Health inspection·June 12, 2025

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 the care plan reflected the individual care needs for one of six sampled residents (Resident 1). * The facility failed to develop additional or different interventions in the care plan to reduce the risk of falls for Resident 1. This failure posed the risk of not providing the appropriate, consistent, and resident-centered care to the resident. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of fall for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. Closed medical record review for Resident 1 was initiated on 6/10/25. Resident 1 was admitted to the facility on [DATE], and was discharged on 6/9/25. Review of Resident 1's care plan for falls initiated 4/2/25, showed the resident was at risk for falls with or without injury related to altered mental status, antidepressant medication, antihypertensive medication, cardiovascular disease, history of falls, and unsteady gait. The interventions included the Falling Star fall prevention program, educating/reminding the resident to call for assistance with all transfers, keeping the call light within reach, keeping within supervised view as much as possible, and providing verbal reminders/cues to ask for assistance when needed and safety devices as ordered. Review of Resident 1's Change in Condition Evaluation dated 5/3/25, showed Resident 1 had a witnessed fall in front of the nurses' station at 1550 hours. Resident 1 was noted to be agitated and attempting to transfer and get up without staff assistance while in her room. Resident 1 was assisted to the nurses' station for monitoring. Resident 1 continued with the behavior, slid down the wheelchair, and fell on her bottom. Review of Resident 1's Transfer Form dated 5/4/25, showed Resident 1 was transferred to the acute care hospital due to unwitnessed fall at 0300 hours. Resident 1 was readmitted to the facility on [DATE]. (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 5 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 06/12/2025 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)