Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**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 provide the appropriate pain
management for three of three sampled residents (Residents 1, 2, and 3). * The facility failed to accurately
document the monitoring of pain levels for Residents 1, 2, and 3 and administer the pain medications
according to the physician's orders. This failure had the potential to put Residents 1, 2, and 3 at risk for
ineffective pain management.Findings: Review of the facility's P&P titled Pain Assessment and
Management dated 2001 showed the purpose of this procedure are to help the staff identify pain in the
resident, develop interventions consistent with the resident's goals and needs, and address the underlying
causes of pain. The Assessing Pain section showed to assess pain using a consistent approach and a
standardized pain instrument appropriate to the resident's cognition level. Review of the facility's P&P titled
Administering Medications dated 2001 showed the medications are administered in a safe and timely
manner, and as prescribed. 1. Closed medical record review for Resident 1 was initiated on 7/11/25.
Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 6/24/25,
showed Resident 1 had a displaced intertrochanteric fracture of the right femur (thigh bone). Review of
Resident 1's MDS assessment dated [DATE], showed Resident 1 had severe cognitive impairment. Review
of Resident 1's Order Summary Report dated 7/11/25, showed a physician's order dated 6/22/25, to
administer acetaminophen (used to treat minor aches and pains) tablet 325 mg two tablets by mouth every
four hours as needed for mild pain (1-3) (on a 0 to 10 pain scale with 0 = no pain and 10 = worst pain).
Non-pharmacological interventions as follows: 1. Relaxation 2. Adjust room temperature/lighting 3.
Reposition 4. Toileting 5. Music/TV 6. Snacks 7. Warm/Cold Compress 8. Other. Review of Resident 1's
MAR for June 2025 showed Resident 1 was administered two tablets of the acetaminophen 325 mg
medication for mild pain (1-3) on the following dates and times:- on 6/25/25 at 0236 hours, for a pain level
of 5; and- on 6/25/25 at 1006 hours, for a pain level of 10. On 7/15/25 at 1126 hours, an interview and
concurrent closed medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1
verified the acetaminophen medication was administered to Resident 1 outside of the pain scale parameter
on multiple occasions. RN 1 stated the licensed nurses should have called Resident 1's physician if the pain
levels were not in the pain scale parameter and if the resident wanted something stronger. On 7/15//25 at
1431 hours, an interview and concurrent closed medical record review was conducted with the DON. The
DON verified the above findings. The DON stated the licensed nurses should have clarified the pain
management orders with Resident 1's physician to ensure the resident had available pain medication for
moderate to severe pain. 2. Medical record review for Resident 2 was initiated on 7/11/25. Resident 2 was
admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination
dated 4/29/25, showed Resident 2 had acquired absence of the right limb below the elbow (amputation).
The resident reported experiencing throbbing pain, particularly in her right arm. Review of Resident 2's
MDS assessment dated
Residents Affected - Few
(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 3
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
07/15/2025
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 0697
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
[DATE], showed the resident's cognition was moderately impaired. Review of Resident 2's Order Summary
Report for July 2025 showed the following physician's orders:- dated 6/14/25, to administer oxycodone
hydrochloride (narcotic pain medication) 5 mg 1.5 tablet by mouth every four hours as needed for moderate
pain (4-6) (on a 0 to 10 pain scale, 0 = no pain and 10 = worst pain). Hold if the RR (respiratory rate) was
less than 12 per minute. Document the non-pharmacological interventions as follows: 1. Relaxation 2.
Adjust room temperature/lighting 3. Reposition 4. Toileting 5. Music/TV 6. Snacks 7. Warm/Cold Compress
8. Other. - dated 12/15/24, to administer oxycodone hydrochloride (narcotic pain medication) 10 mg by
mouth every four hours as needed for severe pain (7-10) (on a 0 to 10 pain scale, 0 = no pain and 10 =
worst pain). Document the non-pharmacological interventions as follows: 1. Relaxation 2. Adjust room
temp/lighting 3. Reposition 4. Toileting 5. Music/TV 6. Snacks 7. Warm/Cold Compress 8. Other. Review of
Resident 2's MAR for June and July 2025 showed Resident 2 was administered the oxycodone
hydrochloride 5 mg medication for moderate pain (4-6) on the following dates and times:- on 6/22/25 at
0926 hours, for a pain level of 8;- on 6/23/25 at 0930 hours, for a pain level of 9;- on 6/23/25 at 1330 hours,
for a pain level of 9; - on 6/25/25 at 0413 hours, for a pain level of 7; - on 6/26/25 at 0616 hours, for a pain
level of 7; - on 7/8/25 at 1442 hours, for a pain level of 7; - on 7/8/25 at 1905 hours, for a pain level of 7; and
- on 7/8/25 at 2346 hours, for a pain level of 8. Review of Resident 2's MAR for June 2025 showed Resident
2 was administered the oxycodone hydrochloride 10 mg medication for severe pain (7-10) on the following
dates and times:- on 6/27/25 at 1404 hours, for a pain level of 6; and- on 6/27/25 at 1828 hours, for a pain
level of 5. On 7/15/25 at 1140 hours, an interview and concurrent medical record review was conducted
with LVN 4. LVN 4 verified the above findings. LVN 4 stated the licensed nurses should have assessed
Resident 2 and administered the pain medication according to the ordered pain scale parameters. LVN 4
stated the licensed nurses should have administered the right dosage of pain medication according to the
resident's pain level. On 7/15//25 at 1440 hours, an interview and concurrent medical record review was
conducted with the DON. The DON verified the above findings. The DON stated the licensed nurse should
have followed Resident 2's physician order on pain management according to the resident's verbalized pain
level. The DON stated the licensed nurse should follow Resident 2's physician orders for the pain
medication parameters. 3. Medical record review for Resident 3 was initiated on 7/11/25. Resident 3 was
admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 6/22/25, showed
Resident 3 had a diagnoses of low back pain and status post lumbar (lower back) surgery. Review of
Resident 3's MDS assessment dated [DATE], showed the resident was cognitively intact. Review of
Resident 3's Order Summary Report for July 2025 showed the following physician's orders: - dated 6/19/25,
to administer acetaminophen 325 mg two tablets by mouth every six hours as needed for mild pain (1-3)
(on a 0 to 10 pain scale, 0 = no pain and 10 = worst pain). Non-pharmacological interventions as follows: 1.
Relaxation 2. Adjust room temperature/lighting 3. Reposition 4. Toileting 5. Music/TV 6. Snacks 7.
Warm/Cold Compress 8 . Other. - dated 6/19/25, to administer hydrocodone-acetaminophen (narcotic pain
medication) 10-325 mg one tablet by mouth every six hours as needed for moderate pain (4-6) (on a 0 to
10 pain scale, 0 = no pain and 10 = worst pain). - dated 6/28/25, to administer hydrocodone-acetaminophen
10-325 mg one tablet by mouth every six hours as needed for moderate pain (4-6) (on a 0 to 10 pain scale,
0 = no pain and 10 = worst pain). Non-pharmacological interventions as follows: 1. Relaxation 2. Adjust
room temp/lighting 3. Reposition 4. Toileting 5. Music/TV 6. Snacks 7. Warm/Cold Compress 8. Other.
Review of Resident 3's MAR for June and July 2025 showed Resident 3 was administered two tablets of
the acetaminophen 325 mg medication for mild pain (1-3) on the following dates and times: - on 6/26/25 at
0620 hours, for a pain level of 4; and- on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055929
If continuation sheet
Page 2 of 3
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
07/15/2025
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 0697
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
7/5/25 at 0857 hours, for a pain level of 5. Review of Resident 3's MAR for June 2025 showed Resident 3
was administered the hydrocodone-acetaminophen 10-325 mg medication (ordered by Resident 3's
physician on 6/19/25) for moderate pain (4-6) on the following dates and times:- on 6/23/25 at 1712 hours,
for a pain level of 7; - on 6/25/25 at 1035 hours, for a pain level of 9; and - on 6/27/25 at 0930 hours, for a
pain level of 9. Review of Resident 3's MAR for June and July 2025 showed Resident 3 was administered
the hydrocodone-acetaminophen 10-325 mg medication (ordered by Resident 3's physician on 6/28/25) for
moderate pain (4-6) on the following dates and times: - on 6/30/25 at 1843 hours, for a pain level of 7; - on
7/1/25 at 1309 hours, for a pain level of 7; - on 7/5/25 at 2042 hours, for a pain level of 8; and - on 7/10/25
at 1829 hours, for a pain level of 7. On 7/15/25 at 1107 hours, an interview and concurrent medical record
review was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 verified the PRN
acetaminophen and hydrocodone-acetaminophen medication orders were administered to Resident 3
outside of the pain scale parameters. LVN 2 verified the PRN pain medications should have been offered
based on the pain scale. LVN 2 stated if the pain level did not meet the parameter, the licensed nurse
should have informed Resident 3's physician. On 7/15//25 at 1419 hours, an interview and concurrent
medical record review was conducted with the DON. The DON verified the above findings. The DON stated
the licensed nurse should have clarified the pain management orders with Resident 3's physician if the
resident's pain level was severe or seven and above on the pain scale.
Event ID:
Facility ID:
055929
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
FAQ · About this visit
Common questions about this visit
What happened during the July 15, 2025 survey of CRYSTAL COVE CARE CENTER?
This was a inspection survey of CRYSTAL COVE CARE CENTER on July 15, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CRYSTAL COVE CARE CENTER on July 15, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide safe, appropriate pain management for a resident who requires such services."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.