Health inspection·December 7, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and treatment related to oxygen administration for one of three final sampled residents (Resident 2). Residents Affected - Few * The facility failed to administer the oxygen to Resident 2 as ordered by the physician. This failure posed the risk of the resident developing complications due to inadequate oxygen therapy. Findings: Medical record review for Resident 2 was initiated on 12/5/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's History and Physical examination dated 12/4/23, showed Resident 2 had the capacity to understand and make decisions. Resident 2 had the left and right upper lungs embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). Review of Resident 2's admission diagnosis list dated 12/1/23, showed COPD, obstructive sleep apnea (noncontinuous airflow blockage during sleep), and acute and chronic respiratory failure. Review of the Order Summary Report showed a physician's order dated 12/1/23, to administer oxygen at three liters per minute via nasal cannula continuously for COPD/SOB and maintain the oxygen saturation levels greater than 90% every shift. On 12/5/23 at 0930 hours, Resident 2 was observed lying in her bed receiving oxygen via nasal cannula at two liters per minute. On 12/5/23 at 1153 hours, an observation and concurrent interview was conducted with RN 1. Resident 2 was observed receiving oxygen via nasal cannula at two liters per minute. RN 1 verified Resident 2 was receiving oxygen at two liters per minute. On 12/5/23 at 1155 hours, an observation and concurrent interview was conducted with LVN 2. Resident 2 was observed receiving oxygen at two liters per minute via nasal cannula. LVN 2 verified Resident 2 was receiving oxygen at two liters per minute. On 12/5/23 at 1245 hours, an observation and concurrent interview was conducted with LVN 1. Resident 2 was observed receiving oxygen at two liters per minute via nasal cannula. LVN 1 verified Resident 2 was receiving oxygen at two liters per minute. (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: 055929 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 055929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 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)