Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Newport Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen utensils and equipment were found in poor condition and not properly cleaned during a kitchen tour. Surveyors observed chipped and cracked spatulas, a deformed whisk, a cracked whisk handle, food portioning scoops with crusted residue and watermarks, and blenders used for puree prep that were still wet and stored before fully air drying. The DSS acknowledged the findings, and the facility’s diet type report showed 61 of 61 residents ate food prepared in the kitchen.
Failure to protect a resident from physical abuse by another resident. A resident was struck in the face at the water station by another resident with schizoaffective disorder and a history of anger-related striking out due to delusions, causing a small laceration with bleeding. The assaulted resident said he was waiting for water to take meds when the other resident suddenly hit him, and staff interviews confirmed the altercation happened quickly while the other resident was agitated and confused.
The facility failed to report an abuse allegation involving staff being excessively rough with residents to CDPH and law enforcement. An Ombudsman reported concerns about rough handling and favoritism, and the DSD investigated the allegation by interviewing residents and staff, but the Administrator did not submit a SOC 341 or notify the required agencies. The DON and DSD later acknowledged the allegation should have been reported first and then investigated.
A resident’s physician order for haloperidol decanoate did not match the pharmacy label. During med pass, an LVN administered Haldol decanoate using two syringes, and later confirmed the order and label were inconsistent. The LVN stated the order and label should match to reduce medication errors and that nursing staff should have contacted the pharmacy or physician for clarification.
Unsafe storage and disposal of medications were observed when an LPN left two syringes filled with Haldol decanoate unattended on a resident's bed during medication administration, and multiple whole pills were found in an unsecured medication disposal bin in Medication Room A. The resident had an order for Haldol decanoate IM every 14 days and was noted to have intact cognition on assessment, while staff later verified the syringes were left unattended and the disposal bin medications were not properly secured.
Outside Food Policy Did Not Meet Federal Requirements: The facility’s policy for food brought in by family and visitors did not meet federal requirements for safe handling, storage, and consumption. The policy stated outside food could not be stored or saved and could not be kept in residents’ personal areas, and interviews with the DSS, RNA, and RN confirmed the facility had no refrigerator designated for these items and treated outside food as immediate consumption only.
A facility failed to ensure refuse was stored in a sanitary manner when one of three garbage dumpsters was observed with its lid partially propped open by cardboard boxes, preventing it from fully closing. The Environmental Services Director verified the condition and stated dumpster lids should be completely closed at all times for infection control purposes.
Glucometer Quality Control and Record Mismatch: The facility failed to keep blood glucose monitoring equipment and QC records accurate for two medication carts. On one cart, the glucometer serial number on the Daily QC Record did not match the meter in use after a nurse changed the device without updating the record. On another cart, the recorded low and high control readings did not match the glucometer display, and staff confirmed the discrepancy.
An LVN did not perform hand hygiene before or after administering oral medications to A resident and two other residents during a medication pass at Medication Cart B. The facility’s P&P for medication administration required staff to follow infection control procedures, including handwashing and antiseptic techniques, and the LVN acknowledged that hand hygiene should have been performed to maintain infection control protocols. The Administrator, DON, and DSD were informed of the findings.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents with known elopement risks were able to leave the facility through an exit door in the smoking area after one resident kicked the door open. No staff were present by the exit door, and the alarm system did not sound as expected. Staff only responded after hearing the door banging, and there was no maintenance log to verify regular checks of the alarm system.
The facility failed to maintain sanitary conditions in its kitchen, with issues such as a dirty ice machine, a microwave with food residue, and a grease-laden kitchen hood. Kitchen utensils were worn and dirty, and expired foods were not discarded. These deficiencies were acknowledged by the Environmental Services Director and Dietary Supervisor, highlighting potential risks of cross-contamination and foodborne illnesses.
The facility failed to maintain infection control practices, lacking documentation for Legionella risk assessment and testing protocols. CNA 1 did not change PPE or perform hand hygiene between residents, risking MDRO transmission. An unpackaged N95 respirator was improperly stored, and clean linens were placed on soiled carts, violating infection control protocols.
A facility failed to notify a physician of a change in a resident's neurological status following a fall. Despite the facility's policy requiring notification of any changes, an LVN did not inform the physician of a change in the resident's pupillary response during a neurological check. The resident had severely impaired cognition and was under specific care plan interventions for neurological evaluations. The deficiency was confirmed by the DON and acknowledged by the Administrator.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. A resident at risk for falls did not have bilateral floor mats as required, and another resident at risk for pain received only one lidocaine patch instead of the prescribed two. These oversights were confirmed by an LVN during observations and interviews.
Two residents in a facility did not receive appropriate pressure ulcer care. One resident's LAL mattress was set incorrectly for their weight, and wound treatment was not administered as per the physician's order. Another resident's mattress setting was also incorrect for their weight. The facility failed to document and monitor the mattress settings, potentially affecting wound healing and skin integrity.
The facility failed to implement fall prevention measures for two residents, leading to potential risks. A resident with a history of falls was not transferred using a gait belt as required by their care plan, despite being at moderate risk for falls. Another resident did not have bilateral floor mats as ordered by the physician, increasing their fall risk. These deficiencies were confirmed through observations and staff interviews.
A facility failed to document necessary PICC line measurements for a resident upon admission, as required by their policy. The resident's care plan indicated the need for measuring the external length of the catheter and arm circumference, but the medical record lacked this documentation. Interviews with staff confirmed the absence of these measurements, which are crucial for identifying potential complications.
A facility failed to provide safe respiratory care for a resident using a CPAP machine. The CPAP machine was not cleaned according to the manufacturer's guidelines, and there was no documentation of cleaning in the resident's medical records. Staff interviews revealed confusion about cleaning responsibilities, and the CPAP mask was not stored properly. The facility's policy required regular cleaning and documentation, which were not followed, leading to a deficiency in care.
The facility failed to provide appropriate pain management for two residents by not administering medications according to physician orders and not documenting non-pharmacological interventions (NPIs) prior to medication administration. One resident received pain medication outside prescribed levels without NPIs or physician notification, while another was given narcotics without documented NPIs. Staff interviews confirmed these deficiencies, and the facility's administration acknowledged the lack of documentation and adherence to pain management protocols.
The facility failed to administer medications on time for several residents due to unexpected circumstances and emergencies, leading to potential health risks. Additionally, there were discrepancies in the documentation of controlled substances, raising concerns about drug diversion. These deficiencies highlight issues in medication management and documentation practices.
A facility's medication error rate was found to be 16.13%, exceeding the acceptable limit of 5%. An LPN failed to administer medications as ordered for a resident, including incorrect application of lidocaine patches and omission of calcium carbonate-vitamin D and povidone-iodine swabs. Another LPN administered an incorrect dosage of calcitriol and improperly applied lidocaine patches for a second resident.
The facility failed to ensure safe storage and disposal of medications and medical supplies. Opened and unsealed items were found in medication carts, compromising sterility. Additionally, a medication disposal bin contained whole pills and other items not properly disposed of, as confirmed by LVN 5 and the DON.
A resident's PHI was exposed during medication administration when an LVN left a computer screen displaying the resident's name, prescribed medications, and indications for use unattended in the hallway. This breach of confidentiality occurred despite the facility's policy to safeguard resident information, as the screen was visible to other residents passing by.
A resident did not receive their preferred beverage, milk, during a lunch meal despite it being listed on their meal ticket. The oversight was confirmed by a CNA and later acknowledged by the DSS, ADM, and DON.
A resident with a documented allergy to dairy products was served milk due to a failure in verifying food allergies during meal preparation. The oversight was confirmed by the Dietary Supervisor and DON, acknowledging the risk of severe allergic reactions.
Kitchen Utensils and Equipment Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen during an initial kitchen tour and concurrent interview with the DSS. Surveyors observed four rubber spatulas with red handles that were chipped, cracked at the edges, and discolored, one stainless steel whisk that was deformed, and one stainless steel whisk with a purple-gray rubber handle that was cracked and worn out. The DSS acknowledged the findings and stated the spatulas should not be used because chipped particles could get mixed with resident food, and the whisks should have been replaced and not used for infection control purposes. Surveyors also observed food portioning scoops with dry, crusted residue and watermarks, including two stainless steel scoops with black handles, two with gray handles, and one with a white handle. In addition, one heavy-duty blender and one clear plastic blender used for puree preparation were still moist and wet with visible water inside and were stored on top of the countertop shelf. The DSS confirmed these findings and stated the dirty and crusted scoops should have been washed and that kitchen equipment should be air dried to prevent bacteria growth. The facility’s diet type report showed 61 of 61 residents consumed food prepared in the kitchen.
Failure to Protect Resident from Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 31 was struck on the left eyebrow by Resident 32 during an altercation at the water station, resulting in a small laceration with bleeding. Resident 31 was waiting to get water to take medications when the incident occurred, and staff separated the residents after the assault. Resident 31 was assessed by nursing staff, had vital signs within normal limits, and was treated for the eyebrow laceration. Resident 32 had a diagnosis of schizoaffective disorder and a history of anger with striking out due to delusions. The facility record identified a care plan problem for Resident 32's history of attacking people out of anger due to delusions, but the care plan did not include specific interventions addressing the attacking behavior. The MDS assessment for Resident 32 showed moderate impaired cognition and no documented behavioral symptoms directed toward others, despite the history noted in the care plan and the incident that occurred. During interviews, Resident 31 stated this was the first time he had been hit by another resident and described waiting in line for water when Resident 32 suddenly hit him. Resident 32 admitted he hit Resident 31 after the interaction at the water station and stated it was his first incident of hitting someone in the facility. Staff interviews confirmed the altercation occurred quickly, that Resident 32 had confusion, delusions, and could be agitated, and that the resident-to-resident assault occurred while Resident 31 was trying to obtain water for medications.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving staff being excessively rough with residents to CDPH and law enforcement. The facility’s Abuse Prohibition and Prevention policy required all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property to be reported immediately, but no later than two hours after the allegation was made. The SOC 341 form reviewed also stated that suspected abuse or neglect involving an elder or dependent adult must be reported to local law enforcement, the Ombudsman, and CDPH. An Ombudsman reported anonymous concerns that two staff members were excessively rough with residents and showed favoritism. The Ombudsman identified one CNA by name and later clarified that the facility had two CNAs whose first and last names matched parts of the name given in the allegation. The DSD was notified of the allegation and stated he investigated it by interviewing residents and staff, then closed the investigation. He also stated the two CNAs remained on schedule during the investigation and that the allegation should have been reported to the Administrator, law enforcement, CDPH, Ombudsman, and DON. The Administrator stated he was aware of the allegation but did not report it to CDPH or law enforcement and did not submit a SOC 341 form. The Administrator, DON, and DSD later acknowledged that the process was to report the abuse allegation to the agencies and then investigate it. The DON stated the facility should have reported the allegation despite incomplete information from the Ombudsman and could have continued the investigation process.
Medication Order Did Not Match Pharmacy Label
Penalty
Summary
The facility failed to ensure the physician’s order for Resident 58’s haloperidol decanoate matched the instructions on the medication label provided by the pharmacy. Resident 58 was admitted to the facility and had an H&P showing the resident could make needs known but could not make medical decisions. The resident’s admission MDS showed a BIMS score of 13, indicating intact cognition. The facility’s P&P stated medications are to be administered in a safe and timely manner and in accordance with prescriber orders, including any required time frame. Resident 58’s order summary showed a physician’s order for Haldol decanoate intramuscular solution 100 mg/ml, inject 2 ml (200 mg) intramuscularly one time a day every 14 days for schizophrenia. The pharmacy label, however, instructed administration of Haldol decanoate 50 mg/ml, inject 4 ml (200 mg) intramuscularly one time every 14 days. During medication administration observation, an LVN administered two syringes filled with 2 ml of Haldol decanoate 50 mg/ml in each syringe. On concurrent review, the LVN verified the physician’s order did not match the pharmacy label and stated the order and label should match to reduce the potential for medication errors; she also stated licensed nurses should have contacted the pharmacy or physician for clarification. The Administrator, DON, and DSD were informed and acknowledged the findings.
Unsafe Storage and Disposal of Medications
Penalty
Summary
The facility failed to store drugs, biologicals, and medical supplies in a safe manner. During a medication administration observation in Resident 58's room, LVN 2 had two syringes filled with 2 ml of Haldol decanoate for the resident. After drawing the curtains for privacy, LVN 2 left the room to use the resident's bathroom for hand hygiene, and the two filled syringes were left unattended on Resident 58's bed. LVN 2 later verified she had returned from the bathroom without the syringes and stated the medications were not to be left unattended at the bedside. The IP also verified the syringes were left unattended and was not observing them while LVN 2 was out of the room. Resident 58's record showed a physician's order for Haldol decanoate 100 mg/ml, 2 ml IM every 14 days for schizophrenia, and the resident's assessment showed a BIMS score of 13 and that the resident could make needs known but could not make medical decisions. The facility also failed to ensure medications in the disposal bin in Medication Room A were properly stored and disposed of. During observation, multiple unidentified whole pills were seen in the medication disposal bin, and the lid of the bin was not secured. RN 1 verified the findings and stated the medications should be secured and diluted with fluids to ensure proper disposal. The DON later verified the same findings and stated she expected licensed nurses to mix disposed tablets with fluids so the medications would be dissolved.
Outside Food Policy Did Not Meet Federal Requirements
Penalty
Summary
The facility failed to ensure its policy and procedure for outside food met current federal regulation regarding the use and storage of food brought to residents by family and other visitors. Review of the facility’s policy titled “Behavioral Health Outside Food,” revised 9/6/24, showed that food brought into the facility could not be stored or saved and could not be kept in residents’ personal areas. The report also cited CMS S&C-09-39 and 42 CFR 483.60(i)(3), which require a policy for the safe and sanitary handling, storage, and consumption of food brought in from outside sources. During interviews, the DSS stated the facility did not have a refrigerator to store residents’ food items brought in from outside sources and that such food was for immediate consumption. RNA 1 stated residents were not allowed to bring food from outside sources or store it for later consumption, and that families could order food for same-day consumption. RN 2 stated outside food had to be sealed and was for immediate consumption, that residents were not allowed to store it for later use, and that the facility did not have a refrigerator designated for residents to store these food items.
Improperly Closed Garbage Dumpster
Penalty
Summary
The facility failed to ensure refuse was stored in a sanitary manner when one of three garbage dumpsters was found with its lid partially propped open by cardboard boxes, preventing the lid from fully closing. The report states that outside garbage receptacles must have tight-fitting lids or covers to prevent scattering of garbage or refuse, breeding of flies, and entry of rodents. The facility’s policy also required kitchen waste and garbage/refuse containers to be kept in clean, leakproof, nonabsorbent, tightly closed containers and for waste to be properly contained in dumpsters or compactors with lids. During observation and concurrent interview with the Environmental Services Director, the open dumpster condition was verified, and the director stated the dumpster lids should be completely closed at all times for infection control purposes.
Glucometer Quality Control and Record Mismatch
Penalty
Summary
The facility failed to ensure essential equipment was maintained in proper working condition for blood glucose monitoring. During review of Medication Cart A, the glucometer serial number on the Daily Quality Control Record for December 2025 did not match the serial number on the glucometer itself. LVN 1 verified that the license nurse had changed the glucometer but did not update the Daily Quality Control Record, and stated the glucometer and record should match to ensure residents' blood glucose checks are accurate. During review of Medication Cart B, the Daily Quality Control Record showed low and high control readings of 52 and 295 on 12/3/25 at 12 AM, but the glucometer did not display those readings. LVN 2 verified the discrepancy, and RN 1 also confirmed that the glucometer did not show the recorded low and high control glucose readings. RN 1 stated glucometers were calibrated and quality control was completed to ensure the functionality of the device. The Administrator, DON, and DSD were informed and acknowledged the findings.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to implement its infection control program in accordance with its policy and procedure for administering medications. The facility’s policy stated that medications are to be administered in a safe and timely manner and that staff follow established infection control procedures, including handwashing and antiseptic techniques, during medication administration. During a medication administration observation at Medication Cart B, LVN 3 did not perform hand hygiene before or after administering oral medications to Resident 25, and he also did not perform hand hygiene before and after administering medications to two other residents. LVN 3 confirmed that he did not perform hand hygiene and stated that he should have done so to maintain infection control protocols. The Administrator, DON, and DSD were later informed of and acknowledged the findings.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Exit Door Alarm
Penalty
Summary
The facility failed to maintain a safe and secure environment for two residents who were at risk for elopement. Both residents had documented histories and care plans indicating their risk for elopement, with one resident being independent in decision-making and the other unable to make medical decisions but able to express needs. Despite these risks, both residents were able to leave the premises through an exit door in the smoking area. The incident occurred when the residents were observed in the courtyard, and one resident kicked the exit door, allowing both to exit the facility. Staff only became aware of the elopement after hearing the banging of the door, and no alarm was heard at the time, even though the door was supposed to be alarmed. Interviews and video evidence confirmed that no staff were present by the exit door at the time of the incident, and the alarm system did not function as intended. The Maintenance Director stated that exit doors were checked daily but admitted there was no maintenance log to document these checks. The lack of staff supervision in the area and the failure of the alarm system contributed to the residents' ability to elope, placing them at risk for harm or injury.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as evidenced by multiple observations during a kitchen tour. The ice machine, which was used by both residents and staff, was found to have a pinkish residue on its interior top portion, indicating it was not maintained in a sanitary condition. The Environmental Services Director acknowledged this finding and confirmed that the ice would not be used due to its dirty condition. Additionally, the microwave used for warming food was observed to have dry, crusted food residue inside, which the Dietary Supervisor confirmed should have been cleaned daily and deep cleaned weekly. Further observations revealed that the kitchen hood over the stove had black, grease residue, which the Dietary Supervisor admitted was not adequately cleaned, as it should be cleaned weekly by staff and every six months by an outside company. Kitchen utensils and equipment were also found to be in poor condition, with items such as whisks, spatulas, and cutting boards being worn out, discolored, and dirty. The Dietary Supervisor acknowledged these findings, stating that the items should be discarded and replaced to prevent cross-contamination. The facility also failed to ensure proper food storage and handling practices. Expired foods were found in the refrigerator, including egg salad and various fruit and pudding cups, which were not labeled accurately or discarded as required. The Dietary Supervisor confirmed these findings, acknowledging that the items should have been labeled correctly and expired items discarded. These deficiencies in maintaining sanitary conditions and proper food handling practices had the potential to lead to cross-contamination and foodborne illnesses among the residents consuming the food prepared in the facility's kitchen.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several deficiencies observed during the survey. The facility did not have documentation of a Legionella facility risk assessment or testing protocols for Legionella and other opportunistic waterborne pathogens. The Administrator admitted that the facility lacked a flow chart of the water system and only identified the water fountain as a risk. The EVS Director confirmed that no testing for Legionella or other pathogens was conducted in areas with potential risks for standing water, such as water heaters and shower rooms. In another instance, CNA 1 did not follow proper infection control procedures when interacting with residents. After touching Resident 498, who had an indwelling medical device, CNA 1 failed to remove her gown and gloves and perform hand hygiene before assisting another resident, Resident A. This action was contrary to the physician's order and the facility's infection prevention protocols, which required changing PPE and performing hand hygiene between residents to prevent the transmission of multidrug-resistant organisms (MDROs). Additional deficiencies were noted in the handling and storage of PPE and clean linens. An unpackaged N95 respirator was found lying on top of a plastic PPE container at the entrance of a COVID-19 isolation room, with no clarity on its ownership or usage status. This improper storage posed a risk of contamination. Furthermore, CNA 6 placed a resident's shower bin containing clean items on a soiled linen cart, and clean bathrobe belts were observed lying on top of a clean linen cart, both of which violated infection control protocols.
Failure to Notify Physician of Change in Resident's Neurological Status
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) informed the physician of a change in condition for a resident (Resident 598) who was reviewed for falls. The facility's policy and procedure (P&P) required that any change in a resident's neurological status be reported to the physician. Despite this, LVN 1 did not notify the physician of a change in Resident 598's pupillary response during a neurological check on December 1, 2024, at 1100 hours. This change was significant as it indicated a potential neurological impairment following an unwitnessed fall on November 30, 2024. The resident's medical records showed severely impaired cognition, and the care plan included specific interventions for neurological evaluations following the fall. The deficiency was identified through interviews and medical record reviews, which revealed that LVN 1 did not compare the neurological assessments as required and failed to notify the physician of the change in pupillary response. The Director of Nursing (DON) confirmed that the nurse should have compared the results of the neurological checks and informed the physician of any changes. The failure to notify the physician was acknowledged by both the DON and the Administrator during interviews conducted on December 5, 2024, and December 15, 2024, respectively.
Deficiencies in Care Plan Implementation for Two Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in their care. For Resident 298, who was at risk for falls due to generalized weakness and a history of cerebrovascular accidents, the care plan required bilateral floor mats to be placed next to the bed. However, during observations, it was noted that only one side of the bed had a floor mat, contrary to the care plan's requirements. This oversight was confirmed by LVN 4 during an interview and medical record review. Similarly, the facility did not adhere to the care plan for Resident 301, who was at risk for pain due to peripheral vascular disease, osteoporosis, and generalized body pain. The care plan specified the application of two lidocaine 4% external patches for pain management. However, during a medication administration observation, LVN 4 applied only one patch to the resident's hip, instead of the prescribed two patches to the hip and foot. This discrepancy was also verified by LVN 4 during a subsequent interview and medical record review.
Failure to Ensure Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure ulcers and promote the healing of existing ones for two residents. For Resident 599, the facility did not ensure that the Low Air Loss (LAL) mattress setting was consistent with the resident's weight, which was set at the 8th light bar, appropriate for a weight of 300 to 330 pounds, while the resident weighed 230 pounds. Additionally, the wound treatment for a Stage 2 pressure ulcer on the coccyx was not administered as per the physician's order, as chlorhexidine was used instead of soap and water for cleaning the wound without proper documentation or physician's order clarification. Resident 599 was admitted to the facility with a risk for developing pressure ulcers and had a Stage 2 pressure ulcer on the coccyx. The resident was cognitively intact and dependent on staff for bed mobility. The facility's failure to adjust the LAL mattress setting according to the resident's weight and to follow the physician's wound treatment order potentially affected the wound healing process. The Treatment Administration Record (TAR) lacked documentation of the LAL mattress settings and monitoring, and the care plan did not include the use of the LAL mattress as an intervention. Similarly, for Resident 598, the LAL mattress setting was not consistent with the resident's weight. The mattress was set at the 8th light bar, while the resident weighed 121 pounds, which required a setting of 2 light bars. The facility did not document the specific LAL mattress setting for the resident, and the TAR did not show monitoring of the mattress unit. Resident 598 had severely impaired cognition and was at risk for developing pressure ulcers, requiring total assistance for bed mobility. The facility's failure to ensure the correct mattress setting could have impacted the resident's comfort and skin integrity.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 298 and 600, were free from accident hazards, which placed them at risk for serious injury. For Resident 600, the facility did not adhere to the fall risk evaluation and care plan that required the use of a gait belt during transfers. On multiple occasions, CNAs did not use the gait belt when transferring Resident 600 to the commode, despite the resident's history of falls and the care plan's specific instructions. Interviews with the CNAs revealed that they were aware of the fall risk but chose not to use the gait belt, believing the resident was stable enough without it. Resident 600 had a history of falls and was at moderate risk for falls due to impaired gait and balance, as noted in the fall risk evaluations. The care plan specified the use of a gait belt and other assistive devices during transfers. However, during an observation, a CNA was seen transferring Resident 600 without the gait belt, which was confirmed by the CNA's admission of not using it despite being informed of the necessity by the charge nurse. The Occupational Therapist also confirmed the protocol for using a gait belt during transfers for Resident 600. For Resident 298, the facility failed to implement the physician's order for bilateral floor mats for fall prevention. During an observation, it was noted that only one side of Resident 298's bed had a floor mat, contrary to the care plan that required mats on both sides. This oversight was verified by an LVN, who acknowledged that the mats should have been placed on both sides to reduce the risk of injury, as Resident 298 was at risk for falls due to generalized weakness and a history of CVA and TIA.
Failure to Document PICC Line Measurements
Penalty
Summary
The facility failed to provide necessary care and services to maintain the IV access for a resident, specifically in the management of a PICC line. The facility's policy and procedure for Central Venous Catheter Care and Dressing Changes, dated 2001, requires the measurement of the external central vascular access device with each dressing change and when catheter dislodgement is suspected. Additionally, for PICCs, arm circumference should be measured and compared to baseline to assess for edema and possible deep-vein thrombosis. However, upon review, it was found that the facility did not document the PICC line external catheter and arm circumference measurements for the resident upon admission, as required by the facility's policy. The resident's medical record, including the History and Physical examination and the Order Summary Report, lacked documentation of these measurements. The resident's care plan indicated the presence of a PICC line on the right upper arm and required the measurement of the external length of the catheter and upper arm circumference. Despite this, the IV Administration Record showed incomplete documentation, with the arm circumference recorded as 32 cm and the catheter length as zero. Interviews with RN 1 and the DON confirmed the absence of these critical measurements upon admission, which are essential for identifying signs of infection, swelling, blood clots, and catheter dislodgement.
Failure to Provide Safe Respiratory Care for a Resident Using CPAP
Penalty
Summary
The facility failed to provide safe respiratory care for a resident using a CPAP machine, as observed during a survey. The CPAP machine, belonging to Resident 12, was not cleaned according to the manufacturer's guidelines, which require regular cleaning to prevent contamination and respiratory complications. The resident reported that staff had not cleaned the CPAP machine since its use began at the facility. Observations confirmed that the CPAP mask was not stored properly, and there was no evidence of cleaning or maintenance in the resident's medical records. The facility's policy and procedure for CPAP/BiPAP support, revised in 2015, outlined specific cleaning instructions, including weekly cleaning of the machine and daily cleaning of components like masks and tubing. However, these procedures were not followed for Resident 12. Interviews with staff, including a CNA and the Director of Staff Development (DSD), revealed a lack of clarity regarding responsibility for cleaning the CPAP equipment. The DSD confirmed that there were no physician's orders or documentation regarding the cleaning of the CPAP machine and its components in the resident's care plan. Further interviews with the Director of Nursing (DON) indicated that both CNAs and LVNs could clean the CPAP mask, but it should be documented by licensed nurses. The DON acknowledged that the CPAP mask and machine should be cleaned routinely and stored properly when not in use. The facility's failure to adhere to these procedures and document the cleaning process resulted in a deficiency in providing safe respiratory care for Resident 12.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Resident 12 and Resident 599, as identified through interviews, medical record reviews, and facility policy reviews. For Resident 12, the facility did not administer pain medication according to the physician's order and failed to ensure non-pharmacological interventions (NPIs) were provided or documented prior to administering pain medications. Resident 12, who was admitted following shoulder surgery, was given acetaminophen and oxycodone outside the prescribed pain levels without documentation of NPIs or physician notification. Resident 12's medical records showed instances where acetaminophen was administered for pain levels that did not match the physician's orders, and there was a lack of documentation for NPIs. Interviews with staff, including a CNA and an LVN, confirmed that pain medications were administered without following the ordered parameters, and there was no documentation of NPIs or physician notification when medications were given outside the prescribed pain levels. The LVN acknowledged the absence of documentation for NPIs and the lack of communication with the physician regarding deviations from the prescribed pain management plan. Similarly, for Resident 599, the facility failed to consistently provide NPIs before administering narcotic pain medication. Resident 599, who developed a bedsore during her stay, was given Roxicodone for moderate to severe pain without documented evidence of attempted NPIs. The DON confirmed that medications should be administered as ordered, with NPIs documented prior to administration. The absence of documentation for NPIs and the administration of pain medications outside the ordered parameters were acknowledged by the facility's administration.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide timely administration of medications as per their policy and procedures for several residents. Licensed Vocational Nurse (LVN) 2 did not administer the 0900 hours medications within the required 60-minute window for two residents, 601 and 602. This delay was attributed to unexpected circumstances and resident emergencies, which led to the medications being administered late. Resident 601, who had recently suffered a stroke, expressed the importance of timely medication to prevent further health complications. Similarly, Resident 602 questioned the delay in receiving his medications, highlighting the expectation for timely administration. LVN 4 also failed to administer medications on time for three residents, 42, 302, and 305, due to attending to another resident's emergency. The medications scheduled for 0900 hours were administered significantly later, with some being given as late as 1341 hours. This delay in medication administration could potentially lead to adverse health effects, especially for residents with conditions such as hypertension and heart failure, who rely on timely medication to manage their health. Additionally, the facility did not accurately document the administration of controlled substances for three residents, 14, 302, and 303. The Drug Control Receipt/Record/Disposition Forms for these residents showed discrepancies in the count of medications, indicating a failure to record the removal of certain tablets. This lack of accurate documentation raises concerns about potential drug diversion and the facility's ability to monitor and reconcile controlled substances effectively.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 16.13%. This deficiency was identified through observations, interviews, and medical record reviews. LVN 2 did not administer three medications as ordered by the physician for Resident 602. Specifically, LVN 2 applied only one lidocaine 4% external patch instead of the prescribed two patches, and failed to administer calcium carbonate-vitamin D and povidone-iodine swabs. LVN 2 acknowledged these errors and noted the absence of the correct calcium carbonate-vitamin D dose in the medication cart or central supply. Additionally, LVN 4 administered incorrect dosages and failed to follow physician orders for Resident 301. LVN 4 gave two capsules of calcitriol 0.5 micrograms instead of the ordered two capsules of calcitriol 0.25 micrograms, effectively doubling the prescribed dose. Furthermore, LVN 4 applied only one lidocaine 4% external patch to Resident 301's hip, contrary to the order to apply two patches to the right hip and right foot. These actions were verified by LVN 4 during a concurrent interview and medical record review.
Improper Storage and Disposal of Medications and Supplies
Penalty
Summary
The facility failed to store drugs, biologicals, and medical supplies safely, as evidenced by improper disposal of opened medical supplies in Medication Carts B and C. During an inspection, it was observed that a sterile glove was opened and unsealed in Medication Cart B, compromising its sterility. In Medication Cart C, several items, including a foam dressing, abdominal pad dressing, xeroform petrolatum dressing, foam wound dressing, and a urethral catheterization tray, were found opened, breaking their sterility. LVN 5 confirmed these findings and acknowledged that all licensed nurses are responsible for cleaning the cart and discarding compromised items. Additionally, the facility failed to properly dispose of discontinued medications. In Medication room [ROOM NUMBER], a medication disposal bin contained multiple whole pills not fully dissolved, an unidentified bottle, insulin pens, nasal spray, an inhaler, and syringes. LVN 5 acknowledged that the medications in the disposal bin were not fully dissolved and that the lid was removable, which is not in compliance with the facility's policy. The DON verified these findings and stated that liquids should have been poured out, and bottles should not have been kept in the disposal bin.
Resident PHI Exposed During Medication Administration
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal health information (PHI) during medication administration. During an observation, a Licensed Vocational Nurse (LVN) prepared medications for a resident and left the medication cart unattended in the hallway. The computer attached to the cart displayed the resident's PHI, including their name, prescribed medications, and the indications for use. This information was visible to other residents passing by, as the screen was facing the hallway. The facility's policy and procedure on confidentiality, revised in October 2017, mandates the protection and safeguarding of residents' personal and medical records, limiting access to authorized staff only. However, the LVN acknowledged the oversight and confirmed that the displayed information was indeed private health information. The LVN admitted that she should have ensured the computer screen did not display the resident's PHI when she was away from the medication cart.
Failure to Provide Resident's Preferred Beverage
Penalty
Summary
The facility failed to accommodate the drink preferences for one of the residents, identified as Resident 12, during a lunch meal. On the specified date, Resident 12 was observed in his room with a lunch tray that did not include the four ounces of whole milk as per his standing order on the meal ticket. Instead, the tray contained chicken salad, water, cranberry juice, chocolate ice cream, and an applesauce bar. Resident 12 expressed his preference for having milk with his lunch, which was not initially provided. A Certified Nursing Assistant (CNA 5) confirmed that the meal ticket indicated the resident's preference for milk, and acknowledged the oversight. The CNA subsequently provided the milk to Resident 12. The Dietary Services Supervisor (DSS) later confirmed that if milk was listed on the meal ticket, it should have been included on the tray. The Administrator (ADM) and Director of Nursing (DON) were informed of these findings, acknowledging the deficiency in meeting the resident's dietary preferences.
Failure to Adhere to Resident's Documented Food Allergies
Penalty
Summary
The facility failed to adhere to a resident's documented food allergies, resulting in the resident being served dairy products despite having a known allergy. The deficiency was identified through interviews, medical record reviews, and policy and procedure reviews. The resident, who had an allergy to dairy products, was served milk during meals, which could have negatively impacted their well-being. This oversight occurred because the kitchen staff did not verify the resident's food allergies when preparing the meal tray, as the allergy section of the dietary communication card was obscured by a ring hook. The resident's medical records, including an acute care hospital history and physical examination, clearly indicated an allergy to dairy products, which was also noted in the resident's plan of care. Despite this, the resident was served whole milk, leading to a complaint from the resident's family member. The Dietary Supervisor and the Director of Nursing confirmed the oversight and acknowledged that the resident should not have been served dairy products, as it could result in severe allergic reactions.
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 2,739 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 | 0.2 mi | ★★★★★ | 62 | 0 |
| Crystal Cove Care Center | 0.3 mi | ★★★★★ | 6 | 0 |
| Mesa Verde Post Acute Care Center | 0.8 mi | ★★★★★ | 25 | 0 |
| Victoria Healthcare And Rehabilitation Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Newport Subacute Healthcare Center | 2.7 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.