Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Cove Care Center during CMS and state inspections, most recent first.
The facility failed to maintain confidentiality of residents’ PHI when a medical records assistant allowed a non-employee family member to sit inside the medical records office for an extended period while discharged records were being filed. Facility policies and HIPAA training prohibited unauthorized access to resident information and limited medical record access to designated staff. However, the non-employee was permitted to remain in the office, where open bookshelves contained medical record folders with visible resident names, and some showed admission and discharge dates and medical record numbers. The DON and Medical Records Director confirmed that unauthorized persons, including volunteers, were not allowed in the medical records area and that the family member was not an employee.
During wound care for a resident with a Stage 3 pressure injury, an RN and an LVN failed to wear required isolation gowns and did not post EBP signage, despite the resident's care plan specifying these precautions. The facility's infection control policy and staff interviews confirmed that EBP protocols were not followed during this high-contact care activity.
A resident with PTSD, anxiety, and hypertension was discharged without being provided with prescribed medications, including Verapamil, Ambien, and oxycodone-acetaminophen. Medical records confirmed these medications were ordered at discharge but not given to the resident, as verified by staff and documentation review.
A resident with a history of hypertension had an elevated blood pressure reading that was not retaken, and the physician was not notified as required. Additionally, the resident did not receive prescribed antihypertensive medication, and there was no documentation of physician notification regarding the missed dose or abnormal vital sign.
Two residents did not receive proper pharmaceutical services: one was not administered prescribed Verapamil and Ambien, and for another, required controlled medication count sheets for Roxicodone and oxycodone were missing from the medical record. Staff confirmed the omissions and lack of documentation.
A nurse failed to follow infection control protocols while providing catheter care to a resident, including allowing a urine drainage bag to touch the floor, making contact between a shoe and the drainage bag, and not performing hand hygiene between glove changes. These actions were not in accordance with facility policies for hand hygiene and catheter care.
A resident did not receive timely bowel management interventions as required by facility policy, resulting in more than three days without a BM, signs of distress, and eventual transfer to acute care for disimpaction. Nursing staff delayed implementing prescribed interventions and notifying the physician, despite daily monitoring requirements and clear evidence of constipation.
A resident with severe cognitive impairment and a history of falls experienced multiple falls, but the facility did not update the care plan with new or different interventions as required. The care plan remained unchanged despite repeated incidents, and documentation failed to address the resident's ongoing behaviors and fall risk. Facility leadership confirmed that no updates or additional interventions were made following the falls.
An LVN left three unlabeled medications in a clear cup unattended on a resident's bedside table, contrary to facility policy requiring safe administration and storage of medications. The DON confirmed that medications should not be left in a resident's room, and the resident was not assessed as capable of self-administering medication.
A resident returned from the hospital with a new order for Zyprexa, an antipsychotic medication, to be administered for psychosis. The facility's care plan addressed the medication but failed to include non-pharmacological interventions, which are required before or alongside psychotropic medications. Despite multiple episodes of psychosis, there was no documentation of non-pharmacological interventions being provided, as confirmed by the DON.
A facility failed to provide timely catheter care and bladder training for a resident with an indwelling urinary catheter, leading to a risk of CAUTIs. Catheter care and urine output monitoring were delayed by seven days, and despite requests, bladder training was not provided. A urology consultation was requested but not documented as followed up, indicating a lack of adherence to the resident's care plan.
The facility failed to provide information and maintain copies of advance directives for two residents. One resident expressed interest in having an advance directive but was not approached by staff, while another resident's advance directive was not documented in the medical record despite being requested. The SSD confirmed these oversights, which were against the facility's policy.
A resident at high risk for pressure injuries was left in a wheelchair for several hours without repositioning, contrary to facility policy. Staff interviews revealed a lack of adherence to care plans and communication issues. Observations showed the resident had redness on the sacral area and was found with soiled incontinence products, indicating inadequate care. The DON acknowledged the deficiency and clarified repositioning protocols.
A facility failed to monitor a resident's fluid intake as per physician's orders for fluid restriction. The resident's MAR showed fluid intake from the nursing department but lacked documentation from the dietary department. Interviews with staff revealed a lack of awareness and documentation regarding the resident's fluid intake during meals, leading to incomplete records and potential health risks.
A facility failed to provide appropriate dialysis care for a resident by not maintaining a dialysis emergency kit at the bedside and not consistently assessing the dialysis access site. The resident, with a permacath access for hemodialysis, lacked necessary emergency supplies, and staff failed to document assessments before and after dialysis treatments. The DON acknowledged these lapses in protocol.
A resident was found to have duplicate medication orders for guaifenesin with different dosages, posing a risk of medication errors. The attending physician confirmed that only one order was intended, and the previous order was not discontinued. The pharmacist received only one order, while the other was a stock item. The DON acknowledged the findings.
The facility failed to ensure proper storage and labeling of medications and supplies, including single-use dressings and expired Covid testing kits. A resident was found with medications in their nightstand without physician's orders. Staff confirmed these deficiencies, indicating a lack of oversight.
The facility failed to provide necessary care for two residents, impacting their well-being. A resident's pacemaker was not monitored, and their surgical wound was not properly assessed or documented. Another resident did not receive ordered lab tests, and their orthostatic blood pressure was incorrectly monitored. Staff interviews confirmed these deficiencies.
The facility failed to provide necessary respiratory care for three residents. A resident was using oxygen without a physician's order, another was receiving oxygen at an incorrect rate and without proper signage or care plan, and a third resident's nebulizer tubing was unlabeled. These deficiencies were confirmed by staff and highlighted non-compliance with facility policies.
The facility failed to ensure the competency of two licensed nurses regarding bladder training for a resident with an indwelling urinary catheter. Additionally, the facility did not provide training materials for in-service trainings, and the annual performance evaluation for an LVN was not completed as required by policy.
The facility failed to ensure proper informed consent and monitoring for psychotropic medications for two residents. A resident's zolpidem consent lacked a physician's signature, and sleep monitoring documentation was inconsistent. Another resident's clonazepam consent was not renewed as required, despite continued administration. These issues were confirmed by staff interviews and record reviews.
The facility failed to maintain sanitary conditions in the kitchen, with several utensils found dirty and in poor condition, posing a risk of cross-contamination and foodborne illnesses. The Registered Dietitian confirmed the deficiencies, which affected 80 out of 86 residents consuming food prepared in the facility's kitchen.
The facility failed to maintain accurate and complete medical records for several residents, leading to potential care gaps. Issues included incorrect advance directive information, missing medication administration records, and incomplete monitoring documentation. These deficiencies were confirmed by facility staff, indicating systemic record-keeping issues.
The facility failed to maintain an effective infection control program, with deficiencies in infection surveillance, hygiene practices, and equipment handling. The infection control data was inaccurate, and mapping was incomplete. A laundry aide transported uncovered linen, and an LVN did not perform hand hygiene during wound care. Additionally, a resident's nasal cannula tubing was improperly handled, posing an infection risk.
A facility failed to provide a resident with a copy of their personal inventory list upon admission, as required by policy. The inventory list, which was meant to document the resident's belongings, was not given to the resident, leaving their personal items potentially unaccounted for. Interviews with staff confirmed the oversight, and the DON acknowledged the requirement for residents to receive a copy of the inventory list.
The facility failed to maintain the specimen refrigerator at the required temperature range of 36-46 degrees F, with an observed temperature of 28 degrees F and ice build-up in the freezer compartment. This was confirmed by an RN and acknowledged by the DON.
A resident was not provided privacy during a medication administration procedure when an LVN failed to pull the privacy curtain and sliding door curtain, leaving the resident exposed. The LVN lifted the resident's gown, exposing the stomach and part of the diaper, before being reminded to ensure privacy. The DON acknowledged the importance of maintaining privacy during such procedures.
A facility failed to notify a resident or their representative of the bed hold policy upon transfer to a hospital. Although the resident's representative signed the notification form upon admission, the sections for confirmation of transfer and bed hold provision were left blank, indicating a lack of notification at the time of transfer. The resident was alert and capable of making decisions, but there was no documented evidence of notification in the medical record. The ADON confirmed that licensed nurses were responsible for this notification.
A resident with a fracture of the right humerus refused to wear a physician-ordered sling, and the facility failed to update her care plan to reflect this refusal. Despite observations showing the resident without the sling, the care plan was not revised, posing a risk of inconsistent care. The ADON confirmed the oversight, acknowledging the resident's tendency to remove the sling.
The facility did not complete annual performance evaluations for a CNA rehired in 2022, as required by policy. The DSD, responsible for these evaluations, had not reviewed all personnel records since starting in January 2025. The DON confirmed the necessity of these evaluations to assess work performance and identify improvement needs.
A resident's care plan was not fully implemented, as the facility failed to ensure the use of dental appliances and coordinate a dental consult after readmission. The resident lacked lower dentures, impacting their ability to eat, and no dental consult was arranged. Additionally, the facility did not develop a care plan for the resident's hard of hearing status, despite documented evidence of hearing difficulties.
A resident in an LTC facility did not receive necessary dental services after readmission, as the facility failed to assist in obtaining lower dentures. Despite the resident's care plan indicating the need for dental appliances, the lower dentures were missing, and no investigation or dental consult was conducted. The resident expressed difficulty eating without the dentures, and the facility's policies for dental services and theft investigation were not followed.
Unauthorized Individual Allowed Access to Visible Medical Records
Penalty
Summary
The facility failed to protect residents’ confidential personal and health information by allowing an unauthorized individual into the medical records office where protected health information (PHI) was openly accessible. Facility policies titled “Resident Rights” and “Protected Health Information (PHI), Management and Protection of,” both dated 2001, stated that unauthorized release, access, or disclosure of resident information was prohibited and that PHI shall not be used or disclosed except as permitted by federal and state laws. The HIPAA compliance training described by a medical records assistant (MRA 1) included instruction not to release or share resident information with anyone other than the resident or the resident’s durable power of attorney. The DON and the Medical Records Director both stated that only designated staff (medical records staff, licensed nurses, therapists, physicians, admissions, administrator, activities staff, DSD, dietary supervisor, and registered dietician) were authorized to access medical records, and that no volunteers or other unauthorized persons were permitted in the medical records department. Despite these policies and training, MRA 1 reported that on a specific date she allowed a family member (Family Member 1), who was her means of transportation and not an employee of the facility, to sit inside the medical records office with her for approximately one to two hours while she put away discharged residents’ 2025 medical records. MRA 1 acknowledged that she knew she was not supposed to bring anyone into the office and stated she asked Family Member 1 to stay inside because it was hot outside. Surveyor observation of the medical records office showed two large open bookshelves with three rows of medical record folders containing visible resident names, and some folders also showed admission dates, discharge dates, and medical record numbers. MRA 1 confirmed that from the chair where Family Member 1 sat, the resident names on the medical record folders were visible. The DON verified that Family Member 1 was not an employee and reiterated that unauthorized persons were not allowed in the medical records office due to the easily accessible medical records that needed protection.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement infection control practices as outlined in its Enhanced Barrier Precautions (EBP) policy during wound care treatment for a resident with a Stage 3 pressure injury. During an observed wound care procedure, an RN and an LVN provided care to the resident without wearing the required isolation gowns, using only gloves. Additionally, there was no EBP signage posted near the resident's room doorway or bedside to alert staff and visitors of the necessary precautions. Both staff members acknowledged during the observation that EBP should have been followed, including the use of gowns and appropriate signage. The resident involved had moderate cognitive impairment and was on hospice care, with a sacrococcyx wound that had been reclassified as a Stage 3 pressure injury following debridement. The resident's care plan specifically required EBP during high-contact care activities, including wound care, and listed interventions such as ensuring the availability of PPE and posting EBP signage. The facility's Infection Preventionist, DON, and Quality Assurance Nurse all confirmed that EBP protocols were not followed during the observed incident.
Failure to Provide Complete Discharge Medication List
Penalty
Summary
The facility failed to ensure that a resident's discharge medication list was complete and that all necessary medications were provided upon discharge. Specifically, the discharge medication list for one resident did not include Verapamil (for blood pressure), Ambien (for insomnia), and oxycodone-acetaminophen (for pain relief). Medical record review confirmed that these medications were ordered for the resident up to and including the day of discharge, but were not marked as given to the resident upon leaving the facility. The omission was verified during an interview with a registered nurse, who confirmed that the medications were not provided at discharge. The resident, who had diagnoses including PTSD, anxiety, and high blood pressure, reported leaving the facility because she did not receive her Verapamil or Ambien medications. The facility's records showed active orders for these medications, as well as for oxycodone-acetaminophen, at the time of discharge. The failure to provide these medications was identified through a complaint and subsequent review of the resident's medical and discharge records.
Failure to Notify Physician and Administer Antihypertensive Medication for Elevated Blood Pressure
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a diagnosis of high blood pressure, PTSD, and anxiety. On review of the resident's medical record, it was found that only one blood pressure reading was obtained, which was 142/86 mmHg—above the normal range. There was no documentation that the blood pressure was retaken or that the physician was notified of this abnormal result, despite facility policy and physician orders requiring such actions for elevated readings. Additionally, the resident had physician orders for Verapamil to be administered for hypertension, with specific instructions to hold the medication if the systolic blood pressure was greater than 110 mmHg. The medication was not administered as ordered, and there was no documentation that the physician was notified of the missed dose or the elevated blood pressure. Interviews with facility staff confirmed that these actions were not taken and not documented in the resident's record.
Failure to Provide Medications and Maintain Controlled Substance Documentation
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents, resulting in medication administration and documentation deficiencies. One resident, with diagnoses including high blood pressure and PTSD, was not administered prescribed Verapamil and Ambien medications during their stay. The resident reported that the facility did not provide these medications and was told a physician visit was required before administration. Medical record review confirmed that the medications were ordered but not given, and facility staff acknowledged the omission. For another resident, who had a history of a fall with a left lower extremity fracture and mild cognitive impairment, the facility did not maintain required controlled medication count sheets for administered Roxicodone and oxycodone. Although the medication administration records showed that these controlled substances were given as ordered, the corresponding count sheets were missing from the medical record. The Medical Records Director verified that these documents were not on file.
Infection Control Lapses During Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices for one resident with a suprapubic catheter. During an observation of urinary catheter care, a nurse's shoe was seen touching the resident's urine drainage bag, and the drainage bag itself was observed resting on the floor. The nurse removed dirty gloves after cleaning the catheter surgical site and immediately donned clean gloves without performing hand hygiene in between. The nurse acknowledged both the improper placement of the drainage bag and the failure to perform hand hygiene. Review of facility policies confirmed that hand hygiene should be performed after glove removal and before donning new gloves, and that catheter tubing and drainage bags must be kept off the floor.
Failure to Implement Timely Bowel Management Interventions
Penalty
Summary
The facility failed to provide necessary care and services for a resident who did not have a bowel movement (BM) for more than three days. According to the facility's bowel regimen management policy, nursing staff are required to review bowel records daily, monitor for no BM for more than 72 hours, and implement interventions as needed, including notifying the physician. In this case, the resident had no BM from 6/1 to 6/6, but interventions were not implemented until 6/6, despite daily monitoring requirements. The resident's medical record showed orders for various laxatives and interventions, but these were not administered in a timely manner according to the policy. The resident exhibited signs of constipation, including abdominal distention, increased agitation, and distress, and required multiple interventions, including enemas and oral laxatives, which were ultimately ineffective. The physician was notified after 72 hours without a BM, and a KUB x-ray confirmed moderate constipation. The resident was subsequently sent to an acute care hospital for disimpaction after seven days without a sufficient BM. The delay in implementing appropriate interventions as outlined in the facility's policy contributed to the deficiency.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update and individualize the care plan for a resident who was at risk for falls, despite multiple incidents of falling. The resident, who had severe cognitive impairment and a history of falls, experienced two falls within a short period. The care plan in place included general fall prevention interventions such as participation in a fall prevention program, reminders to call for assistance, keeping the call light within reach, and supervision. However, after the resident's falls, there was no evidence that the care plan was reviewed or revised to include additional or different interventions tailored to the resident's specific behaviors and needs. Documentation in the medical record and interdisciplinary team (IDT) notes did not address the resident's repeated attempts to transfer without assistance or the falls that occurred. The facility's policy required staff to implement new or different interventions if falls recurred, but this was not done. During interviews, facility leadership confirmed that the care plan was not updated following the falls, and no new interventions were implemented to address the resident's ongoing fall risk.
Unattended Medications Left at Bedside by LVN
Penalty
Summary
A Licensed Vocational Nurse (LVN) left three unlabeled medications in a clear cup unattended on a resident's bedside table, as observed during a medication pass. The LVN confirmed that the medications should not have been left on the bedside table and acknowledged that they should have been taken back and administered when the resident was ready. Facility policy requires medications to be administered safely and not left unattended, and the Director of Nursing (DON) confirmed that medications should not be left in a resident's room. A self-administration assessment had been completed for the resident, indicating the resident was not capable of self-administering medication.
Failure to Implement Non-Pharmacological Interventions for Antipsychotic Use
Penalty
Summary
The facility failed to provide non-pharmacological interventions for a resident who was prescribed Zyprexa, an antipsychotic medication, upon returning from an acute care hospital. The resident was admitted with a physician's order for Zyprexa to be administered every six hours as needed, which was later changed to four times a day for psychosis manifested by episodes of striking out. Despite the care plan addressing the use of Zyprexa, it did not include any non-pharmacological interventions, which are required to be attempted before or alongside the use of psychotropic medications. The medical record review showed multiple episodes of psychosis, evidenced by striking out, on consecutive days, yet there was no documentation of non-pharmacological interventions being provided. During an interview, the Director of Nursing confirmed the absence of documentation for such interventions and acknowledged that the care plan did not include them. This oversight had the potential to lead to the unnecessary use of psychotropic medications for the resident.
Failure to Provide Timely Catheter Care and Bladder Training
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident was admitted with a catheter, and the facility did not begin documenting catheter care and urine output until seven days after admission, despite physician orders to monitor the catheter every shift. The resident's plan of care included recording the catheter's output, but this was not initiated promptly, increasing the risk of catheter-associated urinary tract infections (CAUTIs). Additionally, the facility did not provide bladder training for the resident, despite a request from the resident's responsible party. The responsible party was informed that bladder training was not possible with the catheter in place, and a urology consultation was requested but not documented as followed up. Interviews with facility staff confirmed the delay in catheter care and the absence of bladder training, highlighting a lack of adherence to the resident's care plan and communication with the responsible party.
Failure to Provide and Maintain Advance Directives
Penalty
Summary
The facility failed to provide information regarding the rights to formulate advance directives and did not obtain or maintain copies of advance directives for two residents. For Resident 586, there was no documentation in the medical record indicating whether an advance directive existed. The resident, who had moderate cognitive impairment, expressed interest in having an advance directive but stated that no one from the facility had discussed this with her. The Social Services Director (SSD) confirmed that the social services staff had not discussed advance directives with Resident 586, despite the facility's policy requiring such discussions upon admission. For Resident 10, the facility did not maintain a copy of the advance directive in the medical record, even though the resident had stated that an advance directive existed and a copy was requested. The SSD acknowledged that the copy should have been in the medical record and admitted to not following up within 48 hours to obtain it, as required by the facility's policy. The absence of the advance directive in the medical record was verified during interviews and concurrent medical record reviews with the SSD.
Failure to Prevent Pressure Injuries Due to Inadequate Repositioning
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of pressure injuries for a resident identified as high risk. The resident, who had short and long-term memory problems and was dependent on mobility, was observed sitting in a wheelchair for several hours without being repositioned. The facility's policy required residents in chairs to be repositioned every hour, but this was not adhered to, as the resident remained in the wheelchair from 0745 hours to 1145 hours without repositioning. Interviews with staff revealed a lack of communication and adherence to the care plan. A CNA admitted to placing the resident in the wheelchair and not checking or cleaning the resident for incontinence during this period. The CNA also stated that residents who were total care should be turned every two hours, but this was not done for the resident. An LVN was unaware that the resident had been placed in the wheelchair early and confirmed that the resident should not have been left in the wheelchair for such a long period without repositioning. Further observations showed the resident had blanchable redness on the sacral area and was found with dry fecal matter and a wet diaper, indicating a lack of timely incontinence care. The DON acknowledged the findings and stated that repositioning should be done every two hours or as needed for residents who require assistance with ADL care. The DON also clarified that repositioning on the side is not feasible in a wheelchair, contradicting the LVN's earlier statement about shifting the resident in the wheelchair.
Failure to Monitor Resident's Fluid Intake
Penalty
Summary
The facility failed to adequately monitor the fluid intake of Resident 45, who was under a physician's order for fluid restriction. The medical records and interviews revealed that the facility did not document the resident's fluid intake from the dietary department, which was supposed to be part of the total daily fluid intake. The facility's policy required detailed documentation of fluid intake, including the type and amount of liquid consumed, but this was not adhered to for Resident 45. The resident's Medication Administration Record (MAR) showed fluid intake from the nursing department but lacked records from the dietary department, indicating a gap in monitoring and documentation. Interviews with facility staff, including a CNA and an LVN, confirmed the lack of documentation and awareness regarding the resident's fluid intake from meals. The CNA was unaware of the fluid restriction order and did not report the resident's fluid intake during meals to the nurses. The LVN acknowledged that the MAR only reflected fluid intake from the nursing department and not from the dietary department, leading to incomplete records of the resident's total daily fluid intake. This oversight had the potential to result in fluid overload, negatively impacting the resident's well-being.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, specifically by not maintaining a dialysis emergency kit at the bedside. The resident, who had a permacath access for hemodialysis, did not have the necessary emergency kit available, which is crucial in case of complications such as accidental dislodgement or bleeding. The facility's protocol mandates that a dialysis emergency kit be provided upon admission and maintained at the resident's bedside, a responsibility that falls on the nursing staff. Additionally, the facility did not consistently assess and monitor the resident's dialysis access site. There were multiple instances where the licensed staff failed to document assessments of the dialysis access site before the resident was transported to the dialysis center and upon their return. This lack of documentation included missing assessments from the dialysis center itself. The nursing staff also incorrectly documented the type of dialysis access, either leaving it blank or incorrectly identifying it as a catheter instead of a permacath. Interviews with the LVN and DON revealed that the facility's procedures were not followed, as the dialysis emergency kit was not checked or maintained, and the necessary assessments were not conducted. The DON acknowledged the importance of having the emergency kit available and the need for accurate and timely assessments to prevent confusion and ensure the resident's safety.
Duplicate Medication Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically involving duplicate medication orders with different dosages. Resident 67 had two active orders for guaifenesin, one for a 400 mg oral tablet and another for a 100 mg/5 ml oral liquid, both to be administered as needed for cough and congestion. This duplication posed a risk of medication errors. The issue was identified during a medical record review conducted on February 19, 2025. Interviews with facility staff and the resident's attending physician revealed that the duplicate orders were not intended. The attending physician confirmed that only one order was desired and suggested that the previous order was not discontinued as it should have been. The pharmacist also noted that they had only received the order for the guaifenesin oral tablet and not for the geri-tussin, which was a stock item. The Director of Nursing was informed of these findings and acknowledged the issue.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
The facility failed to ensure the safe and proper storage and labeling of medications and medical supplies. During an inspection of the treatment cart, it was observed that single-use dressings, such as Steri-Strips, hydrocolloid dressings, hydrofera blue, and xeroform gauze, were opened and partially used, despite being intended for single use only. Additionally, a used Santyl ointment, which belonged to a discharged resident, was found without a label. The treatment cart also contained drawers with dark brownish residue and dust-like particles. These findings were confirmed by LVN 9, who acknowledged that the unused supplies should have been discarded. The facility also failed to discard expired Covid testing kits, with several boxes found to have passed their expiration dates. RN 1 confirmed the presence of these expired kits. Furthermore, Resident 54 was found to have a medication cup with a white pasty cream and a bottle of Adapt stoma powder in their nightstand, without any physician's orders for their use. CNA 8 and RN 6 verified these findings, indicating a lack of proper oversight and documentation for the use of these medications.
Deficiencies in Monitoring and Care for Two Residents
Penalty
Summary
The facility failed to provide necessary care and services for two residents, Resident 336 and Resident 45, which impacted their physical well-being. For Resident 336, the facility did not monitor the resident's pacemaker, as there was no documented evidence of follow-up on the pacemaker information. Additionally, the facility did not accurately assess and document the resident's skin condition upon admission, as the resident was admitted with a surgical wound with staples that were not properly assessed. The facility also failed to obtain a physician's order before applying Steri-Strips to the surgical site after staple removal and did not develop a care plan to monitor the surgical site or address the removal of the staples. Resident 336's medical record lacked documentation of monitoring after the removal of the staples, and there was no follow-up with the appointment clinic for further orders. Interviews with LVNs 9 and 10 confirmed these findings, revealing that the initial skin assessment was incomplete and that the application of Steri-Strips was done without a physician's order. Furthermore, RN 4 verified that the pacemaker was not monitored, and there was no follow-up on the pacemaker information. For Resident 45, the facility failed to complete laboratory tests for CBC, Chem 7, and magnesium levels as ordered by the physician. The medical record showed no evidence of these tests being conducted or followed up. Additionally, the facility did not correctly monitor Resident 45's orthostatic blood pressure, as the same blood pressure readings were documented for different positions. LVN 12 confirmed that the laboratory tests were not signed off in the MAR and that there was no documentation of follow-up for the tests or the orthostatic blood pressure readings.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for three residents, as observed during a survey. Resident 686 was found using oxygen via nasal cannula at a rate of 4 liters per minute without a physician's order. This was confirmed by LVN 6, who acknowledged the absence of a physician's order in the resident's electronic health record or paper medical record, despite the resident receiving continuous oxygen therapy since the morning. Resident 336 was observed receiving continuous oxygen at a rate of 2 liters per minute via nasal cannula, also without a physician's order. Additionally, there was no 'Oxygen In Use' sign posted outside the resident's room, and the resident's care plan did not address the use of oxygen. MDS Coordinator 2 confirmed these findings. A follow-up observation revealed that the oxygen was being administered at a rate of 2.5 liters per minute, which was not in accordance with the physician's order of 2 liters per minute. Resident 67's nebulizer tubing was not labeled with the resident's name and date, as required by the facility's policy. The nebulizer mask and tubing were found inside a plastic bag on the nightstand without proper labeling. LVN 4 verified the lack of labeling and acknowledged the need for replacement and labeling. The DON was informed of these findings, which highlighted the facility's failure to adhere to its own policies and procedures regarding respiratory care.
Deficiencies in Staff Competency and Training Documentation
Penalty
Summary
The facility failed to ensure the competency of two licensed nurses, LVN 12 and the ADON, regarding bladder training for a resident with an indwelling urinary catheter. Despite a physician's order for bladder training, the facility did not provide such training, and the staff were not able to demonstrate competency in this area. The ADON and LVN 10 both stated that bladder training was not conducted at the facility, and the ADON was unsure why it was not done. The DON mentioned that if there was a physician's order for bladder training, it should be done by clamping and unclamping the catheter, but this was not implemented. Additionally, the facility failed to provide training materials for in-service trainings, which are essential for ensuring staff competency. The Education/Training Attendance Record showed that LVN 12 attended the training, but the ADON did not. The facility's policy and procedure for the Bowel and Bladder Training Program did not include procedures for bladder training with an indwelling urinary catheter. The DSD confirmed that there were no training materials available, which should have included teaching objectives and competency assessment methods. Furthermore, the facility did not complete the annual performance evaluation for LVN 5, as required by their policy. LVN 5's last performance appraisal was over a year ago, and the DSD verified that the evaluation was not conducted. The DON acknowledged that performance evaluations are necessary to assess the quality of an employee's work and determine if improvement is needed.
Failure to Ensure Proper Informed Consent and Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 336, the facility did not obtain the physician's signature on the informed consent for zolpidem, a hypnotic medication prescribed for insomnia. Additionally, there was a discrepancy in the monitoring documentation for hours of sleep related to zolpidem use, as the records showed zero hours of sleep but also zero episodes of inability to fall asleep on the same date. This inconsistency was verified by RN 4 during an interview and medical record review. For Resident 1, the facility did not renew the informed consent for clonazepam, an antianxiety medication, as required by their policy and state regulations. The last consent was obtained in August 2024, and the medication continued to be administered daily without a renewed consent. This oversight was confirmed by RN 3 and the Director of Nursing (DON) during interviews. The failure to renew informed consent and ensure proper documentation could lead to unnecessary use and ineffective monitoring of psychotropic medications, potentially affecting the residents' well-being.
Sanitation Deficiencies in Kitchen Utensils and Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by unclean kitchen utensils and equipment. During an inspection, it was observed that several kitchen utensils, including cutting knives, a serving fork, a slotted serving scoop, and a dough cutter, were dirty with dry food residue and fuzzy stains. These findings were confirmed by the Registered Dietitian (RD), who acknowledged that the utensils should have been stored clean to prevent infection. The facility's policy on dishwashing, which requires all dishes to be properly sanitized and free of gross food particles, was not adhered to, posing a risk of cross-contamination and foodborne illnesses to the residents. Additionally, the facility did not ensure that kitchen utensils were in good condition. A white basting brush was found to be worn out with frayed bristles, which was verified by the RD. According to the USDA Food Code, utensils must be maintained in a state of good repair and should not allow the migration of deleterious substances to food. The failure to replace the worn-out basting brush with a new one, despite having it available, further highlights the facility's non-compliance with sanitary standards. These deficiencies affected the majority of the residents, as 80 out of 86 consumed food prepared in the facility's kitchen.
Inaccurate and Incomplete Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to potential gaps in care. For instance, Resident 2's Advance Directive Acknowledgement contained incorrect information, and the POLST did not reflect the absence of an advance directive. Similarly, Resident 40's medical records were incomplete, with missing documentation for medication administration and advance directive details. These inaccuracies were acknowledged by the facility's staff, including the SSD and DON, during interviews. Resident 10's MAR lacked documentation for monitoring adverse reactions to anticoagulant use, Covid symptoms, and pain scale assessments. This oversight was confirmed by LVN 12, who admitted to missing the documentation. Resident 20's MAR was also incomplete, missing records of monitoring for adverse reactions to various medications and the application of prescribed treatments. LVN 3 confirmed the monitoring was done but not documented. Additional deficiencies were noted for other residents, such as Resident 68, whose TAR did not show evidence of completed perineal treatment, and Resident 586, whose IV site monitoring was not documented. Resident 336's records contained incorrect personal information, and Resident 51's narcotic sheet was inaccurately recorded. These documentation failures were verified by facility staff, including LVNs and the DON, highlighting a systemic issue with record-keeping practices at the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies in their infection control practices. The facility did not implement their infection control surveillance program for three consecutive months, failing to accurately identify healthcare-associated infections (HAIs) and community-acquired infections (CAIs) according to the McGeer criteria. The infection control data presented to the infection control meeting was neither accurate nor complete, and the facility's mapping of infections was incomplete, only including influenza and RSV infections. Additionally, the Fourth Quarter Microbiology Report was incomplete, missing data from one of the acute care hospitals and the facility itself. The facility also failed to adhere to proper hygiene and infection control practices in several instances. A laundry aide was observed transporting an uncovered linen cart with residents' clothing and blankets, contrary to the facility's policy requiring clean linen to be protected during transport. Furthermore, an LVN did not perform hand hygiene during a wound care treatment for a resident, failing to wash hands between glove changes and after moving from a soiled to a clean body site, which is against the facility's hand hygiene policy. Additionally, a resident was observed using oxygen via a nasal cannula, with the tubing touching the inside of a trash can and the floor, posing a risk for infection. This was confirmed by an LVN, who acknowledged that the nasal cannula tubing should not be in contact with the floor. These failures collectively posed a risk for not identifying infections and controlling the transmission of communicable diseases within the facility.
Failure to Provide Personal Inventory List to Resident
Penalty
Summary
The facility failed to ensure that a resident's personal belongings inventory process was completed accurately for one of the sampled residents. Specifically, the facility did not provide a copy of the personal inventory list to the resident upon admission. The facility's policy and procedure, dated 2001, required that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary. However, during a medical record review for the resident, it was found that the triplicate copies of the inventory form, which included a pink copy meant for the resident, were still intact and not given to the resident. Interviews with facility staff, including MDS 2 and the DON, confirmed that the personal inventory list was completed during admission to keep track of the resident's belongings. MDS 2 verified that the pink copy of the inventory list, dated 1/8/25, was not provided to the resident. The DON acknowledged that the facility's process required the resident to receive a copy of the inventory list upon admission, readmission, and when new belongings were received. This oversight had the potential to result in the resident's personal belongings not being accurately accounted for.
Specimen Refrigerator Temperature Deficiency
Penalty
Summary
The facility failed to maintain the resident's specimen refrigerator in safe operating condition. During an inspection and interview with an RN, it was observed that the specimen refrigerator's temperature was 28 degrees F, which is below the required range of 36-46 degrees F. Additionally, there was ice build-up in the freezer compartment of the refrigerator. The facility's Specimen Refrigerator Temperature Log for February 2025 indicated that the temperature should be between 36F-46F, and the latest recorded temperature on 2/19/25 was 36 degrees F. The RN acknowledged and confirmed these findings. The Director of Nursing (DON) was informed and acknowledged the findings during a subsequent interview.
Failure to Provide Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy for Resident 40 during a medication administration procedure. On February 20, 2025, at 0830 hours, an observation was conducted where LVN 5 administered medication via a gastrostomy tube (GT) to Resident 40 without pulling the privacy curtain by the bed or the curtain of the sliding door. This left Resident 40 exposed to the outside patio and rooms across the patio. During the procedure, LVN 5 lifted Resident 40's gown, exposing the stomach area and a portion of the diaper. LVN 5 acknowledged the oversight when reminded to provide privacy. Resident 40 had short and long-term memory problems, as noted in the medical record review. The Director of Nursing (DON) was informed of the incident and acknowledged the findings, emphasizing the importance of maintaining resident privacy during such procedures.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was provided with a written or verbal notice of the facility's bed hold policy upon transfer to an acute care hospital. This deficiency was identified during a review of closed records for a resident who was transferred to the hospital. The facility's policy requires that residents and their representatives be informed of the bed hold policy in writing at least twice: once in advance of any transfer and again at the time of transfer. However, in this case, the documentation showed that while the resident's representative signed the bed hold notification form upon admission, the sections for confirmation of transfer and bed hold provision were left blank, indicating a failure to notify at the time of transfer. The resident involved was admitted to the facility and later transferred to an acute care hospital. The resident was noted to be alert and capable of making her own decisions prior to the transfer. Despite this, there was no documented evidence in the medical record that the resident or her representative was notified of the bed hold provision when the transfer occurred. An interview with the Assistant Director of Nursing (ADON) confirmed these findings, and it was stated that the licensed nurses were responsible for notifying the resident and/or their representative of the bed hold provision and completing the notification form at the time of transfer.
Failure to Revise Care Plan for Resident Refusing Sling
Penalty
Summary
The facility failed to revise the care plan for a resident who refused to wear a physician-ordered sling on her right upper extremity (RUE). The resident, who was admitted with a diagnosis of an unspecified fracture of the upper end of the right humerus, had a physician's order dated December 22, 2024, to wear a sling while out of bed. Despite this order, observations on February 18 and 19, 2025, showed the resident sitting in a wheelchair without the sling. During an interview on February 24, 2025, the resident confirmed she was aware of the order but chose not to wear the sling, stating that the physician had told her it was not necessary. The Assistant Director of Nursing (ADON) verified the physician's order and acknowledged that the resident should have been using the sling. However, the ADON noted that the resident had a tendency to remove it. The facility's policy and procedure (P&P) require that care plans be revised as residents' conditions change, but the resident's care plan was not updated to reflect her refusal to wear the sling. This oversight posed a risk of not providing appropriate, consistent, and individualized care to the resident.
Failure to Conduct Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to ensure that performance evaluations were completed every 12 months for one of the two Certified Nursing Assistants (CNAs) whose employee files were reviewed. Specifically, CNA 7, who was rehired on October 18, 2022, did not have documented performance evaluations for the past two years. This oversight was confirmed during an interview and personnel record review with the Director of Staff Development (DSD), who acknowledged the lapse and stated that it was her responsibility to conduct these evaluations. The DSD, who began her role in January 2025, had not yet reviewed all CNAs' personnel records. The Director of Nursing (DON) also confirmed that performance evaluations were supposed to be conducted annually to assess the quality of employees' work performance and identify areas needing improvement.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, specifically regarding the use of dental appliances and coordination of a dental consult. The resident, who was readmitted to the facility, did not have his lower dentures, which were necessary for eating. Despite the care plan indicating the need for dental appliances to be in good repair and in place for meals, and for social services to follow up on dental consults, these actions were not taken. The Director of Nursing (DON) confirmed that the resident's lower dentures were missing since readmission and that a dental consult had not been arranged. Additionally, the facility did not develop a care plan to address the resident's hard of hearing status. The resident expressed difficulty hearing and a desire to try hearing aids. Documentation in the medical record indicated the resident's hearing issues, but no specific care plan was initiated to address this. The DON acknowledged that a care plan should have been created when the speech-language pathologist documented the resident's hearing difficulties.
Failure to Provide Dental Services and Investigate Missing Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident, specifically in assisting with obtaining lower dentures after the resident's readmission. The resident, who was at risk for nutritional issues due to recent infection and hospitalization, had a care plan that included ensuring dental appliances were in good repair and in place for meals. Despite this, the resident did not have his lower dentures since readmission, which were noted to be ill-fitting and a choking hazard during a hospital evaluation. The facility did not conduct a loss or theft investigation regarding the missing lower dentures, nor did it coordinate a dental consult for the resident. Interviews with the resident and staff confirmed that the lower dentures were missing since the resident's readmission, and the resident expressed difficulty eating without them. The social services staff, responsible for coordinating dental services, acknowledged awareness of the missing dentures but had not initiated an investigation or dental consult. The facility's policies and procedures for dental services and investigating theft or misappropriation of resident property were not followed. The social services staff did not interview relevant parties or attempt to locate the dentures, and there was no documentation of efforts to ensure the resident could eat adequately while awaiting dental services. These oversights had the potential to negatively impact the resident's well-being.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 2,717 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newport Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pelican Ridge Post Acute | 0.1 mi | ★★★★★ | 62 | 0 |
| Newport Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 11 | 0 |
| Mesa Verde Post Acute Care Center | 1 mi | ★★★★★ | 25 | 0 |
| Victoria Healthcare And Rehabilitation Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Newport Subacute Healthcare Center | 2.9 mi | ★★★★★ | 50 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.