Crystal Cove Care Center

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Some

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and medical record review, the facility failed to ensure the discharge medication list was appropriate for one of two sampled residents (Resident 3) reviewed for discharge. * Resident 3's discharge medication list did not include the Verapamil (blood pressure medication), Ambien (medication used to treat insomnia) and oxycodone-acetaminophen (pain reliever medication). This failure had the potential for the resident not receiving appropriate care and proper medication management after the discharge. Findings:

On 9/18/25, the CDPH, L&C Department received a complaint alleging upon discharge, Resident 3 was not provided with the Verapamil or Ambien medications upon leaving the facility on 6/12/25. On 10/2/25 at 1256 hours, a telephone interview was conducted with Resident 3. Resident 3 stated she left the faciity on 6/12/25, because the facility did not administer her Verapamil or Ambien medications. Closed medical

record review for Resident 3 was conducted on 10/2/25. Resident 3 was admitted to the facility on [DATE REDACTED], and discharged on 6/12/25. Review of Resident 3's Order Summary Report showed the following orders:dated 6/11/25, Ambien oral tablet 10 mg, give one tablet by mouth every 24 hours as needed for insomnia manifested by inability to sleep- dated 6/11/25, Ambien oral tablet 10 mg, give one tablet by mouth every 24 hours as needed for insomnia manifested by inability to sleep for 14 days.- dated 6/11/25, oxycodone-acetaminophen oral tablet 10-325 mg, give one tablet by mouth every four hours as needed for moderate pain 4-6 (on the pain scale of 0 to 10 with 0 = no pain and 10 = worst), hold if RR (respiratory rate) less than 12- dated 6/11/25, oxycodone-acetaminophen oral tablet 10-325 mg, give two tablets by mouth every four hours as needed for severe pain 7-10, hold if RR less than 12- dated 6/12/25, Verapamil Extended Release oral tablet 120 mg, give one tablet by mouth two times a day for high blood pressure.

Hold if SBP greater than 110 mmHg.- dated 6/12/25, Verapamil oral tablet 120 mg, give 120 mg by mouth

in the afternoon for hypertension. Review of Resident 3's H&P examination dated 6/12/25, showed Resident 3's diagnoses included PTSD, anxiety, and high blood pressure. Review of Resident 3's Transfer/Discharge Report dated 6/12/25, showed the following medications were listed on the discharge medication list but not marked as given to the resident upon discharge: - Verapamil 120 mg in the afternoon- Verapamil 120 mg Extended Release 120 mg twice daily- oxycodone-acetaminophen oral tablet 10-325 mg On 10/14/25 at 1709 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 verified Resident 3's Verapamil, Ambien, and oxycodone-acetaminophen medications were not provided to the resident upon the resident's discharge. Cross reference F-F755.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Potential for minimal harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and medical record review, the facility failed to provide the necessary care and services to ensure one of eight sampled residents (Resident 3) attained and maintained the highest practicable physical well-being * The facility failed to provide documented evidence Resident 3's physician was notified of Resident 3's abnormal blood pressure. Additionally, Resident 3's blood pressure was not retaken when it was documented it was above normal. These failures had the potential to negatively impact the resident.Findings: Closed medical record review for Resident 3 was conducted on 10/2/25. Resident 3 was admitted to the facility on [DATE REDACTED], and discharged on 6/12/25. Review of Resident 3's Current Weights and Vitals dated 6/11/25, showed Resident 3's blood pressure was 142/86 mmHg. Further review of Resident 3's medical record showed the blood pressure reading on 6/11/25, was the only reading obtained for Resident 3. According to the National Library of Medicine Website, a normal blood pressure reading is usually 120/80 mmHg. Readings above 140/90 mmHg are categorized high blood pressure level 2. Review of Resident 3's H&P examination dated 6/12/25, showed Resident 3's diagnoses included PTSD, anxiety, and high blood pressure. Review of Resident 3's Order Summary Report showed the following orders:dated 6/12/25, Verapamil Extended Release oral tablet 120 mg, give one tablet by mouth two times a day for high blood pressure. Hold if the SBP greater than 110 mmHg.- dated 6/12/25, Verapamil oral tablet 120 mg, give 120 mg by mouth in the afternoon for hypertension. Review of Resident 3's MAR for June 2025 failed to show the Verapamil medication was administered on 6/12/25. Further review of Resident 3's medical record failed to show documented evidence the resident's physician was notified of the blood pressure reading of 142/86 mmHg on 6/11/25, and the Verapamil medication not administered on 6/12/25.

On 10/8/25 at 1551 hours, an interview and concurrent closed medical record review was conducted with LVN 2. LVN 2 verified Resident 3's blood pressure on 6/11/25 was 142/86 mmHg. When asked if Resident 3's blood pressure was taken again or if Resident 3's physician was notified of the above normal blood pressure, LVN 2 verified Resident 3's blood pressure was not retaken or rechecked. On 10/10/25 at 1027 hours, a telephone interview was conducted with the DON. The DON verified there was no documented evidence to show Resident 3's physician was notified of Resident 3's blood pressure on 6/11/25.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

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 0755

the Roxicodone and oxycodone medications were included in Resident 4's medical record. The Medical Records Director verified these sheets were not on file and verified the findings.

Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

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 - Potential for minimal harm

Based on observation, interview, and facility P&P review, the facility failed to ensure infection control practices were maintained for one of eight sampled residents (Resident 2) reviewed for infection control. * LVN 1's shoe was touching Resident 2's suprapubic catheter urine drainage bag. * LVN 1 failed to perform hand hygiene after removing dirty gloves and before putting on clean gloves. * Resident 2's suprapubic catheter urine drainage bag was touching the floor. These failures had the potential for cross-contamination and spread of infectious organisms in the facility.Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene dated 2021 showed hand hygiene was to be performed after touching a resident, after removing a used glove, and before applying a clean glove. Review of the facility's P&P titled Catheter Care, Urinary dated 2001 showed under infection control, catheter tubing must be kept off the floor. On 10/7/25, at 1400 hours, an observation of urinary catheter care and concurrent interview was conducted with LVN 1. During the catheter care observation, Resident 2's suprapubic catheter urine drainage bag was observed touching the floor. Additionally, LVN 1's right shoe was touching Resident 1's suprapubic catheter urine drainage bag. LVN 1 removed the dirty gloves after cleaning Resident 2's suprapubic catheter surgical site and then put on a clean pair of gloves without performing hand hygiene.

LVN 1 acknowledged Resident 2's urine drainage bag should not be touching the floor and verified he did not perform hand hygiene in between changing his gloves.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet