Other·November 21, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for FACILITY REPORTED INCIDENT (FRI) No: CA00658358. Inspection was limited to the specific FRI investigated and did not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 38492, HFEN; Surveyor 41418, HFEN; and Surveyor 42256, HFEN. THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE FRI. FINDINGS WERE CITED AT F689 FOR RESIDENT 1. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living CNA - Certified Nursing Assistant COTA - Certified Occupational Therapist Assistant CT scan - Computed Tomography (a scan of the body as part of the diagnosis or treatment of illnesses) CVA - Cerebral vascular accident (a stroke which can cause a loss of brain function due to disturbance of blood supply) LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) P&P - policy and procedure RN - Registered Nurse STAT - immediate 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: X7JW11 Facility ID: CA060000131 If continuation sheet 1 of 10 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 10/21/2019 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)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=G ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure adequate assistance and supervision were in place to prevent a fall for one of two sampled residents (Resident 1), which resulted in major injuries requiring hospitalization. * Resident 1 was inappropriately transferred to a shower chair by two CNAs (CNAs 1 and 2). Resident 1 was not capable of holding himself upright and had never been transferred to a shower chair before. Resident 1 was not provided physical assistance to prevent him from falling forward onto the floor and landing on his face. As a result of the fall, Resident 1 sustained blunt force facial trauma, including a dislocated jaw and fractures to the nose, requiring admission to the acute care hospital FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 2 of 10 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 10/21/2019 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 oral surgery and sutures to his nose. Findings: On 10/11/19 at 1046 hours, Resident 1 was observed lying in bed with the head of the bed elevated at approximately 30 degrees. Resident 1 was observed to have sutures on the bridge of his nose and a swollen left upper lip which was also noted to have sutures. a. Medical record review for Resident 1 was initiated on 10/11/19. Resident 1 was admitted to the facility on 7/16/19, with diagnoses including respiratory failure, muscle weakness, and cerebral infarction (area of necrotic tissue in the brain). Review of Resident 1's History and Physical Examination dated 7/18/19, showed Resident 1 had a tracheostomy tube (a surgical opening in the trachea and a tube placed into the opening to assist with for breathing), was nonverbal, and did not have the capacity to make medical decisions. Review of Resident 1's MDS dated 7/26/19, showed Resident 1 was severely cognitively impaired, had left-sided weakness, and required total assistance from one person for bed mobility, toilet use, and bathing. Resident 1 required total assistance from two people for all transfers including being transferred from bed to a wheelchair. Resident 1 had functional limitation on one side of both upper and lower extremities. Resident 1 was assessed to be 5 foot and 5 inches tall and weighed 200 pounds. Review of the Fall Risk Assessment dated 7/16/19, showed Resident 1 was assessed to be a high risk for falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 3 of 10 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 10/21/2019 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 1's plan of care showed a care plan problem dated 7/17/19, addressing deficit in ADL care related to activity intolerance, confusion, and history of CVA. The plan of care showed Resident 1 was bedfast all or most of the time. Review of Resident 1's Occupational Therapy Treatment Encounter Notes dated 10/1/19, showed Resident 1 had poor grade sitting balance and needed maximum assistance. Review of Resident 1's Physical Therapy Discharge Summary dated 10/2/19, showed Resident 1 had poor static sitting balance and needed maximum assistance to maintain his balance. On 10/2/19, Resident 1 sustained a fall from a shower chair onto the floor, landing on his face. Review of the facility's Investigation of Incident/Accident/Injury of Unknown Origin form dated 10/2/19, showed on 10/2/19 at 0830 hours, Resident 1 had a witnessed fall from a shower chair. Review of Resident 1's Progress Notes dated 10/2/19 at 0857 hours, showed at approximately 0830 hours, RN 1 heard the staff asking for help from Resident 1's room. When RN 1 entered the room, she observed Resident 1 on the floor. The RN documented Resident 1 was receiving a haircut from two CNAs (CNAs 1 and 2) while Resident 1 was sitting up in a shower chair. CNA 2 left the room to attend to another resident, which left CNA 1 alone in the room with Resident 1. CNA 1 noticed a kink in Resident 1's indwelling urinary drainage catheter tubing so she moved to the side of Resident 1's shower chair to bend down and adjust the tubing. During this time, Resident 1 lost his balance and fell forward onto the floor, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 4 of 10 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 10/21/2019 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 landing on his face. Resident 1 was assessed to have a laceration to the bridge of the nose, a cut on the left upper lip, bleeding gums and loosened teeth as result of the fall. Review of the Change of Condition note dated 10/2/19 at 0840 hours, showed Resident 1's physician was notified of the incident and ordered STAT x-rays of Resident 1's skull, chest, and bilateral hips. Review of Resident 1's Progress Notes dated 10/2/19 at 0910 hours, showed RN 1 notified Resident 1's responsible party (Responsible Party 1). Review of Resident 1's Progress Notes dated 10/2/19 at 1005 hours, showed Resident 1 was transferred to an acute care hospital (Acute Care Hospital 1) emergency department via ambulance. Review of Resident 1's Acute Care Hospital 1's emergency department's medical records dated 10/2/19 at 1056 hours, showed Resident 1 sustained blunt facial trauma which included the following injuries: - An open nasal fracture with a 0.5 cm laceration extending across to the bridge of the nose requiring four stitches. - An inner upper lip laceration measuring 3 cm by 1 cm with epidermal (outer layer of the skin) tissue loss and epidermal abrasions, requiring seven stitches. - Displacement of the left upper front tooth (incisor) - Loosened left upper second tooth (incisor) Review of the acute care hospital's CT scan report dated 10/2/19, showed Resident 1 sustained a dislocation of the right jaw, acute fractures of the nasal bone, and nasal septum FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 5 of 10 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 10/21/2019 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 (structure that separates the right from the left nasal cavity) with swelling. Further review of Resident 1's Acute Care Hospital 1's medical records showed a consultation for an oral and maxillofacial surgeon was obtained. Resident 1 had to be transferred to another acute care hospital (Acute Care Hospital 2) to be seen by the consulting surgeon for his dental injuries as Acute Care Hospital 1 was unable to provide this needed surgery. On 10/2/19 at 2314 hours, Resident 1 was transferred from Acute Care Hospital 1 to Acute Care Hospital 2 where he was admitted for further treatment of his injuries sustained from falling onto his face from the shower chair. Review of the Oral and Maxillofacial Surgery Consultation dated 10/3/19, showed Resident 1 had a maxillary alveolar ridge (part of the upper jaw that contains tooth sockets) fracture. Review of Resident 1's acute care record titled Operative Record dated 10/5/19, showed Resident 1 underwent a surgical repair of his jaw and teeth. This procedure was done under general anesthesia and included applying an arch bar (a type of stainless steel splint that conforms to the arch of the teeth to stabilize injured teeth. The arch bar was stabilized using multiple stainless steel wires). Resident 1 was identified to have displacement of front teeth which was positioned back within the tooth socket and stabilized. Review of Resident 1's Clinical Summary dated 10/8/19, showed Resident 1 was discharged from Acute Care Hospital 2 and transferred back to the facility. On 10/11/19 at 1215 hours, an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 6 of 10 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 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEWPORT SUBACUTE HEALTHCARE CENTER 2570 Newport Blvd Costa Mesa, CA 92627 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with CNA 1. CNA 1 was assigned to care for Resident 1 on 10/2/19. CNA 1 stated Resident 1's hair was long, dirty and had flakes and she wanted to cut it. CNA 1 stated she asked Resident 1 if she could give him a haircut and Resident 1 nodded yes. CNA 1 stated she asked CNA 2 to help her cut Resident 1's hair and transfer him from the bed to the shower chair. CNA 1 stated she and CNA 2 used a Hoyer lift (mechanical lift) to transfer Resident 1 from his bed to the shower chair. CNA 1 stated neither she or CNA 2 consulted with a respiratory therapist or a licensed nurse about transferring Resident 1 to a shower chair. When asked if the shower chair had any type of device to prevent Resident 1 from leaning forward, CNA 1 said no. CNA 1 stated she stood in front of Resident 1 to prevent him from leaning forward while CNA 2 cut the resident's hair. CNA 1 stated when they were done cutting Resident 1's hair, CNA 2 was paged from the overhead speakers to assist another resident in another room. CNA 2 left Resident 1's room, leaving CNA 1 alone with Resident 1 who was still sitting on the shower chair. CNA 1 stated she noticed a kink in Resident 1's urinary drainage bag tubing and decided to lean down to the side of the chair and fix the kink, which left Resident 1 unsupported in the shower chair. CNA 1 stated while she was bent over fixing the urinary drainage tubing, Resident 1 fell forward hitting his face on the floor. CNA 1 stated she yelled for help and a few staff members including two licensed nurses came to assess Resident 1. CNA 1 stated she observed Resident 1 bleeding from his nose and mouth. CNA 1 stated she had never used a shower chair to shower Resident 1, he was always been placed on a shower gurney when showered, which made it difficult to thoroughly wash the resident's hair. CNA 1 stated, "It was a bad decision to put him in a shower chair." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 7 of 10 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 10/21/2019 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 10/11/19 at 1230 hours, an interview was conducted with CNA 2. CNA 2 stated he had taken care of Resident 1 before and was familiar with the resident's care needs. CNA 2 was asked about Resident 1's needs and ability to sit upright. CNA 2 stated when Resident 1's head of the bed was elevated Resident 1 tended to lean to his left side. CNA 2 stated he had never seen Resident 1 use a chair, wheelchair, or a shower chair before the fall incident on 10/2/19. CNA 2 stated he was assisting CNA 1 with cutting Resident 1's hair. CNA 2 stated he had been behind Resident 1 while cutting the resident's hair and CNA 1 was standing directly in front of Resident 1 but was not physically supporting Resident 1. When asked about the use of the shower chair, CNA 2 stated he made sure the shower chair was locked. CNA 2 stated upon completing Resident 1's haircut, he was called to help another resident in another room and he left CNA 1 alone with Resident 1 while the resident was still sitting in the shower chair. CNA 2 stated he left the room and no more than 20 seconds later, he heard an overhead page stating help was needed in Resident 1's room. CNA 2 stated when he arrived to Resident 1's room he observed Resident 1 lying on the floor, he was awake and had blood on his face. A few staff members were helping Resident 1. On 10/11/19 at 1258 hours, an interview was conducted with COTA 1. COTA 1 stated she took care of Resident 1 before his fall and was familiar with his needs. COTA 1 stated Resident 1 was assessed to have poor sitting balance and needed maximum assistance to hold himself up. COTA 1 stated Resident 1 required the assistance of one person physically holding him up when he was in a sitting position. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 8 of 10 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 10/21/2019 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 10/14/19 at 1429 hours, an interview was conducted with Responsible Party 1. The Responsible Party stated she made medical decisions for Resident 1 as he was not capable to do so. She stated she had been informed of Resident 1's fall on 10/2/19 around 0930 hours. The Responsible Party stated she became very upset when she went to the acute care hospital and saw Resident 1's face with blood and stitches on his nose and blood in his mouth. When asked about Resident 1's haircut, the Responsible Party stated she was never asked by anyone from the facility for permission to cut Resident 1's hair. The Responsible Party stated, "it [hair] was fine the way it was." She stated Resident 1 had muscle weakness and she had never seen him sitting up in a chair. The Responsible Party stated Resident 1 was crying while he was at the acute care hospital because he did not want to return to the facility, they both felt it was unsafe. On 10/11/19 at 1453 hours, an interview was conducted with RN 1. RN 1 stated Resident 1 was not capable of supporting himself in a sitting position. On 10/15/19 at 0919 hours, an interview was conducted with LVN 1. LVN 1 stated she was assigned to care for Resident 1 on 10/2/19. LVN 1 stated she had never seen Resident 1 in a wheelchair, chair or shower chair since his admission to the facility. LVN 1 stated Resident 1 did not have upper trunk control or balance and could not sit up in a chair by himself. LVN 1 stated she did not see Resident 1 in a shower chair on 10/2/19, and did not know CNA 1 and CNA 2 were going to put him in a shower chair. When asked if she knew CNA 1 and CNA 2 were giving Resident 1 a haircut, LVN 1 stated she did. LVN 1 stated she heard yelling for help from the hallway and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 9 of 10 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 10/21/2019 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 when she arrived in Resident 1's room she observed Resident 1 lying on the floor on his side with blood on his face and a few staff members were attending to Resident 1. b. Review of the facility's Investigation of Incident/Accident/Injury of Unknown Origin form dated 10/2/19, showed the cause of the fall was failure of staff to verify appropriate use of medical equipment (shower chair) with the licensed staff. Review of the entire investigation documents showed the only staff member interviewed was CNA 1. There was no other documentation to show any other staff interviews were conducted regarding Resident 1's care or other possible witnesses to the fall on incident. The one interview showed when CNA 1 leaned over to grab Resident 1's urinary drainage bag tubing Resident 1's body jerked and fell forward to the floor. Review of the facility's investigation of the fall did not show all of the circumstances regarding this fall incident. The documentation failed to address Resident 1's poor sitting balance and that he had never been placed in a chair, wheelchair or shower chair since his admission to the facility. On 10/11/19 at 1541 hours, an interview and concurrent medical record review for Resident 1 was conducted with the Administrator. The Administrator verified there was only one staff interview conducted during the resident's fall investigation. When asked about any attempts to interview CNA 2, Administrator stated an interview with CNA 2 was not conducted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7JW11 Facility ID: CA060000131 If continuation sheet 10 of 10