Health inspection·July 5, 2024

F 0806 Level of Harm - Potential for minimal harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on interview, medical record review, and P&P review, the facility failed to ensure the resident's food preferences and allergies were followed for one of five sampled residents (Resident 1). Residents Affected - Some * Resident 1 had an allergy to dairy products but was served milk. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Food Allergies and Intolerances revised 8/2017 showed the residents with food allergies and intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional values. Resident are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment, and the residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat. Closed medical record review was initiated for Resident 1 on 7/3/24. Resident 1 was admitted to facility on 6/14/24. Review of Resident 1's acute care hospital H&P examination dated 6/8/24, showed Resident 1's allergies included the dairy products. The H&P evaluation further showed Resident 1 would have diarrhea for hours after consuming the dairy products including yogurt. Review of Resident 1' Order Summary Report showed Resident 1's allergies included dairy foods. Review of Resident 1's Plan of Care initiated on 6/14/24, showed a care plan problem addressingResident 1's risk for altered nutritional status related to new colostomy placement. The care plan intervention showed Resident 1's food allergies/intolerance included the dairy products. Review of Resident 1's Discharge Progress Note dated 6/15/24 at 1002 hours, showed Resident 1 left the facility with her family member. Resident 1's family member was upset because Resident 1 received dairy milk despite being allergic to the dairy products. The progress notes further showed the nurse clarified with the kitchen staff and confirmed Resident 1 was provided whole milk (containing dairy) on her breakfast tray. On 7/5/24 at 1107 hours, an interview was conducted with the Dietary Supervisor. The Dietary Supervisor verified Resident 1 was served with milk for dinner and breakfast due to the kitchen staff failing to verify the resident's food allergies when prepping the meal tray as the ring hook was covering the allergy section of the dietary communication card. The Dietary Supervisor verified Resident 1 (continued on next page) 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 Page 1 of 2 Event ID: 055518 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newport Nursing and Rehabilitation Center 1555 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)