Health inspection·July 2, 2025

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/2/25 at 0850 hours, an observation and concurrent interview for Resident 4 was conducted with CNA 1. Resident 4 was observed lying in bed with a G-tube feeding. The medication port on the G-tube tubing was observed with black substance inside the tubing. CNA 1 stated she did not know about it and verified the findings. On 7/2/25 at 0930 hours, an observation and concurrent interview for Resident 4 was conducted with LVN 1. Resident 4 was observed lying in bed with a G-tube feeding. The medication port on the G-tube tubing was observed with black substance inside the tubing. LVN 1 stated she did not give the medications to Resident 4 this morning and stated the tubing's medication port should be kept clean and needed to be changed. LVN 1 verified the findings. 2. Medical record review for Resident 5 was initiated on 7/2/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 3/23/25, showed Resident 5 had a G-tube. On 7/2/25 at 1120 hours, an observation and concurrent interview for Resident 5 was conducted with LVN 5. Resident 5 was observed sitting up in bed with a G-tube feeding. The G-tube tubing, specifically the medication port, was observed with black substances inside the tubing. LVN 5 stated the black substances were possibly from the medication stains. LVN 5 stated the G-tube tubing should be changed or kept clean. LVN 5 verified the findings. 3. Medical record review for Resident 6 was initiated on 7/2/25. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's physician's order dated 7/30/24, showed the enteral tubing: flush tubing with 50 ml of water before and after tube feeding two time a day. May use carbonated liquid if water flush is ineffective as needed. Review of Resident 6's physician's order dated 4/15/25, showed the enteral tubing: flush tubing with 30 ml of water before and after medications. Review of Resident 6's MAR for 4/2025 failed to show documentation Resident 6's G-tube was flushed with 30 ml of water before and after medications as ordered by the physician on 4/15/25. Review of Resident 6's physician's order dated 5/14/25, showed to discontinue the order to flush the enteral tubing with 30 ml of water before and after medications. Review of Resident 6's MAR for 5/2025 failed to show documented evidence the staff had flushed the enteral feeding with 30 ml of water before and after the medication administration from 5/1 to 5/10/25. On 7/2/25 at 1300 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 2. RN 2 stated the admission orders were clarified with Resident 6's physician and carried out by the admission nurse. On 7/2/25 at 1400 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON stated there was a physician's order to flush tubing with 30 ml of water before and after medications on 4/15/25, and the order to discontinue was received on 5/14/25. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555751 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 555751 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Newport Subacute Healthcare Center 2570 Newport Blvd Costa Mesa, CA 92627 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DON stated the licensed nurse who entered the order should have entered the frequency for the flush and clarified the order with Resident 6's physician. The DON was unable to locate documentation of the 30 ml flush before and after medication from 4/15/25 to 5/9/25. The DON acknowledged the licensed nurse should have documented when they flushed the water and followed the physician's order. Resident 6 was sent out to the acute care hospital on 5/10/25. The DON stated the purpose of the water flush before and after medication administration was to maintain the patency and prevent clogging of the enteral tubing. The DON verified and acknowledged the above findings. Event ID: Facility ID: 555751 If continuation sheet Page 3 of 3