Health inspection·December 9, 2025

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) was provided the necessary GT services. * The facility failed to ensure Resident 1 was administered the TwoCal HN (a nutritional supplement that is calorie and protein dense) enteral feeding as per the physician's order and failed to ensure it was documented in the MAR. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Enteral Tube Feeding via Gravity revised November 2018 showed the person performing this procedure should record the following information in the resident's medical record:- The date and time the procedure was performed.- Verification of tube placement.- Amount and type of enteral feeding and amount of flush.- The name and title of the individual(s) who performed the procedure.- All assessment data obtained during the procedure.- How the resident tolerated the procedure.- If the resident refused the procedure, the reason(s) why and the intervention taken.- The signature and title of the person recording the data. Review of the facility's P&P titled Charting and Documentation revised July 2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the facility's P&P titled Administering Medications revised April 2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. On 12/1/25, the CDPH, L&C Program received a complaint alleging Resident 1 was denied a food supplement that was supposed to be given every three hours. Medical record review for Resident 1 was initiated on 12/4/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 9/18/25, showed the resident had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report showed the following physician's enteral feed orders:- dated 10/17/25, to provide 3300 kcal/1659 ml TwoCal HN 237 ml every two hours daily; and- dated 11/22/25, to provide 3300 kcal/1659 ml TwoCal HN 237 ml every three hours daily. Review of Resident 1's Progress Note dated 11/10/25, showed per the resident's family, the resident ate a big lunch and bolus feeding was not necessary. Review of Resident 1's MAR for November 2025 showed the above enteral feed orders were not administered to Resident 1 on the following dates:- 11/10, 11/12, 11/16, 11/22, and 11/26/25 at 1800 hours;- 11/14/25 at 2100 hours; and- 11/15/25 at 1200 hours. Review of Resident 1's Progress Note dated 11/26/25, showed the resident's enteral feeding scheduled at1800 hours was given at 1900 hours due to Resident 1's family member requesting the nurse to come back in 20 minutes. The nurse continued with medication administration and came back at 1900 hours to administer the enteral tube feeding. On 12/9/25 at 0914 hours, a telephone interview was conducted with (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: 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 12/09/2025 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)