Health inspection·March 13, 2025

F 0758 Level of Harm - Potential for minimal harm Residents Affected - Some 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 medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was provided the non-pharmacological interventions for the use of psychotropic medication (medication that affects the mind, emotions, and behavior). This failure had the potential to result in the unnecessary use of psychotropic medications for Resident 1. Findings: Review of the facility's P&P titled Antipsychotic Medication Use (undated) showed for enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. Closed medical record review for Resident 1 was initiated on 3/11/25. Resident 1 was admitted to the facility on [DATE] and discharged on 2/18/25, to the acute care hospital. Review of Resident 1's progress notes showed the following: - dated 2/12/25, Resident 1 returned from the acute care hospital with a new physician's order to administer Zyprexa (antipsychotic medication) 2.5 mg tablet every six hours as needed. - dated 2/14/25, the physician provided anew order for Zyprexa 2.5 mg four times a day. Review of Resident 1's Order Summary Report for February 2025 showed a physician's order dated 2/14/25, to administer Zyprexa 2.5 mg tablet by mouth four times a day for psychosis manifested by episodes of striking out. Review of Resident 1's plan of care showed a care plan problem dated 2/12/25, addressing Resident 1's use of the Zyprexa medication. However, the care plan interventions did not include the non-pharmacological interventions for the use of the above medication. Review of Resident 1's MAR for February 2025 showed the following monitoring for the resident's episodes of psychosis as evidenced by striking out: - On 2/13/25, Resident 1 had one episode during the day shift, six episodes during the evening (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 03/13/2025 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)