During a February inspection, investigators discovered Resident 686 had been receiving continuous oxygen at 4 liters per minute via nasal cannula since morning, but no physician's order existed in the medical record. Licensed Vocational Nurse 6 acknowledged the resident should have had a doctor's order for oxygen therapy.
The pattern repeated with Resident 336, who received continuous oxygen at 2 liters per minute without any physician order. When inspectors returned three days later, they found the resident receiving oxygen at 2.5 liters per minute — exceeding the 2-liter rate specified in an order that had finally been obtained. The facility also failed to post required "Oxygen In Use" signs outside the resident's room and never developed a care plan addressing the oxygen therapy.
Staff demonstrated concerning gaps in basic medical knowledge. When a family member requested bladder training for Resident 336, who had an indwelling urinary catheter, the Assistant Director of Nursing told them "bladder training was not possible for a resident with an indwelling urinary catheter." However, the Director of Nursing later confirmed that bladder training with catheters involves clamping and unclamping techniques.
The Assistant Director of Nursing had worked at the facility for four years but stated they "had not done a bladder training for a resident with an indwelling urinary catheter" during that time. An education record showed Licensed Vocational Nurse 12 attended bladder training in-service, but the Assistant Director of Nursing was not listed as receiving the training.
Infection control violations extended throughout the facility. During wound care for Resident 336, Licensed Vocational Nurse 9 repeatedly removed and donned gloves without performing hand hygiene between each step. The nurse cleaned the surgical site, applied Steri-Strips, and placed an adhesive dressing while changing gloves five times without washing hands.
When questioned, the nurse stated, "I thought that by removing the gloves, it would be okay." She acknowledged she should have performed hand hygiene when moving from dirty to clean areas during wound care.
Inspectors observed Resident 686's nasal cannula tubing touching the inside of a trash can and later lying on the floor while the resident used oxygen therapy. Licensed Vocational Nurse 6 confirmed the tubing "should not be touching the floor as it posed the risk for infection."
The facility's infection surveillance program contained systematic errors. Monthly reports incorrectly classified community-acquired infections as healthcare-associated infections and marked infections as meeting McGeer criteria when they did not. For December 2024, the facility reported 33 healthcare-associated influenza infections, but surveillance logs showed none actually met the required criteria.
Resident 87 was classified as having a community-acquired infection despite being admitted before the onset of symptoms. Resident 86 was marked as having healthcare-associated pneumonia despite not meeting McGeer criteria for the diagnosis.
Documentation failures affected multiple residents. Resident 40's medication record showed no evidence of receiving Advair Diskus and Hydralazine on February 2, despite the nurse claiming to have administered both medications. Licensed Vocational Nurse 13 stated the electronic system "must have been lagged so it did not save his documentation."
Resident 20's monitoring record was incomplete for February 6, missing documentation of adverse medication reactions, depression episodes, schizophrenia symptoms, and tardive dyskinesia screening for the evening shift. Licensed Vocational Nurse 3 confirmed he had performed the monitoring but "forgot to document in the MAR."
The facility failed to conduct annual performance evaluations for staff members. Licensed Vocational Nurse 5, hired in February 2021, had not received an evaluation since January 2024. Certified Nursing Assistant 7, rehired in October 2022, had no performance evaluations completed in the past two years.
Medical consent forms contained wrong resident names and birthdates. Resident 336's POLST form showed a different resident's name and incorrect birthdate, while immunization consent forms for influenza, pneumonia, and COVID-19 vaccines all contained the wrong resident name.
Kitchen inspections revealed dirty utensils with food residue and stains stored as clean. Three cutting knives, a serving fork, a slotted scoop, and a dough cutter all showed crusted residue and fuzzy stains. A basting brush had frayed bristles that should have been replaced.
The facility's psychotropic medication monitoring showed inconsistencies. Resident 336 received zolpidem for insomnia but had zero hours of sleep documented on February 20, while simultaneously showing zero episodes of being unable to fall asleep. The informed consent form for the medication lacked the required physician signature.
Resident 1's clonazepam consent had not been renewed since August 2024, violating the facility's policy requiring six-month renewals. The Director of Nursing acknowledged the consent was not renewed according to facility policy and state regulations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crystal Cove Care Center from 2025-02-24 including all violations, facility responses, and corrective action plans.
