Health inspection·September 19, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 necessary treatment and services to maintain the highest practicable well-being for one of twelve sampled residents (Resident 10). * The facility failed to monitor Resident 10 who was on antibiotic treatment for UTI. In addition, the facility failed to ensure Resident 10's plan of care was updated to address Resident 10's treatment interventions and management of the UTI. This failure had the potential for the delay of the identification of the adverse effects related to the resident's use of antibiotic treatment and for the resident to not receive the appropriate and individualized care that could potentially affect the resident's health and well-being. Findings: Review of the facility's P&P titled Care Planning-Interdisciplinary Team revised 3/2022 showed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 4/2021 showed a significant change in condition is a major decline or improvement in the resident's status that requires interdisciplinary review and or revision to the care plan; and the nurse will record in the resident's medical record information relative to changes in resident's medical/mental condition or status. According to CDC Healthy Habits: Antibiotic Do's Administrator Don'ts dated 9/23/25, showed the common side effects of antibiotics range from minor to severe health problems and can include rash, dizziness, nausea, diarrhea, yeast infection. The more serious side effects can include C. diff infection which causes diarrhea that can lead to severe colon damage and death and severe and life threatening allergic reactions. Medical record review for Resident 10 was initiated on 9/17/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 8/10/25, showed Resident 10 required assistance to make medical decisions. Review of Resident 10's Order Summary Report showed the following physician's orders:- dated 7/20/25, for Ceftriaxone (an antibiotics) sodium solution reconstituted 1 gram, to give 1 gram intravenously every 24 hours for infection for five days and discontinued on 7/21/25; and- dated 7/22/25, for Ertapenem sodium (an antibiotics) injection solution reconstitute 1 gram, to give 1 gram intravenously one time a day for UTI until 7/27/25. a. Review of Resident 10's nursing assessment dated [DATE] at 1508 hours, showed Resident 10 was noted with a change of condition including tachycardia (increased heart rate). The physician was notified and ordered urinalysis stat and antibiotic treatment of Ceftriaxone 1 gm IV every 24 hour for five days. Review of Resident 10's Change of Condition Report dated 7/21/25 at 1600 hours, showed Resident 10 with a change of condition related to urinary tract infection as evidenced by the urinalysis result with an order for antibiotic therapy initiation. However, further review of Resident 10's medical record failed to show if the resident's change 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 2 Event ID: 555751 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 09/19/2025 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)