Crystal Cove Care Center

F-F726.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52238 potential for actual harm Based on observation, interview, medical record review and facility P&P review, the facility failed to provide Residents Affected - Few the necessary respiratory care and services for three of three final sampled residents (Residents 67, 336, and 686) reviewed for the respiratory care.

* The facility failed to obtain a physician's order prior to the oxygen administration for Resident 686.

* The facility failed to obtain a physician's order prior to the oxygen administration for Resident 336. The facility failed to place an Oxygen In Use sign outside the door of Resident 336's room as per the facility's P&P. In addition, the facility failed to develop a care plan problem to address Resident 336's oxygen use. Furthermore, the facility failed to administer oxygen as per the physician's order to Resident 336.

* The facility failed to ensure Resident 67's nebulizer tubing was labeled with Resident 67's name and the date.

These failures had the potential to negatively impact the residents' well-being.

Findings:

Review of the facility's P&P titled Oxygen Administration dated 2001 showed the following:

- Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration;

- Review the resident's care plan to assess for any special needs of the resident; and

- Under the Steps in the Procedure section, to place an Oxygen in Use sign on the outside of the room entrance door and place an Oxygen in Use sign in a designated place on or over the resident's bed.

1. On 2/18/25 at 0907 hours, during the initial tour of the facility, Resident 686 was observed in bed using an oxygen via nasal canula at a rate of 4 liters per minute.

Medical record review for Resident 686 was initiated on 2/18/25. Resident 686 was admitted to the facility on [DATE REDACTED].

Further review of Resident 686's medical record failed to show for the physician's order for Resident 686's oxygen use.

On 2/18/25 at 1211, 1238, and 1509 hours, a follow-up observation was conducted in Resident 686's room. Resident 686 was observed using the oxygen via nasal canula at a rate of 4 liters per minute.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0695 On 2/18/25 at 1513 hours, an observation and concurrent interview was conducted with LVN 6. LVN 6 verified Resident 686 was receiving a continuous oxygen via nasal canula at a rate of 4.5 liters per minute. Level of Harm - Minimal harm or potential for actual harm On 2/18/25 at 1539 hours, a follow-up interview and concurrent record review was conducted with LVN 6. LVN 6 verified there was no physician's order for the use of oxygen in Resident 686's EHR or paper medical Residents Affected - Few record. LVN 6 acknowledged if a resident was receiving the oxygen, the resident should have a physician's order. LVN 6 also acknowledged Resident 686 had been on a continuous oxygen therapy via nasal canula since the morning.

39453

2. On 2/18/25 at 0854 hours, during the initial tour of the facility, Resident 336 was observed lying in bed with continuous oxygen being administered at a rate of 2 liters per minute via nasal cannula. There was no Oxygen in Use sign posted outside of the room door.

Medical record review for Resident 336 was initiated on 2/18/25. Resident 336 was admitted to the facility on [DATE REDACTED].

a. Review of Resident 336's Order Summary Report did not show a physician's order to administer the oxygen.

Review of Resident 336's Plan of Care did not show a care plan problem was developed to address Resident 336's use of oxygen.

On 2/18/25 at 1531 hours, an observation, interview, and concurrent medical record review for Resident 336 was conducted with MDS Coordinator 2. MDS Coordinator 2 verified Resident 336's continuous oxygen was being administered at a rate of 2 liters per minute via nasal cannula, and there was no Oxygen In Use sign posted outside the resident's door. MDS Coordinator 2 also verified there was no physician's order to administer the oxygen to Resident 336, and there was no care plan developed to address Resident 336's oxygen use.

b. On 2/21/25 at 1001 hours, a follow-up observation was conducted for Resident 336. Resident 336 was observed lying in bed with a continuous oxygen being administered at a rate of 2.5 liters per minute via nasal cannula.

Further review of Resident 336's Order Summary Report showed a physician's order dated 2/18/25, to administer oxygen via nasal cannula at a rate of 2 liters per minute.

On 2/21/25 at 1002 hours, an observation, interview, and concurrent medical record review was conducted with LVN 9. LVN 9 verified Resident 336's continuous oxygen was being administered at a rate of 2.5 liters per minute via nasal cannula. LVN 9 verified the physician's order showed to administer continuous oxygen via nasal cannula was at a rate of 2 liters per minute.

50787

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0695 3. Review of the facility's P&P titled Administering Medications through Small Volume (Handheld) Nebulizer dated 2001 showed when the equipment is completely dry, to store in a plastic bag with the resident's name Level of Harm - Minimal harm or and date on it. potential for actual harm

On 2/18/25 at 1034 hours, during the initial tour of the facility, Resident 67's nebulizer mask and tubing were Residents Affected - Few observed inside a plastic bag located on top of the nightstand without a resident's name and date labeled.

Medical record review for Resident 67's was initiated on 2/19/24. Resident 67 was admitted to the facility on [DATE REDACTED].

Review of Resident 67's Order Summary Report showed physician's order dated 3/27/25, for Pulmicort (a breathing treatment) Inhalation Suspension 0.5 mg/ml 2 ml inhale orally two times a day for shortness of breath.

On 2/18/25 at 1130 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 67's bagged nebulizer mask and tubing had no resident's name and date labeled. LVN 4 acknowledged and stated she would have the nebulizer mask and tubing tubing replaced and labeled.

On 2/24/25 at 1630 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453

Residents Affected - Few Based on observation, interview, and facility document review, the facility failed to ensure the competency of two of two licensed nurses (LVN 12 and the ADON) interviewed regarding bladder training and failed to ensure the annual performance evaluation was conducted for one of three licensed nurses (LVN 5) reviewed for the annual performance evaluation.

* The facility failed to ensure LVN 12 and the ADON were able to demonstrate their competency on the bladder training for a resident with an indwelling urinary catheter.

* The facility failed to provide the training materials used for the in-service trainings provided to the facility staff.

* The facility failed to ensure the annual performance evaluation was completed for LVN 5.

These failures had the potential to put the residents at risk for care not being provided in a safe and competent manner.

1. According to [NAME] and Wilkins' article titled Reducing CAUTIs with a Bladder Retraining Program dated 2013 showed the bladder retraining with a catheter involves a structured approach to help the residents regain the normal bladder function, particularly after surgeries or periods of catheterization. One common method is the clamping and unclamping technique which aims to gradually increase the bladder capacity and restore the sensation of fullness. This method has been utilized to reduce the CAUTIs by encouraging the natural bladder function and minimizing the continuous drainage.

Medical record review for Resident 336 was initiated on 2/18/25. Resident 336 was admitted to the facility on [DATE REDACTED].

Review of Resident 336's Order Summary Report showed the following physician's orders:

- on 2/15/25, to monitor for proper placement, no kinking or compression that could obstruct the urine flow to gravity bag during the indwelling urinary catheter care every shift; and

- on 2/16/25, for the indwelling urinary catheter 16 Fr/10 ml balloon for urinary retention, to check if intact/functioning every shift; and

- on 2/21/25, for the indwelling urinary catheter care every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0726 Review of Resident 336's Progress Note showed a Nurse's Note dated 2/17/25 at 1234 hours, showed Responsible Party 1 was notified the resident's indwelling urinary catheter would be removed if there was no Level of Harm - Minimal harm or indication for it. The nurse's note showed Responsible Party 1 stated he did not want to have the indwelling potential for actual harm urinary catheter removed and wanted a bladder training while the indwelling urinary catheter was inserted.

The note further showed the nurse let Responsible Party 1 know the bladder training with the indwelling Residents Affected - Few urinary catheter was not possible, and the facility could help with the toileting schedule if the indwelling urinary catheter was removed; however, Responsible Party 1 preferred to not have the indwelling urinary catheter removed and would like a follow-up with the urology.

Further review of Resident 336's medical record did not show a bladder training was provided for Resident 336 while having the indwelling urinary catheter nor a urology consultation was followed up.

On 2/21/25 at 1008 hours, an interview and concurrent medical record for Resident 336 was conducted with LVN 10. When asked about the bladder training for Resident 336, LVN 10 stated the process they followed in

the facility included only to remove the indwelling urinary catheter, but there was no bladder training provided at the facility. LVN 10 stated the facility did not provide bladder training to Resident 336. LVN 10 stated if there was an order to remove the indwelling urinary catheter, the licensed nurses would removed the indwelling urinary catheter and scan the resident's bladder. LVN 10 further stated if the bladder scan showed more than 400 ml of urine in the resident's bladder, then they would do a straight catheterization.

On 2/21/25 at 1416 hours, an interview and concurrent medical record for Resident 336 was conducted with

the ADON. When asked about the bladder training for Resident 336, the ADON stated she told Responsible Party 1 the bladder training was not possible for a resident with an indwelling urinary catheter. When asked to elaborate, the ADON stated she meant the staff was not able to a bladder training in the facility. The ADON stated she was not sure why a bladder training for a resident with an indwelling urinary catheter was not done at the facility. The ADON further stated she worked at the facility for four years, and they had not done a bladder training for a resident with an indwelling urinary catheter. The ADON stated a toileting schedule was an option where the CNAs would assist the resident to void upon rising, and before and after meals.

On 2/24/25 at 1352 hours, an interview and concurrent medical record review and facility document review for Resident 336 was conducted with the DON. The DON stated if there was a physician's order for a bladder training on a resident with an indwelling urinary catheter, then the nurses had to do it by clamping and unclamping the indwelling urinary catheter. The DON stated if the physician wanted to remove the indwelling urinary catheter without performing a bladder training, then they would explain that procedure to the resident.

The DON stated the facility staff were given an in-service on the bladder training.

Review of the facility's Education/Training Attendance Record for the Bowel and Bladder Training dated 2/5/25, showed LVN 12 had signed the attendance record. In addition, the record did not show the ADON was provided with the in-service training on Bowel and Bladder Training. The training documents included

the facility's P&P for the Bowel and Bladder Training Program (undated). The facility's P&P for the Bowel and Bladder Training Program did not show the procedure on how to do a bladder training program for the residents with an indwelling urinary catheter.

49258

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0726 2. Review of the facility's P&P titled In-Service Training, All Staff (undated) showed the primary objective of in-service training is to ensure the staff are able to interact in a manner that enhances the resident's quality Level of Harm - Minimal harm or of life and quality of care and can demonstrate competency in the topic areas of the training. Training potential for actual harm methods and teaching materials are appropriate to the level of education and expected roles of those attending. Residents Affected - Few

On 2/24/25 at 0920 hours, an interview and concurrent facility document review was conducted with the DSD. Review of the In-Service Training Binder for January to December 2024 and January 2025 showed only the sign in sheets signed by the CNAs and licensed nurses who attended the trainings. Further review of the In-Service Training Binder failed to show the training materials for each in-services provided. The DSD verified there were no training materials for the in-services provided. The DSD stated the training matrials should be included because it would provide the teaching objectives, specific topics discussed, and how the staff would be assessed for their competency.

On 2/4/25 at 1445 hours, an interview was conducted with the DON. The DON stated the in-service trainings should include the training materials because it would show what were discussed, the expectations from the staff, and how the competency would be assessed. The DON was made aware and acknowledged the above findings.

3. Review of the facility's P&P titled Performance Evaluations (undated) showed the performance evaluation would be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review.

On 2/24/25 at 0902 hours, an interview and concurrent facility personnel record review was conducted with

the DSD. Review of LVN 5's personnel record showed LVN 5 was hired on 2/1/21. The personnel record showed LVN 5's last employee's performance appraisal was on 1/30/24. Further review of LVN 5's personnel

record failed to show LVN 5 was evaluated one year after the last performance evaluation. The DSD verified

the above findings. The DSD stated the licensed nurses would be evaluated either by a designated RN supervisor or the DON.

On 2/4/25 at 1445 hours, an interview was conducted with the DON. The DON stated the performance evaluation should be done annually at the minimum. The DON stated the performance evaluation would be needed to determine the quality of the employee's work performance and to determine if the employee would need an improvement. The DON was informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Potential for 49258 minimal harm Based on interview, facility document review, and facility P&P review, the facility failed to ensure the Residents Affected - Some performance evaluations were completed every 12 months for one of two CNAs' (CNA 7) employee files reviewed. This failure had the potential for the staff to not maintain competencies to provide the residents with needed and appropriate care and services.

Findings:

Review of the facility's P&P titled Performance Evaluations (undated) showed the performance evaluation would be completed on each of the employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review.

On 2/24/25 at 0902 hours, an interview and concurrent facility personnel record review was conducted with

the DSD. Review of CNA 7's personnel record showed CNA 7 was rehired on 10/18/22. Further review of CNA 7's personnel record failed to show the performance evaluations were completed every 12 months for

the past two years. The DSD verified the findings. The DSD stated it was the responsibility of the DSD to perform the annual evaluation for the CNAs. The DSD stated she started to work as the facility's DSD only last January 2025 and had not reviewed all the CNAs' personnel records.

On 2/4/25 at 1445 hours, an interview was conducted with the DON. The DON stated the performance evaluations were done annually at the minimum. The DON stated the performance evaluations were needed to determine the quality of the employee's work performance and if the employees would need improvement.

The DON was informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453 Residents Affected - Few Based on interview and medical record review, the facility failed to ensure two of five final sampled residents (Residents 1 and 336) reviewed for unnecessary medications was free from the unnecessary psychotropic medication.

* The facility failed to ensure the informed consent for zolpidem (hypnotic medication) was signed by the physician. In addition, the facility failed to ensure the monitoring for hours of sleep related to the use of zolpidem matched the documentation of the episode when Resident 336 was unable to sleep.

* The facility failed to ensure the informed consent for Resident 1's clonazepam (antianxiety medication) medication was renewed and the consent was obtained from the responsible party and signed by the physician.

These failures had to potential to result in unnecessary use and ineffective monitoring for the use of psychotropic medication that could negatively affect Resident 336's well-being.

Findings:

1. Medical record review for Resident 336 was initiated on 2/18/25. Resident 336 was admitted to the facility

on [DATE REDACTED].

Review of Resident 336's Order Summary Report showed the following physician's orders:

- dated 2/14/25, to administer zolpidem 10 mg by mouth at bedtime for insomnia;

- dated 2/17/25, to monitor for the hours of sleep related to the use zolpidem every evening and night shift; and

- dated 2/17/25, to monitor the episodes of inability to fall asleep or stay asleep.

a. Review of Resident 336's Informed Consent - Psychoactive Medication - V4 dated 2/17/25, did not show it was signed by the physician.

b. Review of Resident 336's MAR for February 2025 showed Resident 336 was administered the zolpidem medication from 2/15 to 2/20/25 at 2100 hours. Further review of the MAR showed Resident 336 had zero hours of sleep on 2/20/25; however, there was also documentation showing Resident 336 had zero episode of not falling asleep on 2/20/25.

On 2/21/25 at 1338 hours, an interview and concurrent medical record review for Resident 336 was conducted with RN 4. RN 4 verified the informed consent form for the zolpidem medication was not signed by the physician. RN 4 also verified the monitoring for hours of sleep related to the use of zolpidem medication did not match the documentation of the episode when Resident 336 was unable to sleep.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0758 50787

Level of Harm - Minimal harm or 2. Review of the facility's P&P titled Psychoactive/Psychotropic Medication use dated 5/2024 showed the potential for actual harm section for Renewals of Informed Consent showing the prescriber must renew the written informed consent every six months, providing any recommended dosage adjustments and the option for the resident to revoke Residents Affected - Few consent as required by state specific regulations.

According to the California Department of Public Health, All Facilities Letter (AFL) 24-07 dated 2/28/24, showed the facilities must obtain a resident's written informed consent for treatment using the psychotherapeutic drugs, and consent renewal every six months. The section for Renewals of Informed Consent showed the facilities must provide the resident with any recommended dosage adjustments and the option of revoking consent. If the resident decides to discontinue using the drug, the prescriber is responsible for planning any necessary, gradual dose reduction, as well as possible behavioral interventions.

Review of Resident 1's medical record was conducted on 2/20/25. Resident 1 was admitted on [DATE REDACTED].

Review of Resident 1's BIMS dated 2/1/25, showed a BIMS score summary of 12 (moderate cognitive impairment).

Review of Resident 1's Order Summary Report showed a physician's order dated 2/4/25, for clonazepam 1.5 mg by mouth to be given every evening at 1700 hours, for anxiety m/b inability to relax.

Review of Resident 1's MAR for February 2025 showed the following physician's orders:

- dated 8/16/24, to administer clonazepam 1.5 mg PO in the evening at 1700 hours, for anxiety and verbalization of anxiousness, discontinued on 2/4/25; and

- dated 2/5/25, to administer clonazepam 1.5 mg PO in the evening at 1700 hours, for anxiety m/b inability to relax.

Further review of the MAR showed the clonazepam 1.5 mg medication was administered daily at 1700 hours, on 2/1 to 2/19/25.

Review of Resident 1's Informed Consent-Psychoactive Medication dated 8/6/24, showed an initial consent for the use of clonazepam 2 mg in the evening for anxiety signed by Resident 1 and the physician.

On 2/24/25 at 1435 hours, an interview and concurrent review of Resident 1's informed consent was conducted with RN 3. RN 3 verified and acknowledged Resident 1's latest clonazepam informed consent was obtained on 8/6/24.

On 2/24/25 at 1630 hours, an interview was conducted with the DON. The DON was informed of Resident 1's clonazepam informed consent was obtained on 8/6/24. The DON verified the informed consent was not renewed as per the facility P&P and AFL. The DON acknowledged and verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43119

Residents Affected - Few Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure

the sanitary requirements were met in the kitchen as evidenced by:

* The facility failed to ensure the kitchen utensils were clean and free of food particle or residue.

* The facility failed to ensure the kitchen utensil was in good condition.

These failures had the potential for cross contamination and foodborne illnesses to the residents consuming

the foods prepared in the facility's kitchen.

Findings:

Review of the facility's Diet Type Report dated 2/18/25, showed 80 of 86 residents consumed the foods prepared in the kitchen.

1. Review of the facility's P&P titled Dishwashing dated 2023 showed all the dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. Gross food particles shall be removed by careful scraping and pre-rinsing in running water.

According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch,

the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

On 2/18/25 at 0833 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the RD. The following was observed and verified by the RD:

- Three cutting knives with black handles were dirty, with fuzzy stains on the blades and had dry food residue.

- One serving fork with black handle was dirty with dry, crusted residue, had watermark and fuzzy stains.

- One stainless steel slotted serving scoop with cream handle was dirty and had fuzzy stains.

- One white dough cutter was dirty with dry, crusted residue and had fuzzy stains.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0812 The RD acknowledged the above findings and stated the kitchen utensils should have been stored clean for infection control purposes. Level of Harm - Minimal harm or potential for actual harm 2. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 Residents Affected - Few and 4-2 or shall be discarded.

According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.

During the initial kitchen tour on 2/18/25 at 0833 hours, a concurrent observation and interview was conducted with the RD. One white basting brush was observed worn out and bristles was frayed. The RD verified the findings and stated they had a new one and it should have been changed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49258

Residents Affected - Few Based on interview, medical record review, facility document review, and the facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for six of 22 final sampled residents (Residents 2, 5, 10, 40, 336, and 586) and three nonsampled residents (Resident 20, 51, and 68).

* Resident 2's Advance Directive Acknowledgement showed a wrong information regarding the advance directive, and the POLST failed to show the resident had no advance directive.

* Resident 5's bowel continence documentation was not completed.

* Resident 10's MAR failed to show the monitoring was completed for anticoagulant (medication use to prevent blood clot) use, Covid symptoms, and pain scale on 2/15/25.

* Resident 20's MAR was incomplete for medication administration on 2/14/25; and the monitoring for adverse reactions related to the use of anticoagulant, quetiapine, and risperidone (antipsychotic medications) medications, episodes of depression related to the use of zoloft (medication use to treat depression) medication, episodes of schizophrenia (false beliefs or seeing or hearing things that are not there, and disorganized speech and thinking) related to the use of quetiapine medication, and the monitoring for the tardive dyskinesia (involuntary movements of the face, arms, legs, neck, and other body parts) on 2/6/25, for

the evening shift.

* Resident 40's MAR failed to show the Advair Diskus (inhaler use for shortness of breath) and Hydralazine (medication use to lower blood pressure) administration on 2/2/25 at 0600 hours. In addition the POLST failed to show the resident had no advance directive.

* Resident 51's Narcotic and Controlled Substance Sheet on Tramadol HCl was inaccurately recorded.

* Resident 68's TAR failed to show the treatment for the perineal area was completed on 2/16/25, for the morning shift.

* The facility failed to ensure Resident 336's POLST had the correct name and birthdate. In addition, the facility failed to ensure Resident 336's Informed Consents for immunizations, and the Consent to Treat had

the correct name.

* Resident 586's IV Administration Record failed to show the IV (intravenous, a plastic catheter that is placed through the skin into a vein used to give fluids and medications) site monitoring was completed on 2/16 and 2/17/25.

These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 Review of the facility's P&P titled Charting and Documentation (undated) showed the documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of Level of Harm - Minimal harm or procedures and treatments will include care-specific details, including: potential for actual harm - The date and time the procedure/treatment was provided; Residents Affected - Few - The name and title of the individual(s) who provided the care;

- The assessment data and/or any unusual findings obtained during the procedure/treatment;

- How the resident tolerated the procedure/treatment;

- Whether the resident refuse the procedure/treatment;

- Notification of family, physician or other staff, if indicated; and

- The signature and title of the individual documenting.

Review of the facility's P&P titled Advanced Directives (undated) showed the POLST is a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. Upon admission the interdisciplinary team assess the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the

record that is retrievable by any staff.

Review of the facility's P&P titled Administering Medications (undated) showed if the drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The induvial administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Topical medications used in the treatments are recorded on the resident's TAR. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:

- The date and time the medication was administered;

- The dosage;

- The route of administration;

- The injection site;

- Any complaints or symptoms for which the drug was administered;

- Any results achieved and when those results were observed; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 - The signature and title of the person administering the drug.

Level of Harm - Minimal harm or 1. Medical record review for Resident 2 was initiated on 2/18/25. Resident 2 was readmitted to the facility on potential for actual harm [DATE REDACTED].

Residents Affected - Few Review of Resident 2's MDS assessment dated [DATE REDACTED], showed Resident 2 was cognitively intact.

Review of Resident 2's Advance Directive Acknowledgement dated 2/11/25, showed Resident 2 had executed an advance directive for healthcare and the copy was requested. However, review of Resident 2's medical record failed to show the copy of the advance directive.

Review of Resident 2's POLST dated 2/11/25, showed Section D: Information and Signatures were left blank for advance directive dated, available and reviewed, advance directives not available, no advance directive, and healthcare agent information if named in advance directive.

Review of Resident 2's Baseline Care Plan Person-centered Care Planning - V3.1 dated 2/14/25, showed

the SSD discussed with Resident 2 stating Resident 2 did not have an advance directive. The completion was offered to Resident 2 and the resident was educated on the importance. Resident 2 stated she still had

the blank copy provided by the SSD on her first admission but had not been able to complete it. The SSD advised Resident 2 if the resident had any questions to let the SSD know and to notify any of the staff or SSD once the resident had completed the form.

On 2/19/25 at 1450 hours, an interview and concurrent medical record review was conducted with the SSD.

The SSD stated if the resident was to be transferred out of the facility in an emergency, the POLST would be sent with the resident to show the selected treatment, if there was an Advanced Directive and health care agent. The SSD stated the POLST should be filled up by either the licensed nurse or social services staff and would be reviewed and signed by the physician. The SSD stated after she spoke with Resident 2 on 2/14/25, Resident 2 verified she did not have an advance directive. The SSD verified the Advance Directive Acknowledgement form should have been updated. The SSD further verified the POLST should be filled up with the appropriate and correct information regarding Resident 2.

On 2/24/25 at 1445 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 2.

2. Medical record review for Resident 40 was initiated on 2/18/25. Resident 40 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 40's MDS assessment dated [DATE REDACTED], showed Resident 40 had short and long-term memory problems.

a. Review of Resident 40's Order Summary Report showed the following physician's orders:

- dated 1/26/25, to administer advair diskus aerosol powder breath activated (fluticasone-salmeterol) 500-50 mcg/dose one inhalation to inhale orally every 12 hours; and

- dated 1/24/25, to administer hydralazine hydrochloride 50 mg one tablet enterally every eight hours for HTN and to hold for SBP less than 110 mmHg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 Review of Resident 40's MAR for February 2025 showed on 2/2/25 at 0600 hours, did not show documented evidence Resident 40 received the advair diskus and hydralazine hydrochloride medications, and there was Level of Harm - Minimal harm or no blood pressure reading recorded. potential for actual harm

On 2/20/25 at 1400 hours, a medical record review was conducted with the ADON. The ADON verified the Residents Affected - Few above findings.

On 2/21/25 at 1450 hours, a telephone interview was conducted with LVN 13. LVN 13 verified he administered the Advair diskus and hydralazine to Resident 40 on 2/2/25 at 0600 hours. LVN 13 further stated the save button on the PCC must have been lagged so it did not save his documentation.

On 2/24/25 at 1513 hours, an interview was conducted with the DON. The DON stated after administering

the medication or treatment to the resident, the charge nurse should document it. The DON stated the documentation was important so everybody was on the same page with the residents, and the facility staff could provide appropriate care for all the residents if there was an accurate documentation. The DON was informed and acknowledged the above findings.

b. Review of Resident 40's Advance Directive Acknowledgement dated 1/24/25, showed Resident 40 had not executed an advance directive for healthcare and declined to initiate an advance directive at this time.

The form was signed by Responsible Party 2.

Review of Resident 40's POLST dated 1/24/25, showed Section D: Information and Signatures were left blank for the advance directive dated, available and reviewed, advance directives not available, no advance directive, and healthcare agent information if named in advance directive.

On 2/19/25 at 1450 hours, an interview and concurrent medical record review was conducted with the SSD.

The SSD stated if the resident was to be transferred out of the facility in an emergency, the POLST would be sent with the resident to show the selected treatment if there was an Advance Directive and health care agent. The SSD stated the POLST should be filled up by either the licensed nurse or social services staff and would be reviewed and signed by the physician. The SSD further verified the POLST should be filled up with the appropriate and correct information regarding Resident 40.

On 2/24/25 at 1445 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 40.

50967

3. Medical record review for Resident 10 was initiated on 2/21/25. Resident 10 was admitted to the facility on [DATE REDACTED].

Review of Resident 10's MDS assessment dated [DATE REDACTED], showed Resident 10 had moderate cognitive impairment.

Review of Resident 10's Order Summary Report showed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 - a physician's order dated 1/13/25, to monitor for symptoms of Covid-19/RSV/Influenza such as cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, new loss of taste or smell, Level of Harm - Minimal harm or congestion or runny nose, nausea, vomiting, diarrhea, headache, and to monitor for emergency warning potential for actual harm signs such as trouble breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, and bluish lips or face. Residents Affected - Few - a physician's order dated 1/13/25, to monitor for pain using a 0-10 pain scale: 0 = no pain; 1-3 = mild pain; 4-6 = moderate pain; and 7-10 = severe pain every shift.

- a physician's order dated 1/19/25, to monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, SOB, and nose bleeds related to anticoagulant/antiplatelet medication every shift.

Review of Resident 10's MAR for February 2025 showed no documented evidence Resident 10 was monitored for adverse reactions related to anticoagulant use, symptoms of Covid-19/RSV/Influenza, and pain for the morning shift (0700 hours to 1500 hours) on 2/15/25.

On 2/21/25 at 1450 hours, an interview was conducted with LVN 12. LVN 12 stated Resident 10 was monitored for the adverse reactions related to use of anticoagulant, symptoms of Covid-19/RSV/Influenza, and pain for the morning shift of 2/15/25. LVN 12 verified she missed documenting the monitoring for Resident 10.

4. Medical record review for Resident 20 was initiated on 2/21/25. Resident 20 was admitted to the facility on [DATE REDACTED].

Review of Resident 20's MDS assessment dated [DATE REDACTED], showed Resident 20 had moderate cognitive impairment.

Review of Resident 20's Order Summary Report showed the following:

- a physician's order dated 12/25/24, to apply estradiol vaginal cream one gram in the vagina at bedtime every Monday, Wednesday, and Friday for vaginal discomfort.

- a physician's order dated 12/26/24, to monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, SOB, and nose bleeds related to anticoagulant medication every shift.

- a physician's order dated 12/26/24, to monitor for episodes of depression as evidenced by verbalization of sadness related to use of zoloft every shift.

- a physician's order dated 1/27/25, to monitor for episodes of schizophrenia as evidenced by auditory hallucination related to use of quetiapine every shift.

- a physician's order dated 1/27/25, to monitor for side effects of tardive dyskinesia such as facial or tongue movement, inability to sit still, and drooling related to use of quetiapine and risperidone every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 - a physician's order dated 1/27/25, to monitor for adverse reactions related to use of quetiapine and risperidone such as dry mouth, blurred vision, and confusion every shift. Level of Harm - Minimal harm or potential for actual harm Review of Resident 20's MAR for February 2025 showed no documented evidence Resident 20 was monitored for on 2/6/25, the evening shift (1500 hours to 2300 hours) for the following: Residents Affected - Few - adverse reactions related to use of anticoagulant, quetiapine and risperidone;

- episodes of depression related to the use of zoloft;

- episodes of schizophrenia related to the use of quetiapine; and

- side effects of tardive dyskinesia.

Further review of Resident 20's MAR for February 2025 showed no documented evidence the vaginal cream was applied to Resident 20 on 2/14/25, for the evening shift.

On 2/21/25 at 1424 hours, a telephone interview was conducted with LVN 3. LVN 3 verified he monitored Resident 20 for the above findings but forgot to document in the MAR.

5. Medical record review for Resident 68 was initiated on 2/21/25. Resident 68 was admitted to the facility on [DATE REDACTED].

Review of Resident 68's MDS assessment dated [DATE REDACTED], showed Resident 68 was cognitively intact.

Review of Resident 68's Order Summary Report showed a physician's order dated 11/16/24, to cleanse the perineal area with normal saline, pat dry, apply house supply barrier cream, and leave open to air daily and as needed if soiled every shift for skin maintenance.

Review of Resident 68's TAR for February 2025 showed no documented evidence the perineal care was provided to Resident 68 on 2/16/25.

On 2/21/25 at 1025 hours, an interview and concurrent record review was conducted with LVN 9. LVN 9 stated the treatment nurse was responsible in providing treatment like wound care and GT care for the morning shift. LVN 9 stated when the CNA would provide peri care to the resident, she would go with the CNA to apply the ordered treatment to the resident. LVN 9 stated she would also check if the resident had any concerns or discomfort and would document after the treatment was completed. LVN 9 stated if the treatment was not documented, it meant it was not done. LVN 9 verified she worked on 2/16/25, and was assigned to the perineal treatment to Resident 68. LVN 9 stated she was busy that day and could not remember if she provided the perineal treatment to Resident 68.

6. Medical record review for Resident 586 was initiated on 2/20/25. Resident 586 was admitted to the facility

on [DATE REDACTED].

Review of Resident 586's MDS assessment dated [DATE REDACTED], showed Resident 586 had moderate cognitive impairment and no acute change in mental status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 Review of Resident 586's Order Summary Report showed a physician's order dated 2/16/25, to monitor IV site every shift for signs and symptoms of infection such as redness, swelling, warmth, and pain. Level of Harm - Minimal harm or potential for actual harm Review of Resident 586's IV Administration Record for February 2025 showed no documented evidence the IV site monitoring for signs and symptoms of infection was completed on 2/16 and 2/17/25, for the evening Residents Affected - Few shift.

On 2/20/25 at 1418 hours, an interview and concurrent medical record and facility document review was conducted with the ADON. The ADON verified two IV certified LVNs had worked on 2/16 and 2/17/25 for the evening shift. The ADON verified the missing documentation for IV site monitoring on 2/16 and 2/17/25, for Resident 586. The ADON stated it was very important to check and document if the IV line was intact and had no signs and symptoms of infection.

On 2/24/25 at 1513 hours, an interview was conducted with the DON. The DON stated after administering medication or treatment to the resident, the charge nurse should document it. The DON was informed and acknowledged the above findings for Residents 10, 20, 68, and 586.

39453

7. Medical record review for Resident 336 was initiated on 2/18/25. Resident 336 was admitted to the facility

on [DATE REDACTED].

Review of Resident 336's POLST dated 2/14/25, showed a different resident name and the wrong birthdate.

Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for influenza vaccine, showed a different resident name.

Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for pneumonia vaccine, showed a different resident name.

Review of Resident 336's Informed Consent - Immunization (Updated) - V2 dated 2/14/25, for Covid-19 vaccine, showed a different resident name.

Review of Resident 336's Consent to Treat dated 2/14/25 showed a different resident name.

On 2/21/25 at 1338 hours, an interview and concurrent medical record review for Resident 336 was conducted with RN 4. RN 4 verified the above findings.

50787

8. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy dated May 2022 showed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 On 02/19/25 at 1218 hours, medication storage inspection for Medication Cart #1 was conducted with LVN 12. The controlled drug inspection was done and showed Resident 51's Tramadol (controlled substance Level of Harm - Minimal harm or used to treat moderate to moderately severe chronic pain in adults) bubble pack with three slots of empty potential for actual harm bubbles with red asterisk written next to it and actual remaining tablets as 12. This observation was acknowledged and verified by LVN 14. Residents Affected - Few

Review of the Narcotic and Controlled Substance Sheet showed the Tramadol HCL 50 mg medication with

the prescription number 2317044, to take one tablet by mouth every six hours PRN for moderate to severe pain.

Review of the Narcotic and Controlled Substance Sheet was conducted and showed the following entries:

- dated 8/25/24, with 22 remaining tablets

- three blank spaces thereafter, then an entry dated 11/13/24, with 18 remaining tablets.

- on the bottom part of the sheet, three entries dated 10/17/24, with no time, quantity administered as wasted and quantity remaining of 3, 2, and 1 tablets.

Review of Resident 51's medical record was initiated on 2/19/25. Resident 51's admitted was on 6/22/24.

Review of Resident 51's Order Summary Report showed the physician's order dated 8/12/24, for tramadol HCl oral tablet *Controlled Drug* 50 mg by mouth every six hours as needed for moderate pain (pain level of 4-6) to hold if RR below 12 breaths per minute.

An interview with the DON was conducted on 02/20/25 at 0905 hours. The DON stated he was not aware of Resident 51's wasted tramadol medications. The DON further stated he would investigate the wasted tramadol.

A written statement from RN 1 who co-signed Resident 51's Narcotic and Controlled Substance Sheet was submitted to the DON dated 2/21/25. RN 1 stated the tramadol bubble pack back portion, two tablets were secured with tape and one tablet was ripped halfway, thus wasted the three tablets with LVN 13.

Interview with LVN 13 was conducted on 2/24/25 at 0900 hours. LVN 13 stated she was doing the narcotic count with another nurse, observed the back of the bubble pack opened. LVN 13 stated she applied a tape, informed her supervisor (RN 1) of the condition of the bubble pack. LVN 13 and RN 1 wasted the medications and signed the signature part of Resident 51's Narcotic and Controlled Substance Sheet. LVN 13 was unable to account why the 10/17/24 entries in the Narcotic and Controlled Substance Sheet was written at the bottom part of the sheet and the information was inaccurate.

43119

10. Medical record review for Resident 26 was initiated on 2/19/25. Resident 26 was admitted to the facility

on [DATE REDACTED], and readmitted on [DATE REDACTED]. Resident 26 had a diagnosis of end stage renal disease which required to have an access site for the hemodialysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0842 Review of Resident 26's H&P evaluation dated 3/25/24, showed Resident 26 had the capacity to understand and make medical decisions. Level of Harm - Minimal harm or potential for actual harm Review of Resident 26's Plan of Care initiated on 4/22/22, showed a care plan problem addressing Resident 26's risk for complications of the shunt/catheter site on the left upper chest permacath. Residents Affected - Few

Review of Resident 26's Dialysis Communication Observation/Assessment Sheets for January 2025 showed, yes for the bruit and thrill assessments for the pre and/or post hemodialysis treatments on 1/22, 1/24, 1/29, and 1/31/25.

Further review of the Dialysis Communication Observation/Assessment Sheets for January 2025 showed the assessment of the permacath located on the right side of the chest on 1/22/24.

On 2/20/25 at 1454 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 stated the licensed nurses were responsible for the documentation on the Dialysis Communication

Observation/Assessment Sheet. LVN 5 verified the above findings. LVN 5 verified Resident 26's permacath was on the left upper chest and not properly assessed and documented in Resident 26's medical record. LVN 5 acknowledged Resident 26's permacath hemodialysis access should not be assessed for the presence of the bruit and thrill.

On 2/20/25 at 1514 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

52238

9. Medical record review for Resident 5 was initiated on 2/18/25. Resident 5 was admitted to the facility on [DATE REDACTED].

Review of Resident 5's Documentation Survey Report for February 2025 showed the missing documentation for the bowel continence documentation on the following dates and shifts:

- 2/16/25, for the day shift;

- 2/15, 2/19, and 2/21/25, for the evening shift; and

- 2/1, 2/10, and 2/16/25, for the NOC shift.

On 2/24/25 at 1308 hours, an interview was conducted with the ADON. The ADON acknowledged the missing documentation in Resident 5's bowel and bladder elimination record. The ADON also acknowledged

the CNAs caring for Resident 5 did not document and should have documented the information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453 potential for actual harm Based on observation, interview, medical record review, facility document review, and facility P&P review, Residents Affected - Few the facility failed to maintain the infection control program designed to help prevent the development and transmission of diseases and infections.

* The facility failed to implement their infection control surveillance program for November 2024, December 2024, and January 2025. The facility failed to correctly identify the HAIs and CAIs. The facility failed to conduct an accurate infection surveillance as per the McGeer criteria. The facility failed to ensure the residents infections were mapped and tracked. In addtion, the facility failed to ensure the infection control data presented to the infection control meeting was accurate and complete.

* The facility failed to ensure the clean personal clothing and linen cart were covered during transportation.

* The facility failed to ensure LVN 10 had performed hand hygiene while providing a wound care treatment to Resident 336.

* The facility failed to ensure Resident 686's nasal canula tubing was not touching the trash can or floor.

These failures posed the risk for not identifying infections and controlling the transmission of communicable disease to other residents throughout the facility.

Findings:

1. Review of the facility's P&P titled Infection Prevention and Control Program (IPCP) dated 2001 showed an IPCP is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Elements of the IPCP section showed the surveillance data and reporting information is used to inform the committee of potential issues and trends. The Surveillance and Reporting section showed the process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of HAIs) are used as measures of the IPCP effectiveness, and the information obtained from the infection control surveillance activities is compared with acknowledged standards (for examples, acceptable rates of new infections), and used to assess the effectiveness of established infection prevention and control practices.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0880 On 2/20/25 at 0836 hours, an interview and concurrent medical record review, facility document review, and facility P&P review was conducted with the IP and DSD. The IP stated she identified the CAI and HAI based Level of Harm - Minimal harm or on the date of admission and onset of signs and symptoms of infection. The IP stated she started working potential for actual harm two weeks ago, and the DSD was the previous IP. The DSD acknowledged she was the previous IP. The DSD stated she was responsible for conducting the surveillance of the residents' infections within the facility Residents Affected - Few from November 2024 to January 2025. The DSD was asked to review and explain the facility's infection control surveillance program. The DSD stated the facility utilized the McGeer Criteria to define infection surveillance activities. The DSD was asked to review and explain the facility's infection control surveillance program. The DSD stated she reviewed the infection screening report in the residents' EHR, change in condition reports, and nurses' progress notes. The DSD stated she marked the infection as HAI if the onset of the signs and symptoms of infection 72 hours after admission, and when the infection met the McGeer Criteria. The DSD also stated she separated the monthly infection control surveillance report and logs from

the flu response or those flu and flu-like infections, and other infections other than the flu-like symptoms.

a. Review of the Monthly Infection Control Surveillance from November 2024 to January 2025 failed to show infections were classified as CAI or HAIs accurately. In addition, review of the Infection Prevention and Control Surveillance Log from November 2024 to January 2025 failed to show HAIs were accurately identified as meeting the McGeer criteria or not. For example:

- The Monthly Infection Control Surveillance for November 2024 showed 19 CAIs. However, the log showed Resident 87 was admitted on [DATE REDACTED], and the onset of the signs and symptoms was 11/6/24.

- The Monthly Infection Control Surveillance for December 2024 showed five HAIs. However, review of the Infection Prevention and Control Surveillance Log for December 2024 showed Resident 86 did not meet the McGeer Criteria for pneumonia but was marked as HAI.

- The Monthly Infection Control Surveillance for flu-response for December 2024 showed 33 HAIs. However,

review of the Infection Prevention and Control Surveillance Log for flu-response for December 2024 showed

the 33 HAIs did not meet McGeer Criteria.

- The Monthly Infection Control Surveillance for January 2025 showed seven HAIs. However, review of the Infection Prevention and Control Surveillance Log for January 2025 showed the following:

* Resident 338 did not meet the McGeer Criteria for fungal skin infection but was marked as HAI;

* Resident 36 did not meet the McGeer Criteria for bronchitis but was marked as HAI; and

* Resident 15 did not meet the McGeer Criteria for respiratory tract infection but was marked as HAI.

- The Monthly Infection Control Surveillance for flu-response for January 2025 showed three HAIs. However,

review of the Infection Prevention and Control Surveillance Log for flu-response for January 2025 showed

the following:

* Resident 56 had duplicate entries for signs and symptoms of infection, with the onset dates of 1/23 and 1/24/25; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0880 * Resident 13 did not meet the McGeer Criteria for influenza-like illness but was marked as HAI.

Level of Harm - Minimal harm or b. Review of the facility's mapping of infections showed incomplete mapping and trending of all infections in potential for actual harm the facility. The mapping only included the influenza and RSV infections.

Residents Affected - Few c. Review of the facility's documented titled Fourth Quarter Microbiology Report for October to December 2024 showed incomplete reporting of the total infections in the facility. The report showed zero on the respiratory infections, and did not include those not meeting McGeer Criteria.

The IP and DSD verified the above findings. The DSD acknowledged she made a mistake when identifying

the CAIs and HAIs as meeting McGeer Criteria or not. The DSD stated the Microbiology Report was from General Acute Care Hospital 1, and she did not include the reports from General Acute Care Hospital 2, and

the facility's report.

2. Review of the facility's P&P titled Laundry and Bedding, Soiled dated 2001 showed clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.

On 2/20/25 at 1055 hours, the Laundry Aide was observed transporting an uncovered linen cart with the residents' clothing was hanging on the handlebars of the linen cart, and blankets were on the linen cart.

On 2/20/25 at 1058 hours, an observation and concurrent interview was conducted with the Laundry Aide. Residents' clothing was observed hanging on the handlebars, and blankets were on the linen cart which was not covered. The Laundry Aide verified the above findings. The Laundry Aide stated she used a blanket to cover the clothing and blankets, but only when she transported the clean linen outside the facility.

3. Review of the facility's P&P titled Handwashing/ Hand Hygiene dated 2001 showed hand hygiene is indicated before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal.

On 2/21/25 at 0937 hours, a wound care observation for Resident 336 and concurrent interview was conducted with LVN 9. LVN 9 stated Resident 336's staples at the surgical site were removed at her appointment, and she came back at 1600 hours, yesterday (2/20/25). LVN 9 stated, there was an opening, so I need to apply the Steri-Strips. The following was observed:

- LVN 9 was observed washing her hands then donning clean gloves and cleaning Resident 336's mid back surgery site with a gauze soaked with normal saline.

- Without performing hand hygiene, LVN 9 was observed removing gloves then donning clean gloves and patting Resident 336's mid back surgery site with a dry gauze.

- Without performing hand hygiene, LVN 9 was observed removing gloves then donning clean gloves and applying Steri-Strips to Resident 336's mid back surgery site.

- LVN 9 was observed removing gloves, donning clean gloves and applying Steri-Strips to Resident 336's mid back surgery site four more times without performing hand hygiene until the entire surgical site was applied with Steri-Strips.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 055929 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055929 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663

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 0880 - Without performing hand hygiene, LVN 9 was observed removing gloves then donning clean gloves and applying an adhesive dressing to Resident 336's mid back surgery site. Level of Harm - Minimal harm or potential for actual harm - Then, LVN 9 was observed removing gloves and washing her hands after the wound care treatment.

Residents Affected - Few On 2/21/25 at 1451 hours, a follow-up interview was conducted with LVN 9. When asked about performing a hand hygiene during wound care treatment, LVN 9 stated she washed her hands when she was done with

the wound care treatment. LVN 9 stated, it was not a wound I was doing, I was just putting the Steri-Strips. I thought that by removing the gloves, it would be okay. LVN 9 acknowledged she should have performed hand hygiene when performing a wound care from dirty to clean, and immediately after removing gloves.

52238

4. On 2/18/25 at 0907 hours, during the initial tour of the facility, Resident 686 was observed in bed using an oxygen via nasal caula at a rate of 4 liters per minute and the green color nasal cannula tubing was observed touching the inside of the trash can next to the oxygen concentrator.

Medical record review for Resident 686 was initiated on 2/18/25. Resident 686 was admitted to the facility on [DATE REDACTED].

On 2/18/25 at 1211, 1238, and 1509 hours, a follow-up observation was conducted in Resident 686's room. Resident 686 was observed using her oxygen via nasal canula at a rate of 4 liters per minute and the green color nasal canula tubing was observed touching the floor.

On 2/18/25 at 1513 hours, an observation and concurrent interview was conducted with LVN 6. When asked if the nasal canula tubing should be touching the floor when the resident was using the oxygen, LVN 6 stated

the nasal canula tubing should not be touching the floor as it posed the risk for infection. LVN 6 verified the green color nasal canula tubing was touching the floor while Resident 686 was using her oxygen via nasal canula.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 055929