 stated in order to leave she would have had to pass him and that was way too close for comfort. Resident 5 stated she was shocked and she could not believe it was happening. Resident 5 stated Resident 41 had moved the towel that was covering his leg over, exposing himself. Resident 5 stated she saw Resident 41's hand going back and forth, and noticed his eyes were closed and he had a facial expression of pleasure. Resident 5 stated it was very disturbing and she did not feel safe here. Resident 5 stated eventually Resident 41 went back to his room after what felt like an eternity. When asked if anybody had spoken to her about the incident since she reported it to the SSD on 7/1/19, Resident 5 stated no. Resident 5 stated she felt like nothing gets done about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 24 of 83 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 07/15/2019 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 her complaints and Resident 41 received special treatment. 2. Review of the facility's P&P titled Abuse Investigation and Reporting revised July 2017, showed all reports of injuries of unknown source shall be thoroughly investigated by facility management. The individual conducting the investigation will at a minimum, interview staff members who had contact with the resident during the period of the alleged incident, and interview the resident's roommates. Witness reports will be obtained in writing. Medical record review for Resident 46 was initiated on 7/9/19. Resident 46 was admitted to the facility on 3/27/18, and readmitted on 8/4/18. Review of the MDS dated 5/17/19, showed Resident 46 had severely impaired cognition and was totally dependent on staff for care. Review of a Health Status Note dated 7/2/19, showed Resident 46 sustained a bump to the back of her head, and an investigation was completed. On 7/12/19 at 1044 hours, an interview and concurrent facility record review was conducted with LVN 3. LVN 3 stated he conducted the investigation for the bump Resident 46 sustained to the back of her head, which was identified on 7/2/19. LVN 3 stated he was unable to determine the cause of the bump Resident 46 sustained to the back of her head. LVN 3 stated as part of his investigation he interviewed staff. Review of LVN 3's investigation, documented on the Investigation of Incident/Accident/Injury of Unknown Origin dated 7/2/19, showed LVN 3 interviewed CNA 2 and an x-ray technician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 25 of 83 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 07/15/2019 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 investigation failed to show additional staff were interviewed as part of his investigation. LVN 3 was asked if he attempted to locate any additional staff (RNs, LVNs CNAs, RNAs, dietary staff, maintenance staff, or activities staff) who may have had contact with Resident 46 or may have witnessed how Resident 46 sustained a bump to the back of her head. LVN 3 stated he did not and verified CNA 2 and the x-ray technician were the only staff members he interviewed during the investigation. LVN 3's investigation failed to show documentation Resident 46's roommates were interviewed as part of the investigation. LVN 3 stated on 7/2/19 (date Resident 46 was discovered to have a bump on the back of her head) Resident 46 had two roommates; Residents 25 and 43. LVN 3 verified his investigation failed to show documentation attempts were made to interview Resident 46's roommates. 3. Review of Resident 59's medical record was initiated on 7/9/19. Resident 59 was admitted to the facility on 8/25/18. Review of the MDS dated 6/7/19, showed Resident 59 was cognitively intact. a. On 7/9/19 at 0900 hours, during initial tour, an interview was conducted with Resident 59. Resident 59 stated a staff borrowed her sweater and would not return it. Resident 59 stated she had reported the incident to the staff. Resident 59 stated she did not want to go out of her room because she was protecting her personal property. On 7/11/19 at 1106 hours, an interview was conducted with RN 1. RN 1 acknowledged Resident 59 had alleged a CNA borrowed her clothes and had not returned it. RN 1 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 26 of 83 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 07/15/2019 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 59 had episodes of falsely accusing staff of taking her clothes. RN 1 stated the CNA Resident 59 was referring to was CNA 6. When asked if an investigation was initiated to address Resident 59's allegation, RN 1 stated he asked CNA 6 and other staff. When asked if the investigation was documented, RN 1 stated no. When asked what happened to CNA 6, RN 1 stated nothing was done since CNA 6 was not capable of taking Resident 59's clothes. When asked if the facility staff were allowed to take or borrow any resident's personal items, RN 1 stated no. When asked what needed to be done when there was an allegation of staff taking resident's personal items, RN 1 stated an investigation had to be done. When asked how he knew CNA 6 did not take Resident 59's clothes when there was no investigation initiated, RN 1 did not respond. On 7/11/19 at 1340 hours, an interview was conducted with the DON. The DON stated Resident 59's allegation of her clothes was taken by the CNA did not happen. The DON stated Resident 59 had falsely accused other people of taking her things. The DON stated the SSD investigated this incident and had found her clothes inside the cabinet. On 7/11/19 at 1401 hours, an interview was conducted with SSD. The SSD stated when allegations of staff taking items from residents, it needed to be investigated. The SSD stated on 6/9/19, Resident 59 complained she lost all her clothes. The SSD stated all her clothes were found inside the resident's cabinet. The SSD stated this was the only incident logged in her Theft and Loss Control Log, The SSD stated she was not made aware of an incident when Resident 59 alleged a staff member had taken her clothes. The SSD acknowledged an investigation was not initiated. The SSD stated an investigation should have been initiated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 27 of 83 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 07/15/2019 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 since the allegation involved a facility staff member to rule out the possibility of abuse. b. Review of Resident 59's Progress Notes showed an entry dated 5/15/19, showing an activity staff reported Resident 59 had aggressive behavior towards Resident 39. During activities, Resident 59 grabbed the playing cards and threw them in Resident 39's face. Resident 59 called Resident 39 a vulgar name, and Residents 39 and 59 were separated. Review of Resident 39's medical record was initiated on 7/11/19. Resident 39 was admitted to the facility on 10/28/17. Review of the Neuropsychological Test Summary Evaluation Result and Report for Two or More Tests dated 5/31/19, showed Resident 39 had slightly declining moderate dementia. On 7/11/19 at 0917 hours, an interview was conducted with the Activity Assistant. The Activity Assistant stated Resident 59 enjoyed playing bingo, cards, and black jack. When asked if Resident 59 had shown aggressive behaviors during activities with other residents, she stated no. When asked if she was aware of an incident involving Residents 39 and 59, she stated no. On 7/11/19 at 1106 hours, an interview was conducted with RN 1. RN 1 stated he was informed by the Activity Assistant about Resident 59 throwing cards in Resident 39's face and calling her a vulgar name. When asked if an investigation was initiated, RN 1 stated he talked to Residents 39 and 59 and both of them denied it happened. RN 1 stated the incident was not an altercation since only one resident was aggressive. RN 1 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 28 of 83 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 07/15/2019 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 39 did not respond to Resident 59's aggressive behavior. RN 1 stated the incident did not warrant further investigation since both residents were denying it. When asked how the Activity Assistant witnessed the incident, RN 1 did not respond. When ask if resident to resident altercations needed to be investigated, RN 1 stated it depended on the incident. When asked if a resident to resident altercation was a form of abuse, RN 1 did not respond. When asked how the facility ensured Residents 39 and 59 were safe, RN 1 stated both were separated immediately. When asked what other interventions were put in place to ensure Residents 39's and 59's safety, RN 1 did not respond. On 7/11/19 at 1405 hours, an interview was conducted with the Activity Assistant. The Activity Assistant stated during activities, Resident 59 got upset and threw bingo cards in Resident 39's face. Resident 59 called Resident 39 a vulgar name. The Activity Assistant stated she separated Residents 39 and 59 and informed RN 1 about the incident. On 7/11/19 at 1340 hours, an interview was conducted with the DON. When asked what was done to address the incident of Resident 59 throwing cards in Resident 39's face, the DON stated the residents were separated. When asked if an investigation was initiated, the DON acknowledged there was none. The DON stated Resident 59 had behaviors. When asked if this incident was considered as a resident to resident altercation, the DON stated resident to resident altercation meant both residents were fighting. The DON stated Resident 39 did not do anything to Resident 59 and did not consider this incident as a resident to resident altercation. The DON stated the incident was not investigated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 29 of 83 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 07/15/2019 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 7/15/19 at 0959 hours, a concurrent interview and record review was conducted with the SSD. The SSD stated resident to resident altercation occurs when two or more residents fight each other. The SSD stated she was not made aware of the incident. The SSD stated the incident had to be investigated.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 08/15/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 30 of 83 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 07/15/2019 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 future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to develop a care plan problem addressing the use of side rails for one of 21 final sampled residents (Resident 71). This failure had the potential of Resident 71 not receiving appropriate care. Findings: On 7/15/19 at 0842 hours, Resident 71 was observed in bed with bilateral side rails elevated. Medical record review for Resident 71 was initiated on 7/9/19. Resident 71 was readmitted to the facility on 9/7/18. Review of Resident 71's Physical Restraint Assessment 2.0 dated 6/14/19, showed Resident 71 had bilateral side rails elevated for safe mobility. Review of Resident 71's plan of care failed to show a care plan problem addressing Resident 71's use of bilateral side rails. On 7/15/19 at 1027 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed Resident 71's plan of care and was unable to find a care plan problem addressing Resident 71's use of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 31 of 83 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 07/15/2019 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 side rails. RN 1 stated there should be a care plan problem addressing Resident 71's use of side rails.

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

F684 09/29/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility document review, the facility failed to ensure coordination of hospice services for one of 21 final sampled residents (Resident 59). The facility failed to ensure a process for communicating hospice services for Resident 59. This failure had the potential to put the residents on hospice services at risk of uncoordinated medical care between the facility and hospice agency. Findings: Medical record review for Resident 59 was initiated on 7/9/19. Resident 59 was admitted to the facility on hospice services on 8/25/18. Review of Hospice Provider A's General Inpatient Services Addendum dated 6/14/18, under Section 3 for Responsibility of Hospice showed the hospice was responsible for all services provided, including coordination of services. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 32 of 83 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 07/15/2019 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 of Resident 59's Order Summary Report dated 6/27/19, showed a physician's order dated 8/25/18, to admit Resident 59 to hospice services from Hospice Provider A. Review of the Hospice Provider A's calendar dated July 2019 showed the hospice RN visited once a week and the CHHA visited were twice a week. There was no entry in the calendar to show when the CHHA was to visit Resident 59 from July 22 to July 31, 2019. On 7/11/19 at 0819 hours, an interview was conducted with CNA 2. CNA 2 stated the CHHA provided care on certain days of the week. When asked what days the CHHA visited Resident 59, CNA 1 stated she was not sure. On 7/11/19 at 0830 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 59 was on hospice. LVN 4 stated she was not sure what days the hospice RN and CHHA visited Resident 59. On 7/11/19 at 1058 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 acknowledged Resident 59's hospice calendar was incomplete and did not provide accurate and complete information to the facility staff. Cross reference to F849.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 08/15/2019 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 33 of 83 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 07/15/2019 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 pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for one of 21 final sampled residents (Resident 58). Resident 58 was readmitted to the facility without pressure ulcers to the heels and was assessed to be at high risk for developing pressure ulcers. * The facility failed to ensure the interventions such as offloading of the heels were developed and implemented to prevent the development of pressure ulcers. * The facility failed to ensure Resident 58's skin assessments were consistently conducted prior to Resident 58 developing a pressure ulcer to the right heel. * The facility failed to ensure Resident 58's heels were offloaded as care planned after Resident 58 had developed a pressure ulcer to the right heel. * The facility failed to ensure Resident 58's heel protectors were applied as ordered by the physician after Resident 58 had developed a pressure ulcer to the right heel. These failures resulted in Resident 58 developing a pressure ulcer to the right heel while at the facility and posed the risk for delayed healing and worsening of the pressure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 34 of 83 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 07/15/2019 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 ulcer. Findings: Review of the facility's P&P titled Pressure Sore Prevention (undated) showed it is the policy of the facility to identify at risk residents and to define early interventions for prevention of pressure ulcers. In individuals who are at high risk, the goal will be aimed at reducing the risk factors and at instituting preventative measures. Interventions will have four overall goals including to protect against the adverse effects of external mechanical forces (pressure, friction, and shear). Strategies to prevent pressure ulcers for bed bound individuals included to use devices that totally relieve pressure on the heels. Skin care included to inspect the resident's skin at least every day. The above interventions should be included on the written care plan for each resident assessed to be at risk for developing pressure ulcers. Review of the facility's P&P titled Pressure Ulcers/Injuries Overview revised 7/17 showed the pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominent area. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear, and may be painful. Avoidable means the resident developed a pressure ulcer/injury and that one or more of the following was not completed: evaluation of the resident's clinical condition and risk factors; and definition or implementation of interventions that are consistent with the resident's needs, goals, and professional standards of practice. Stage 2 pressure ulcers appear as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer, and may also present as an intact or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 35 of 83 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 07/15/2019 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 open/ruptured blister. An Unstageable pressure ulcer appears as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar (dead tissue). Review of the National Pressure Ulcer Advisory Panel's Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers dated 2014 showed the reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. The recommendations showed to inspect the skin of the heels regularly and to ensure the heels are free of the surface of the bed for preventing and treating heel pressure ulcers. Ideally, the heels should be free of all pressure - a state sometimes called "floating heels" or "offloading." Pressure on the heels can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. On 7/9/19 at 0939 hours, during the initial tour of the facility, Resident 58 was observed lying on a regular mattress. One pillow was observed under Resident 58's legs, but the heels were observed resting directly on the mattress. No heel protectors were observed in place. Medical record review for Resident 58 was initiated on 7/9/19. Resident 58 was readmitted to the facility on 12/10/18. Review of the Body Assessment dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 36 of 83 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 07/15/2019 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 12/10/18, completed on readmission, showed Resident 58 did not have any identified skin issues or pressure ulcers to the heels on readmission. Review of Resident 58's plan of care showed care plan problems dated 12/11/18, to address Resident 58's impaired skin integrity and the potential for pressure ulcer development. The interventions failed to address any preventive measures to prevent the pressure ulcer development for the resident. Review of the Pressure Ulcer Risk Assessment dated 12/12/18, showed Resident 58 was at high risk for developing pressure ulcers related to a poor general physical condition, mental status, and activity/mobility; and fair moisture factors (may be incontinent of bowel and/or bladder, but not continually soiled and/or wet, or have profuse diaphoresis; frequently damp, but not continually damp) and nutritional factors. Review of Resident 58's MDSs dated 3/5 and 6/5/19, showed Resident 58 was totally dependent on the staff for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned the body while in bed) and had impairment on both sides of the lower extremities. Review of the Dietary Quarterly Progress Note dated 6/6/19, showed Resident 58 was within her usual body weight range and had no significant changes. Review of the Wound Evaluation Flow Sheet dated 6/12/19, showed Resident 58 developed a facility-acquired pressure ulcer to the right heel presenting as a fluid-filled blister that measured 4 cm (length) x 4 cm (width) x 0 cm (depth). On 7/4/19, the pressure ulcer to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 37 of 83 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 07/15/2019 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 right heel was reclassified as an Unstageable pressure ulcer. The Wound Evaluation flow sheet showed the wound bed was 100% eschar on 7/4/19. Further review of Resident 58's plan of care showed a care plan problem dated 6/12/19, with a revision date of 7/4/19, to address Resident 58's Unstageable pressure ulcer to the right heel. The interventions included to offload the heels from pressure at all times and apply bilateral heel protectors. Review of the Order Summary Report showed a physician's order dated 7/4/19, to apply bilateral heel protectors one time a day and remove the bilateral heel protectors at bedtime. On 7/9/19 at 1221 hours, Resident 58 was observed lying in bed with one pillow under the legs. However, both heels were observed resting directly on the mattress and no heel protectors were in place. On 7/10/19 at 0754, 0855, 0942, and 1020 hours, Resident 58 was observed lying in bed with both heels resting directly on the mattress. No heel protectors were observed in place. On 7/10/19 at 1021 hours, an interview was conducted with CNA 1. CNA 1 stated he was familiar with Resident 58 and was assigned to her on 7/9 and 7/10/19. CNA 1 stated Resident 58 could not move by herself and was dependent on the staff for repositioning. CNA 1 verified Resident 58 was on a regular mattress and stated he turned Resident 58 every two hours. When asked about Resident 58's skin, CNA 1 stated Resident 58's skin was ok and she had no pressure ulcers. CNA 1 verified Resident 58's heels were not offloaded and were resting directly on the mattress. CNA 1 verified he did not offload Resident 58's heels FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 38 of 83 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 07/15/2019 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 previous day either because he was not aware Resident 58 had a pressure ulcer on the right heel. When asked how to offload the heels, CNA 1 stated by placing enough pillows under the legs so the heels do not touch or rest on the mattress. CNA 1 verified Resident 58 did not have heel protectors in place today (7/10/19) or the previous day. When asked to locate Resident 58's heel protectors, CNA 1 stated Resident 58 did not have heel protectors available after looking in Resident 58's closet and drawers. CNA 1 stated the treatment nurse was responsible for applying the heel protectors in the morning. When asked what preventative measures were taken for Resident 58 before she developed the pressure ulcer to the right heel, CNA 1 stated he kept the resident clean and dry and turned her every two hours. On 7/10/19 at 1039 hours, an interview was conducted with LVN 5. LVN 5 stated she was one of the treatment nurses. LVN 5 stated Resident 58 had a facility-acquired Unstageable pressure ulcer to the right heel that started as a fluid-filled blister. LVN 5 stated Resident 58 did not have any skin impairments or pressure ulcers to the heels on readmission. LVN 5 was asked to observe Resident 58 in bed. LVN 5 verified Resident 58's heels were not offloaded and were resting directly on the mattress. LVN 5 verified Resident 58 did not have heel protectors in place. When asked if Resident 58 could move, LVN 5 stated Resident 58 could move her legs slightly, but her lower extremities were not contracted and her heels could still be offloaded with pillows. When asked if Resident 58 was at risk for developing pressure ulcers, LVN 5 stated yes. LVN 5 was asked what preventative measures were in place prior to Resident 58 developing the Unstageable pressure ulcer to the right heel. LVN 5 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 39 of 83 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 07/15/2019 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 58's heels were supposed to be offloaded because she was totally dependent on the staff. When asked how she ensured the resident's heels were offloaded, LVN 5 stated the nurses were supposed to make rounds to ensure the resident's heels were offloaded. When asked why Resident 58's heels were not offloaded, LVN 5 stated she did not know, but the CNA should have offloaded the resident's heels. On 7/10/19 at 1230 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 was asked how the blister on Resident 58's right heel could have developed. LVN 5 stated blisters could develop from shearing or pressure. When asked if the blister could have developed on its own, LVN 5 stated no. LVN 5 was asked if Resident 58's pressure ulcer to the right heel was avoidable. LVN 5 stated the pressure ulcer to Resident 58's heel was avoidable. LVN 5 was asked how often the skin assessments were conducted. LVN 5 stated the charge nurses were responsible for conducting the skin assessments and documented the skin assessments in the weekly summaries. Review of the Weekly Progress Notes dated 6/9/19, under the Skin Condition section (where a head to toe skin assessment was supposed to be conducted and documented) showed to "Please see TAR." LVN 5 stated the charge nurses were supposed to be conducting their own skin assessments to identify any new skin concerns instead of relying on the TAR. LVN 5 stated the TAR only showed the wounds or pressure ulcers that had already been identified that had existing orders. LVN 5 verified Resident 58's plan of care did not show to offload the heels as an intervention to prevent the development of pressure ulcers to the heels. When asked which residents required their heels to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 40 of 83 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 07/15/2019 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 offloaded as a preventative measure, LVN 5 stated all residents who were totally dependent for bed mobility should have their heels offloaded to prevent pressure ulcers from developing. On 7/11/19 at 1342 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked about Resident 58's nutrition and hydration status. The RD stated Resident 58 had a history of weight gain, but was within her usual body weight range. The RD stated Resident 58 received a tube feeding formula that provided adequate nutrition and protein levels to promote wound healing. The RD stated Resident 58 was also on supplements including vitamin C and zinc to promote wound healing. The RD was asked about Resident 58's nutrition and hydration status prior to developing the blister on the right heel. The RD stated Resident 58's nutrition and hydration status was stable prior to Resident 58 developing the pressure ulcer to the right heel and continued to be adequate to promote healing of the pressure ulcer. On 7/12/19 at 0720 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified he completed the Weekly Progress Notes dated 6/9/19. When asked what type of skin assessment was conducted as part of the Weekly Progress Notes, LVN 6 stated a head to toe skin assessment was supposed to be conducted. LVN 6 was asked what "Please see TAR" meant. LVN 6 stated, "Please see TAR" meant to go see the Treatment Administration Record to see the pressure ulcer condition and physician orders for the pressure ulcer. LVN 6 verified there was no documentation to show he conducted a head to toe skin assessment on Resident 58 to identify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 41 of 83 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 07/15/2019 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 new skin issues or pressure ulcers. LVN 6 stated the nurses also conducted assessments, including of the skin every shift that was documented on the Subacute Nursing Assessment. Review of the Subacute Nursing Assessment dated 6/9/19, showed to see the TAR under the skin assessment section. LVN 6 verified the findings. LVN 6 was asked which residents required their heels to be offloaded. LVN 6 stated the residents who could not move or reposition themselves required their heels to be offloaded. LVN 6 was asked how he communicated the residents' care needs and ensured they were being met to the CNAs. LVN 6 stated he communicated the residents' care needs to the CNAs at the beginning of each shift and had to check during the shift to ensure they were being met. LVN 6 stated he sometimes had to offload the resident's heels if the CNAs forgot to or did not know to do so. On 7/12/19 at 0831 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated she was one of the unit supervisors. Review of the Subacute Nursing Assessments dated 6/1 to 6/12/19, failed to show documentation Resident 58's heels were offloaded. Further review of the Subacute Nursing Assessments showed the skin assessments were not completed (left blank) on some shifts or had entries that showed to see the TAR. RN 2 verified the findings and stated the nurses were supposed to be conducting skin assessments on each shift to identify new skin issues. RN 2 was asked what preventative measures were in place to prevent the residents from developing pressure ulcers on the heels. RN 2 stated totally dependent residents who were immobile were supposed to have their heels offloaded as an intervention to prevent heel pressure ulcers. RN 2 stated the charge nurses were supposed to conduct rounds to ensure the residents' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 42 of 83 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 07/15/2019 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 heels were offloaded. On 7/12/19 at 0842 hours, the observations of Residents 2 and 70 were conducted with LVN 8. When asked what preventative measures were in place to prevent pressure ulcers on the heels, LVN 8 stated for the residents who were immobile or dependent on the staff, their heels needed to be offloaded. LVN 8 stated Residents 2 and 70 were totally dependent on the staff and required their heels to be offloaded. Residents 2 and 70 were observed lying in their beds with their heels resting directly on their mattresses. LVN 8 verified Residents 2 and 70's heels were not offloaded. On 7/12/19 at 0847 hours, the observations of Residents 7 and 64 was conducted with LVN 9. When asked which residents required their heels to be offloaded to prevent pressure ulcers on the heels from developing, LVN 9 stated totally dependent residents. LVN 9 stated Residents 7 and 64 were totally dependent on the staff and required their heels to be offloaded. Residents 7 and 64 were observed lying in their beds with their heels resting directly on their mattresses. LVN 9 verified Residents 7 and 64's heels were not offloaded.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 08/15/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 43 of 83 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 07/15/2019 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure the residents and staff were safe from potential hazards. * The facility failed to ensure the safety of one of 21 sampled residents (Resident 73). Resident 73 was assessed as high risk for falls and had episodes of multiple falls. Resident 73's call light was on the floor not within reach. This posed the risk for Resident 73 to incur more falls which may result in injuries. * The facility failed to ensure a barbecue grill was not blocking an exit from Room A. This failure had the potential to prevent residents and staff from exiting the room in the event of an emergency. Findings: 1. Review of Resident 73's medical record was initiated on 7/9/19. Resident 73 was admitted to the facility on 8/25/12. Review of the History and Physical Examination dated 9/28/18, showed Resident 73 had recurrent falls. Review of the MDS dated 6/20/19, showed Resident 73 was cognitively intact. Resident 73 required limited assistance from one person for bed mobility, transfers, dressing and personal hygiene. Resident 73 required extensive assistance from one person for toileting. Resident 73 was occasionally incontinent or urine and frequently incontinent of bowel. Resident 73's balance was not steady and was only able to stabilize with assistance from staff when moving from a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 44 of 83 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 07/15/2019 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 seated to a standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfer. Resident 73 had two or more falls with minor injury. Review of the care plan showed a care plan problem dated 8/26/12, and most recently revised 6/25/18, addressing Resident 73's high risk for falls. The Interventions included to be always remind Resident 73 to call for help and ensure the call light was within reach. Resident 73 needed a prompt response to all requests for assistance. Review of the Interdisciplinary Notes dated 6/20/19, showed Resident 73 had multiple episodes of falls. Resident 73 had impaired mobility and was noncompliant with safety measures provided. The IDT recommended for staff to make sure Resident 73's call light was within reach, conduct hourly rounds and offer assistance with ADL care and toileting needs. Review of the Interdisciplinary Notes dated 5/2/19, showed Resident 73 was high risk for falls and had multiple episodes of falls. The recommendation was to place the call light with Resident 73's reach, check hourly, and offer assistance in a timely basis. On 7/9/19 at 0828 hours, on initial tour, Resident 73 was observed sitting on his bed while eating breakfast. Resident 73's call light was on the floor. Resident 73 bent forward toward the floor and tried to reach for the call light but was unable to. Resident 73 pulled on the call light from the wall. Resident 73 stated he was able to press the call light when he needed assistance to go to the bathroom. On 7/9/19 at 0845 hours, a concurrent observation and interview was conducted with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 45 of 83 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 07/15/2019 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. CNA 2 verified Resident 73's call light was on the floor and was out of his reach. CNA 2 stated the call light had to be within Resident 73's reach. CNA 2 stated Resident 73 had previous episodes of falls in the facility. CNA 2 verified the call light had been disconnected. CNA 2 acknowledged the call light indicator by Resident 73's door way was not lit when the call light cord was disconnected. On 7/10/19 at 0904 hours, Resident 73 was observed lying in bed while watching television. Resident 73's call light was observed on the floor. On 7/10/19 at 0916 hours, a concurrent observation and interview was conducted with CNA 5. CNA 5 acknowledged Resident 73's call light was on the floor. CNA 5 stated Resident 73 was able to use the call when he needed assistance in going to the bathroom. CNA 5 acknowledged Resident 73's call light was to be within his reach. On 7/11/19 at 1034 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 stated Resident 73 was able to use the call light when he needed assistance. RN 1 stated Resident 73 was at high risk for falls and had multiple episodes of falls in the facility. RN 1 verified the IDT recommended to ensure Resident 73's call light was within his reach. RN 1 verified Resident 73's care plan problem addressing his high risk for falls included an intervention to ensure Resident 73's call light was always within his reach. RN 1 stated Resident 73's use of the call light was necessary to ensure his needs were attended immediately to prevent another fall. RN 1 stated the staff had to conduct rounds to ensure the call lights were within FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 46 of 83 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 07/15/2019 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 reach for all the residents. (Cross Reference

F919) 2. On 7/9/19 at 0903 hours, a barbecue grill was observed obstructing the sliding door to Room A. The sliding door opened onto the smoking patio. On 7/9/19 at 1206 hours, an interview was conducted with LVN 2. LVN 2 was asked if residents and staff could safely exit through the sliding door. LVN 2 stated they could not. When asked why the sliding door should be unobstructed, LVN 2 stated it was a risk for residents not being able to exit in case of an emergency. On 7/9/19 at 1424 hours, an observation and concurrent interview was conducted with RN 1. The barbecue grill was observed blocking the sliding door to Room A, after it was moved by LVN 2 earlier. RN 1 was asked why the barbecue grill should not be obstructing the sliding doors. RN 1 stated so residents had an alternative exit in the event of an emergency.

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 08/05/2019 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 47 of 83 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 07/15/2019 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 §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one of 21 final sampled residents (Resident 61) received care and services to maintain the acceptable nutritional status. The facility failed to ensure Resident 61 received the prescribed enteral formula (liquid nourishment administered through a GT). This failure posed the risk for Resident 61 to have unplanned weight loss. Findings: On 7/9/19 at 0751 hours, during the initial tour of the facility, Resident 61 was observed lying in bed. A 1500 ml bottle of Jevity 1.2 dated 7/8/19, was observed at Resident 61's bedside connected to a continuous feeding pump. The continuous feeding pump was off and was not infusing; 1300 ml of the formula was observed remaining in the bottle. Medical record review for Resident 61 was initiated on 7/9/19. Resident 61 was readmitted to the facility on 2/26/19. Review of the Order Summary Report showed a physician's order dated 2/27/19, to infuse Jevity 1.5 at 50 ml per hour for 20 hours to provide 1500 kcal/1000 ml. On 7/9/19 at 0959 and 1028 hours, a bottle of Jevity 1.2 dated 7/8/19, was observed at Resident 61's bedside and connected to a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 48 of 83 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 07/15/2019 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 continuous feeding pump. On 7/9/19 at 1035 hours, an interview and concurrent medical record review was conducted with RN 6. RN 6 verified the incorrect enteral formula was given to Resident 61. RN 6 stated Resident 61 was supposed to get Jevity 1.5, not Jevity 1.2. On 7/11/19 at 1338 hours, an interview and concurrent medical record review was conducted with the RD. The RD stated Jevity 1.5 provided more calories per ml than Jevity 1.2 did. The RD stated Jevity 1.5 provided Resident 61 the calories and nutrition required for Resident 61 to maintain his nutritional status. The RD stated giving Resident 61 Jevity 1.2 would result in a caloric deficit.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 08/15/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care for three of 21 final sampled residents (Residents 46, 61, and 73) and two nonsampled residents (Residents 8 and 55). * The facility failed to ensure an Ambu (AirShields Manual Breathing Unit) bag (a handFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 49 of 83 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 07/15/2019 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 held device used to provide a continuous supply of oxygen to a person's lungs) was at Resident 55's bedside. This had the potential for Resident 55 not getting oxygen into his lungs in the event of an emergency. * The facility failed to ensure Resident 61's supplemental oxygen therapy was humidified as ordered by the physician. This posed the risk for Resident 61 to develop mucus plugs in the airway. * The facility failed to ensure Residents 8's and 46's nebulizer masks were labeled with the date they were changed to ensure the masks were changed weekly as per the facility's P&P. This posed the risk for equipment contamination and respiratory complications. * Resident 73's nebulizer tubing was on the floor and last changed on 6/30/19. This posed a risk for Resident 73 to develop respiratory complications. Findings: 1. Medical record review of Resident 55 was initiated on 7/9/19. Resident 55 was admitted to the facility on 2/16/19. Review of Resident 55's Order Summary Report dated 7/12/19, showed an order dated 3/30/19, for an Ambu Bag at the bedside for emergency procedures every shift. On 7/9/19 at 0745 hours, an observation was conducted in Resident 55's room. Resident 55 was observed to have a tracheostomy (a surgically created opening through the front of the neck and into the windpipe) connected to a mechanical ventilator (a machine to assist with breathing). An Ambu bag was not at Resident 55's bedside. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 50 of 83 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 07/15/2019 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 7/9/19 at 0808 hours, an observation and a concurrent interview was conducted with LVN 11. LVN 11 was asked to find Resident 55's Ambu bag. LVN 11 was unable to locate the Ambu bag. LVN 11 stated Resident 55 should have it. On 7/9/19 at 0810 hours, an observation and a concurrent interview was conducted with RT 2. RT 2 tried to locate Resident 55's Ambu bag but was unable to. RT 2 was asked if Resident 55 needed an Ambu bag. RT 2 stated, "yes." When asked whose responsibility it was to check the presence of Ambu bags at residents' bedsides, RT 2 stated, "everyone." 2. On 7/9/19 at 0751 hours, during the initial tour of the facility, Resident 61 was observed in bed with a tracheostomy tube (a tube inserted through the neck into the airway to maintain an open airway) in place connected to continuous oxygen at 5 LPM via the concentrator. An empty oxygen humidifier bottle was observed connected to the concentrator. Medical record review for Resident 61 was initiated on 7/9/19. Resident 61 was readmitted to the facility on 2/26/19. Review of the Order Summary Report showed a physician's order dated 2/26/19, to change the prefilled oxygen humidifier bottle every Monday night and as needed. Review of Resident 61's plan of care showed a care plan problem dated 2/26/19, to address Resident 61 having a tracheostomy tube related to impaired breathing mechanics. The interventions showed to give humidified oxygen as prescribed. Review of the Aerosol Therapy Record dated 7/6/19 at 0135 hours, showed Resident 61's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 51 of 83 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 07/15/2019 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 sputum consistency was thick. On 7/9/19 at 0908 hours, the oxygen humidifier bottle connected to Resident 61's concentrator was observed empty. On 7/9/19 at 0910 hours, an interview was conducted with RT 1. RT 1 verified Resident 61's oxygen humidifier bottle was empty and needed to be replaced. RT 1 was asked what was the purpose of the oxygen humidifier. RT 1 stated Resident 61's airway was normally dry and the resident had thick secretions. RT 1 stated the oxygen humidifier was to help prevent mucus plugs in the airway. 3. Review of Resident 46's medical record was initiated on 7/9/19. Resident 46 was admitted to the facility on 3/27/18, and readmitted on 8/4/18. Review of the Order Summary Report dated 7/15/19, showed a physician's order dated 1/21/19,for Duoneb solution (a bronchodilator) 0.5-2.5 (3) mg/3 ml one unit dose inhalation every six hours as needed for cough. Review of Resident 46's medical record failed to show when Resident 46's nebulizer mask was last changed. On 7/9/19 at 0830 hours, an observation and concurrent interview was conducted with RN 1. A nebulizer mask was observed at Resident 46's bedside inside a plastic bag labeled with the date 6/2/19. RN 1 verified the findings. RN 1 stated the facility policy was to change nebulizer masks every week. RN 1 stated resident nebulizer masks were changed weekly to ensure cleanliness and for infection control. 4. Review of Resident 8's medical record was initiated on 7/9/19. Resident 8 was admitted to the facility on 9/15/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 52 of 83 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 07/15/2019 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 of the Order Summary Report dated 7/10/19, showed a physician's order dated 10/4/18, for albuterol sulfate solution (a bronchodilator) 2.5 mg/3 ml, one dose inhalation four times. Review of Resident 8's medical record failed to show when Resident 8's nebulizer mask was last changed. On 7/9/19 at 0918 hours, an observation and concurrent interview was conducted with RN 1. RN 1 was observed in Resident 8's room changing Resident 8's nebulizer mask. RN 1 was asked if the previous nebulizer mask was labeled with the date in which it had been changed, to which he replied, no. RN 1 stated the nebulizer mask should have been labeled with the date in was changed. On 7/10/19 at 0951 hours, an interview was conducted with RN 1. RN 1 verified he was unable to determine the last date Resident 8's nebulizer mask was changed. 5. According to the facility's P&P, titled Changing Disposable Equipment -Respiratory, showed disposable equipment will be changed as regularly scheduled and as necessary. The Changing Disposable Supplies table showed HHN (hand held nebulizer) tubing was changed every Sunday. Review of Resident 73's medical record was initiated on 7/9/19. Resident 73 was readmitted to the facility on 8/25/12. Review of Resident 73's Order Summary Report dated 6/27/19, showed an order dated 8/31/18, to administer Duoneb Solution 0.5-2.5 (3) mg/3 ml, 1 unit dose inhalation every four hours as needed for congestion. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 53 of 83 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 07/15/2019 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 of the Medication Administration Record dated 7/1/19-7/31/19, showed Duoneb was administered to Resident 73 on 7/4/19. On 7/9/19 at 0826 hours, Resident 73 was observed sitting on his bed. Resident 73's nebulizer tubing dated 6/30/19, was on the floor. Resident 73 stated he was given medications using the nebulizer. On 7/9/19 at 0907 hours, a concurrent observation and interview was conducted with RN 1. RN 1 verified the tubing was dated 6/30/19, and was on the floor. RN 1 acknowledged nebulizer tubing should be placed in the respiratory bag and not touching the floor. RN 1 stated respiratory tubing used for the nebulizer had to be changed every seven days. RN 1 stated Resident 73 was receiving medication using the nebulizer. On 7/11/19 at 0909 hours, an interview was conducted with RT 1. RT 1 stated respiratory tubing had to be kept off the floor. RT 1 stated the water left inside the tube during treatment was a good medium for microorganism to grow. RT 1 stated the nebulizer tubing had to be changed every seven days to prevent residents from getting infections.

F700 SS=D Bedrails CFR(s): 483.25(n)(1)-(4)

F700 08/15/2019 §483.25(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. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 54 of 83 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 07/15/2019 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 §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure three of 21 final sampled residents (Residents 42, 59, and 71) remained free from accident hazards due to the use of side rails. * The facility failed to attempt alternatives prior to the use of side rails for Residents 42. * The facility failed to obtain consent from Resident 71's responsible party before implementing bilateral side rails. * The facility failed to assess Resident 59 for entrapment risk from side rail use. These had the potential to place the residents at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 55 of 83 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 07/15/2019 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 hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. 1. Medical record review for Resident 42 was initiated on 7/9/19. Resident 42 was admitted to the facility on 11/3/18, and readmitted on 7/3/19. On 7/9/19 at 0821 hours, an observation and concurrent interview was conducted of Resident 42. Resident 42 was observed lying in bed with bilateral side rails elevated at the head of the bed. Resident 42 stated she used the side rails to position herself in bed during adult brief changes. Review of Resident 42's medical record showed a consent for the use of side rails was obtained on 7/3/19, by RN 1. Review of Resident 42's medical record failed to show alternatives to side rails were attempted prior to the use of side rails. Review of the Physical Restraint Review form dated 7/4/19, showed alternative measures were attempted on 7/4/19, the day after the side rails were already in use, having been implemented the day prior, on 7/3/19. On 7/11/19 at 0909 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated he admitted Resident 42 to the facility on 7/3/19. RN 1 stated, upon admission, Resident 42's side rails were elevated bilaterally per Resident 42's request. RN 1 stated he performed a bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 56 of 83 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 07/15/2019 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 safety side rail assessment and obtained consent for the use of side rails on 7/3/19. RN 1 verified he attempted the alternatives to the use of side rails on 7/4/19, the day after the side rails were being used by Resident 42. 2. On 7/15/19 at 0842 hours, Resident 71 was observed in bed with bilateral side rails elevated. Medical record review for Resident 71 was initiated on 7/9/19. Resident 71 was readmitted to the facility on 9/7/18. Review of Resident 71's Risks and Benefits of Bedrail Review and Acknowledgement Form dated 9/7/18, showed under the area for the responsible party to give authorization for the use of side rails was blank. The signature section was signed by facility staff; however, there was no signature from the responsible party. On 7/15/19 at 0857 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no consent documented for Resident 71's use of side rails. 3. On 7/9/19 at 0858 hours, Resident 59 was lying in bed. Resident 59 had bilateral side rails extending from the head of the bed to the level of her upper thigh. Resident 59's left side rail was down while the right side rail was elevated. Resident 59 stated she wanted her side rails down so she could get out of bed. Medical record review for Resident 59 was initiated on 7/9/19. Resident 59 was admitted to the facility on 8/25/18. Review of the MDS dated 6/7/19, showed Resident 59 was cognitively intact. Resident 59 needed limited assistance from one person FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 57 of 83 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 07/15/2019 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 for bed mobility and transfers. Review of the Physical Restraint Assessment dated 8/25/18, showed Resident 59 was alert, oriented and ambulatory with a walker. Resident 59 had no restraints and less restrictive measures were not applicable. Review of the Bed Safety Rail Assessment dated 8/27/19, under section 1, "Is the resident likely to fall from bed?" showed a NO answer was circled, side rail may not be appropriate. Review of the Risk and Benefits of Bedrail Review and Acknowledgement dated 8/27/19, showed Resident 59 was provided bilateral 1/4 side rails as an enabler. Under the section, Potential Benefits, showed Resident 59 preferred the use of side rails. On 7/11/19 at 1106 hours, a concurrent observation, interview, and medical record review was conducted with RN 1. RN 1 verified Resident 59 had bilateral side rails on her bed. RN 1 verified the Physical Restraint Assessment dated 8/25/19, showed Resident did not need side rails at the time of admission. RN 1 verified the Bed Safety Rail Assessment dated 8/27/19, showed Resident 59's use of side rails was not appropriate and an entrapment assessment was not necessary. RN 1 acknowledged an entrapment assessment was not conducted prior to providing bilateral side rails to Resident 59.

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 09/29/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when usedFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 58 of 83 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 07/15/2019 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 §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure cardiac, blood pressure, and pain medications were given within the parameters of the physician's orders for two of 21 final sampled residents (Residents 9 and 38). * Resident 9 was given cardiac medication outside the parameters five times. This posed the risk of decreasing the resident's heart rate to an unsafe level. * Resident 38 was given blood pressure and pain medication outside the parameters fifteen times. This posed the risk of ineffectively managing the resident's pain and decreasing the blood pressure to an unsafe level. Findings: 1. Medical record review for Resident 9 was initiated on 7/11/19. Resident 9 was originally FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 59 of 83 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 07/15/2019 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 admitted to the facility on 6/27/17, and was readmitted on 2/28/19. Review of the Order Summary Report dated 4/25/19, showed an order dated 2/28/19, to administer Digoxin 125 mg one tablet enterally one time a day for atrial fibrillation and hold the medication if the heart rate was less than 60 bpm. Another order dated 3/1/19, showed to administer diltiazem extended release (a calcium channel blocker for high blood pressure) 90 mg one capsule enterally every eight hours for atrial fibrillation and hold the medication if the SBP was less than 100 mmHg or if the heart rate was less than 60 bpm. Review of Resident 9's Medication Administration Record for May 2019 showed on 5/1/19 at 0900 hours, Digoxin 125 mcg was administered when Resident 9's heart rate was 58 bpm. The diltiazem was administered on 5/1/19 at 0600 hours and 5/3/19 at 1400 hours, when the heart rate was 56 bpm and on 5/14/19 at 1400 hours, when the heart rate was 55 bpm. Review of Resident 9's Medication Administration Record for July 2019 showed the diltiazem was administered on 7/7/19, when the resident's heart rate was 56 bpm. On 7/15/19 at 0851 hours, an interview was conducted with LVN 2. LVN 2 was asked if the nurses needed to follow the medication parameters ordered by the physician. LVN 2 stated, "always." LVN 2 was shown all the instances when the medications were administered to Resident 9 when his heart rate fell below the parameters set by the physician. LVN 2 verified the findings. 2. Medical record review for Resident 38 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 60 of 83 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 07/15/2019 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 initiated on 7/12/19. Resident 38 was originally admitted to the facility on 8/16/17, and readmitted on 6/2/19. a. Review of the Order Summary Report dated 7/15/19, showed a physician's order 6/13/19, to administer oxycodone-acetaminophen (a narcotic pain medication) 5-325 mg one tablet by mouth every four hours as needed for moderate pain (level 4-6) (on a pain scale of 010 with 0 = no pain and 10 = severe pain). Review of Resident 38's Medication Administration Record for June 2019 showed Resident 39 was administered oxycodoneacetaminophen on 6/14/19 at 1635 hours, 6/18/19 at 2000 hours, and 6/28/19 at 2000 hours for a pain level of 7/10, and on 6/21/19 at 0530 hours, and 6/27/19 at 1214 hours for a pain level of 8/10. Review of Resident 38's Medication Administration Record for July 2019 showed the oxycodone-acetaminophen was administered on 7/7/19 at 1630 hours, 2100 hours for a pain level of 7/10, and on 7/8/19 at 1800 hours for a pain level of 7/10. b. Review of Resident 38's Order Summary Report dated 6/3/19, showed an order to administer carvedilol 25 mg, one tablet by mouth two times a day for hypertension (high blood pressure) and hold if SBP was less than 110 mmHg. Review of Resident 38's Medication Administration Record for June 2019 showed on 6/17/19 at 1700 hours, carvedilol was administered when Resident 38's blood pressure was 99/60 mmHg. On 6/28/19 at 1700 hours, carvedilol was administered when Resident 38's blood pressure was 91/51 mmHg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 61 of 83 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 07/15/2019 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 c. Review of Resident 38's Order Summary Report showed an order dated 6/2/19, for oxycodone-acetaminophen 10-325 mg half a tablet by mouth every six hours as needed for severe pain (level 7-10). Review of Resident 38's Medication Administration Record for June 2019 showed on 6/9 at 2100 hours, and 6/13/19 at 0949 hours, oxycodone-acetaminophen 10-325 mg was administered for a pain level of 6/10. d. Review of the Order Summary Report dated 4/29/19, showed to administer oxycodone hcl 5 mg one tablet by mouth every four hours as needed for severe pain (level 7-10). Review of Resident 38's Medication Administration Record for May 2019 showed on 5/5/19 at 0206 hours, and 5/52 at 1224 hours, oxycodone 5 mg was administered for a pain level of 6/10. On 7/15/19 at 0830 hours, an interview was conducted with RN 1. RN 1 was asked if the nurses were expected to follow the medication parameters ordered by the physician. RN 1 stated yes. RN 1 was shown the instances when the medications were given outside the parameters for Resident 38. RN 1 verified the findings.

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 08/15/2019 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 62 of 83 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 07/15/2019 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, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 10%. Two of three licensed nurses (LVNs 10 and 2) were found to have made errors during the medication administration observation. * The facility failed to ensure Resident 58's bowel management medications were held after Resident 58 had two episodes of loose stools or diarrhea. This posed the risk for Resident 58 to have further episodes of loose stools or diarrhea. * The facility failed to check Resident's 25's heart rate before the administration of a diuretic. This posed the risk for Resident 25 developing an abnormal heart rate. Findings: 1. On 7/11/19 at 0835 hours, a medication administration observation for Resident 58 was conducted with LVN 10. LVN 10 prepared and administered Resident 58's medications, including one tablet of docusate (a laxative/stool softener) 100 mg and Miralax powder (a laxative) 17 grams via the GT. Review of Resident 58's Order Summary Report showed a physician's order dated 12/10/18, to administer docusate 100 mg two times a day for bowel management and to hold the medication for loose stools. The Order Summary Report also showed a physician's order dated 12/10/18, to administer Miralax powder 17 gm one time a day for bowel management and to hold the medication for loose stools. On 7/11/19 at 0942 hours, an interview and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 63 of 83 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 07/15/2019 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 concurrent medical record review was conducted with RN 2. Review of the Look Back Report showed Resident 58's last two bowel movements were large loose stools or diarrhea. RN 2 verified the findings and stated the docusate and Miralax should have been held per the physician's orders. On 7/11/19 at 0950 hours, an interview was conducted with LVN 10. LVN 10 verified he did not check if Resident 58's last bowel movement was loose or diarrhea prior to administering the docusate and Miralax. LVN 10 verified the docusate and Miralax should have been held. 2. On 7/11/19 at 0837 hours, an observation of medication administration was conducted with LVN 2. LVN 2 checked Resident 25's blood pressure but failed to check the heart rate. LVN 2 administered 20 mg of Lasix (diuretic medication). Medical record review for Resident 25 was initiated on 7/11/19. Review of the Order Summary Report dated 6/27/19, showed an order to administer 20 mg of Lasix one time a day and to hold if the SBP was less than 110 mmHg or if the heart rate was less than 60 bpm. On 7/11/19 at 0900 hours, an interview was conducted with LVN 2. LVN 2 was asked if he needed to check the heart rate of Resident 25 before administering the medication. LVN 2 stated he should have checked the heart rate because there were parameters to hold the medication if the heart rate was less than 60 bpm.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 08/15/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 64 of 83 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 07/15/2019 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 be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure the key opening a refrigerator used to store the medications was kept secured. This had the potential for unauthorized persons accessing the medications stored inside the refrigerator. Findings: The facility's skilled nursing unit medication refrigerator was located at the nurses' station. On 7/11/19 at 1431 hours, during an interview with the Maintenance Director about who was responsible for cleaning the skilled nursing unit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 65 of 83 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 07/15/2019 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 medication refrigerator, the Maintenance Director was observed asking LVN 7 for assistance to open the refrigerator. LVN 7 was observed pointing to a gray plastic tube located in an open wire basket at the nurses' station. The medication refrigerator key was observed attached to this gray tube. During a concurrent interview and observation with the DON, the DON verified the medication refrigerator key was unsecured and accessible to unauthorized staff and visitors.

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

F812 09/29/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain safe food handling practices. The facility failed to ensure the main kitchen and satellite kitchen were kept clean and in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 66 of 83 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 07/15/2019 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 sanitary condition. * Dietary Aide 1's personal food was stored in the kitchen refrigerator. * The facility failed to ensure the food products were labeled and dated. There was an expired food item in the kitchen refrigerator. * The facility failed to ensure hand hygiene was observed prior to staff handling the ice machine. These failures had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings: Review of the CMS-672 Resident Census and Conditions of Residents form, completed by the facility and dated 7/10/19, showed 39 of 79 residents received food prepared by the facility. 1. On 7/9/19 at 0738 hours, a tour of the kitchen was conducted. Dietary Aide 1 took out a plastic bag from the refrigerator and placed it under a cart. Dietary Aide 2 acknowledged the plastic bag contained her lunch box. Dietary Aide 2 acknowledged she was not supposed to put her lunch bag in the kitchen refrigerator. On 7/9/19 at 0939 hours, an interview was conducted with the DSS. The DSS stated he kitchen staff had to store their personal food in the break room and the staff's personal food was not to be stored in the kitchen refrigerator to prevent cross contamination. 2. On 7/9/19 at 0745 hours, an observation of the walk in refrigerator was conducted with the Cook. A stainless steel bowl of vanilla pudding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 67 of 83 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 07/15/2019 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 a used by dated of 4/7/19. The Cook stated the vanilla pudding was dated incorrectly. The Cook stated the vanilla pudding had expired on 7/7/19. An open box of soy milk was observed without an opened date. The Cook acknowledged the soy milk had no opened date. When asked why an opened date was necessary, the Cook stated the staff had to know up to what date the soy milk was safe to consume. 3. On 7/15/19 at 0909 hours, a concurrent observation and interview was conducted with the DSS and the Maintenance Director. The Maintenance Director entered the kitchen and went to the ice machine. The Maintenance Director stated he was in charge of cleaning and sanitizing the ice machine. The Maintenance Director did not perform hand hygiene. The Maintenance Director proceeded to open the upper cabinet of the ice machine. The Maintenance Director stated the ice machine cabinet was clean and wiped the inner part of the cabinet cover with his unwashed hands. The Maintenance Director replaced the ice machine upper cabinet cover and left. The DSS verified the Maintenance Director did not perform hand hygiene prior to handling the inside surface of the ice machine. The DSS stated this had the potential to contaminate the ice machine bin.

F842 SS=B Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 08/15/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 68 of 83 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 07/15/2019 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 is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 69 of 83 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 07/15/2019 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 (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to ensure the residents' identifying information was not made available to the public when the confidential resident rosters containing nine resident names from three separate abbreviated surveys were observed in the survey binder. This failure violated the residents' right to privacy. Findings: On 7/9/19 at 1703 hours, two binders were observed at the reception desk. One binder titled Annual Survey Results contained results of annual surveys and another untitled binder contained results of abbreviated surveys. Review of the abbreviated survey binder showed the confidential resident rosters for the surveys dated 2/25, 3/15, and 4/4/19. The Administrator was called to the reception desk and asked who was responsible for putting the survey results in the binders and ensuring the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 70 of 83 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 07/15/2019 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 rosters were not included. The Administrator stated he was. When asked why the confidential resident rosters should not be included in the binder, the Administrator stated for patient confidentiality. The Administrator verified three confidential resident rosters were located in the binder.

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 08/15/2019 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 71 of 83 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 07/15/2019 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 care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 72 of 83 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 07/15/2019 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 (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 73 of 83 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 07/15/2019 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 participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 74 of 83 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 07/15/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to ensure a designated IDT member was appointed to coordinate care between the facility and hospice agency for one of 21 final sampled residents (Resident 59) receiving hospice services. This failure had the potential to put Resident 59 at risk of not receiving coordinated medical care between the facility and the hospice agency. Findings: Review of Hospice Provider A's General Inpatient Services Addendum dated 6/14/18, under Section 2, showed the facility shall designate a member of the IDT who was responsible for coordinating care to the hospice patient. Hospice Provider A's General Inpatient Services Addendum did not identify the IDT member to coordinate care between the facility and hospice agency for hospice services. On 7/11/19 at 0830 hours, an interview was conducted with LVN 4. LVN 4 stated the hospice coordinator was the Administrator. On 7/11/189 at 1055 hours, an interview was conducted with LVN 2. LVN 2 stated he was not aware of who the hospice coordinator was. LVN 2 stated he did not know there was one. LVN 2 stated he called the hospice nurse when he had concerns about Resident's 59's care. On 7/11/19 at 1058 hours, an interview was conducted with RN 1. RN 1 stated the charge nurse or the RN supervisor was the hospice coordinator. On 7/15/19 at 0845 hours, a concurrent interview and facility document review was conducted with the DON. The DON stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 75 of 83 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 07/15/2019 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 the facility's hospice coordinator. The DON acknowledged Hospice A's contract did not show the designated IDT coordinator responsible for coordinating services between the hospice agency and the facility. Cross reference to F684.

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

F880 08/15/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 76 of 83 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 07/15/2019 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 communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to implement infection control measures. * The facility failed to ensure one of 21 sampled residents (Resident 73) had a clean and sanitary merry walker. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 77 of 83 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 07/15/2019 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 facility failed to ensure two of two shower beds were free from cracks, holes and uncleanable surfaces. These failures had the potential to cause the growth and spread of bacteria. Findings: 1. On 7/9/19 at 0758 hours, during initial tour, a merry walker (a walker/chair combination ambulation device) was observed at Resident 73's bedside. Resident 73 stated he used the merry walker to go around the facility. Resident 73's merry walker had gauze padding on the arm rests. There was a brownish stain and debris on the gauze and on the side post of Resident 73's merry walker. A sticky brownish material was observed by the gauze padding. Resident 73 stated he was not sure when his merry walker was last cleaned. Resident 73 stated he asked the staff to place pads on the arm rests to avoid bruising and tears on his arms. On 7/10/19 at 0828 hours, Resident 73's merry walker was observed at the bedside. The gauze padding on Resident 73's merry walker had brownish stains and debris. A sticky brownish material was observed on the merry walker legs. On 7/10/19 at 0828 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 verified the brown stains and debris on the gauze padding and surfaces of the merry walker. LVN 2 stated he was not sure what the brownish stains were and stated the merry walker had to be cleaned. When asked how the gauze padding was cleaned, LVN 2 stated he was not able to say. 2. On 7/12/19 at 0926 hours, an observation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 78 of 83 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 07/15/2019 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 a concurrent interview was conducted with RN 1. Shower Bed 1 was observed with multiple holes and cracks exposing the porous material inside the bed. When RN 1 was asked how they ensured the shower bed was properly cleaned and sanitized, RN 1 stated the shower bed needed to be replaced because it was not cleanable and had the potential for contamination. On 7/12/19 at 0948 hours, an observation and a concurrent interview was conducted with RN 2. Shower Bed 2 was observed to have multiple large cracks and holes exposing the porous material inside the bed. When RN 2 was asked how they ensured the surface of the shower bed was properly cleaned and sanitized, RN 2 stated the shower bed needed to be replaced immediately because it could not be properly cleaned.

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

F881 08/15/2019 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to ensure the infection control surveillance data related to unnecessary use of antibiotics was reviewed and an action plan was developed to reduce the use of antibiotics in the facility by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 79 of 83 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 07/15/2019 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 Infection Control Committee. This created the potential for continued use of inappropriate antibiotics for residents. Findings: According to the Center for Disease Control, the repeated and/or improper use of antibiotics was the primary cause of the proliferation of drug-resistant bacteria. Each time a person used antibiotics, sensitive bacteria were killed; however, resistant bacteria may be left. These resistant bacteria may then grow and multiply. When antibiotics failed to work, the consequences included longer lasting illnesses, extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death. Review of the Infection Control Surveillance Logs for the months of January to June 2019 showed the following number of residents whose conditions did not meet McGeer's Criteria (a set of criteria used in long term care facilities to determine if a resident's signs and symptoms met the criteria of a true infection): - January 2019: 1 incident - February 2019: 5 incidents - March 2019: 2 incidents - April 2019: 9 incidents - May 2019: 3 incidents - June 2019: 3 incidents On 7/12/19 at 1029 hours, an interview and concurrent review of the facility's infection control program was conducted with the Infection Preventionist. The Infection Preventionist stated she reported to the Quality Assurance committee quarterly. When asked what the action plan was to reduce the use of unnecessary antibiotics, the Infection Preventionist stated data was reported to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 80 of 83 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 07/15/2019 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 Quality Assurance committee, but the committee had not developed an action plan.

F919 SS=F Resident Call System CFR(s): 483.90(g)(2)

F919 08/15/2019 §483.90(g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. §483.90(g)(2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure all facility residents had functioning call lights. This deficient practice resulted in residents not being able to use the call light to communicate their needs. Findings: On 7/9/19 at 0828 hours, during the facility's initial tour, Resident 73 was sitting on his bed eating breakfast. The call light cord was observed tied on the side rail with the activation end of the cord lying on the floor. Resident 73 bent forward and tried to reach for the end of the call light containing the button to push to call for assistance but was unable to reach it. Resident 73 pulled on the call light cord connected to the plug at the wall. On 7/9/19 at 0839 hours, the call light indicator located outside Resident 73's door was observed not lit. The Medical Records Director was passing by in the hallway and verified the call light indicator in Resident 73's room was off. When asked how the staff was made aware if Resident 73 needed assistance, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 81 of 83 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 07/15/2019 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 Records Director stated the call light indicator would be on and the room number would be shown on the computer system at the nurses' station. Upon observation of the monitoring system at the nurses' station, the Medical Record Director verified Resident 73's room was not shown on the computer system. When asked what happened when the call lights were pulled out from the plug, the Medical Records Director stated she had to call the Maintenance Supervisor. On 7/9/19 at 0845 hours, a concurrent observation and interview was conducted with CNA 2. CNA 2 verified Resident 73's call light had been pulled out from the wall. CNA 2 verified the call light indicator above Resident 73's door was not on when the call light cord was disconnected. On 7/9/19 at 0849 hours, a concurrent observation and interview was conducted with the Maintenance Director. The Maintenance Director verified the call light indicator was not on when Resident 73's call light cord was disconnected from the wall plug. The Maintenance Director stated the staff had to press the reset button on the wall to reactivate the call light when it got disconnected. The Maintenance Director stated the facility acquired the new call light system and had not been made aware of the problem. The Maintenance Director stated he was going to have to get the call light system inspected. On 7/10/19 at 0927 hours, a concurrent observation and interview was conducted with the Maintenance Director and Applications Engineer from the call light vendor. The Applications Engineer verified the call light indicator lights remained off when the call light cords were unplugged from the wall. The Applications Engineer stated he had to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 82 of 83 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 07/15/2019 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 investigate further. The Maintenance Director stated the pigtail cords were used on all of the residents' call lights in the facility. The Maintenance Director stated the pigtail cords prevented the wall socket from being pulled out of the wall. The Maintenance Director stated he was going to have to check on the pigtail cords depending on the recommendation of the Applications Engineer. Cross reference to

F689. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O69U11 Facility ID: CA060000131 If continuation sheet 83 of 83