Health inspection·July 15, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few Hoyer lift, Resident 1 made a big wiggle of her shoulder and body. The sling made a big swing, resulting in Resident 1 falling on the floor. Review of Resident 1's Hospitalist Discharge Summary note from the acute care hospital dated 7/7/25, showed Resident 1 was being lifted with a lift and accidentally dropped on her back. Upon the evaluation in the acute care hospital, Resident 1 was discovered to have the acute spinal processes fractures in the cervical and thoracic spines. On 7/15/25 at 0950 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was asked about Resident 1's fall from the mechanical lift used during the transfer on 6/28/25. The DON stated CNA 1 was working with the Hoyer lift and had transferred Resident 1 from the bed to the shower bed by herself. The DON stated there must be two people when transferring a resident using the Hoyer lift. CNA 1 told her that she should have called another staff member for help. On 7/15/25 at 1200 hours, Resident 1 was observed lying on a low air-loss mattress and appeared to be overweight. Resident 1 stated she was back from the acute care hospital. Resident 1 stated she fell from the mechanical lift. Resident 1 was asked if the staff were transferring her with a mechanical lift. Resident 1 stated one staff member was trying to transfer her from the bed to the shower bed with the lift and she fell on her back. On 7/15/25 at 1215 hours, an interview was conducted with LVN 1. LVN 1 stated the resident was bedbound and totally dependent on the staff's assistance for care, including transfers. On 7/15/25 at 1240 hours, an interview and concurrent medical record review for Resident 1 was conducted with the MDS Coordinator. The MDS Coordinator stated Resident 1 was totally dependent on the staff's assistance for care and needed two or more people's assistance for transfers. The MDS Coordinator further stated for Resident 1 using a mechanical lift for transfers, there should have had two people transfer the resident. On 7/15/25 at 1530 hours, an interview and concurrent medical record review for Resident 1 was conducted with CNA 1. CNA 1 was asked about Resident 1's fall. CNA 1 stated Resident 1 requested to have a shower, and CNA 1 transferred Resident 1 from the bed to the shower bed using a mechanical lift. CNA 1 stated Resident 1 made a shaking movement when she was lifted and the sling was moving, then the resident was out of the sling. CNA 1 also stated Resident 1 was big and fell on the ground. CNA 1 further stated she did not ask another nurse to help because she thought LVN 3 was in the room. When asked if LVN 3 assisted CNA 1 with the mechanical lift, CNA 1 stated LVN 3 was working with Resident 1's roommate. In addition, CNA 1 stated she was aware Resident 1 needed two people to transfer using a mechanical lift. On 7/15/25 at 1645 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was asked for a care plan to address the assistance needed for Resident 1's transfers and bed mobility and if there was a plan of care developed status post fall on 6/28/25. The DON was not able to provide any documentation. The DON verified the findings. 2. Medical record for Resident 2 was initiated on 7/15/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's care plan dated 3/11/24, showed the resident had ADL self-care performance deficits related to fatigue, limited mobility, limited range of motion, musculoskeletal impairment, and stroke. The care plan showed for the interventions, Resident 2 required total assistance for two persons with transfers. On 7/15/25 at 0845 hours, Resident 2 was observed being transferred from the bed to the shower bed. RNA 1 was observed lifting Resident 2 using a mechanical lift. CNA 2 was standing at the head of the shower bed and CNA 3 on the other side of the shower bed further away from Resident 2. Both CNAs tried to reposition the shower bed. CNA 3 was observed not in close proximity to Resident 2 while RNA 1 was maneuvering the Hoyer lift with the resident in the sling. RNA 1 was observed lowering Resident 2 to the shower bed and the shower bed was observed in an unlocked position. CNA 2 elevated the rail of the shower bed when Resident 2 was lying in the shower bed. The shower bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555751 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newport Subacute Healthcare Center 2570 Newport Blvd Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was observed with little movement while in an unlocked position. On 7/15/25 at 0905 hours, an interview was conducted with RNA 1 and CNA 2. Both RNA 1 and CAN 2 were informed of the observation regarding no other staff monitoring Resident 2 in close proximity while the resident was being transferred in a sling, using a mechanical lift. Both staff members acknowledged they should have had one staff member close to the resident to monitor the resident in a sling while RNA 1 was controlling the mechanical lift. Both staff also acknowledged and stated they should have locked the shower bed while Resident 2 was being transferred to the shower bed. RNA 1 and CNA 2 verified the findings. On 7/15/25 at 1435 hours, an interview was conducted with the DSD. The DSD was asked about the safe transfers for the residents using the mechanical lift. The DSD stated they must have two people transfer the residents using the mechanical lift. One person would be doing the maneuvering and controlling the mechanical lift, and another person needed to touch and monitor the sling and be close to the resident. The DSD stated the shower bed should be in a locked position when transferring the resident to the shower bed. Event ID: Facility ID: 555751 If continuation sheet Page 3 of 3