Crystal Cove Care Center
CRYSTAL COVE CARE CENTER in NEWPORT BEACH, CA — inspection on February 24, 2025.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 40's MDS dated [DATE], showed Resident 40 had short and long-term memory problems.
On 2/20/25 at 0830 hours, a medication administration observation was conducted with LVN 5. LVN 5 left the privacy curtain open on the left side of the bed facing the sliding door.
The curtain of the sliding door was also left open, exposing Resident 40 to the outside patio and rooms across the patio.
LVN 5 was observed pulling Resident 40's gown up and exposed Resident 40's stomach area to access the GT for the administration of the medications.
Additionally, a portion of Resident 40's diaper was also exposed. LVN 5 was about to administer the medications via GT when LVN 5 was reminded of providing privacy to Resident 40. LVN 5 stated she should have provided privacy to Resident 40 by pulling the privacy curtain by the bed and the curtain of the sliding door prior to administering the medications.
On 2/24/25 at 1513 hours, an interview was conducted with the DON.
When asked about providing the residents privacy, the DON stated it was not only providing privacy to the resident during medication administration was important, but also the resident's right for privacy.
The DON was informed and acknowledged the above findings.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
Review of the facility's P&P titled Personal Property dated 2001 showed the resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.
Medical record review for Resident 10 was initiated on 2/18/25. Resident 10 was admitted to the facility on [DATE].
Review of Resident 10's Resident Inventory of Personal Effects form dated 1/8/25, signed by the resident and facility staff, showed the triplicate copies of the form were attached together with white, yellow, and pink colors.
The bottom section of the form showed On admission: [NAME] Copy in Health Record, Pink Copy Resident Copy.
On 2/20/25 at 1449 hours, and interview and concurrent medical record review for Resident 10 was conducted with MDS 2. MDS 2 stated the personal inventory list was done during admission to keep the inventory of the resident's belongings. MDS 2 further stated the resident was to receive the pink copy of the inventory list. MDS 2 verified the triplicate copies of the inventory list dated 1/8/25, were intact and the pink copy was not given to Resident 10.
On 2/21/25 at 1034 hours, an interview was conducted with the DON.
When asked about the facility's process regarding the resident's personal inventory, the DON stated the personal inventory list was filled out upon admission, readmission, and when new belongings were received.
The resident, family, and staff signed the inventory list.
The DON further stated the residents were to receive a copy of the inventory list upon admission, readmission, and when new belongings were received.
The DON was informed and acknowledged the findings.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
ADON.
The ADON verified the above findings.
The ADON stated the licensed nurses were responsible
minimal harm notification form at the time of transfer.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered dated 2001 showed a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Further review of the facility's P&P showed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.
Medical record review for Resident 5 was initiated on 2/18/25. Resident 5 was admitted to the facility on [DATE], with diagnoses including unspecified fracture of the upper end of right humerus, subsequent encounter for fracture with routine healing.
Review of Resident 5's Order Summary Report dated 2/20/25, showed a physician's order dated 12/22/24, for the resident to wear a sling to the RUE while out of bed.
Review of Resident 5's H&P examination dated 12/23/24, showed the resident was alert and oriented, interactive, with normal speech.
Review of Resident 5's Plan of Care showed a care plan problem dated 2/18/25, addressing the resident's risk for pain related to fracture of the upper end of right humerus.
The interventions included to apply a sling to the RUE while out of bed.
On 2/18/25 at 0925 hours, Resident 5 was observed in her room sitting in a wheelchair and not wearing a sling to her RUE.
On 2/19/25 at 0821 hours, Resident 5 was observed in her room sitting in a wheelchair and not wearing a sling to her RUE.
On 2/24/25 at 1414 hours, an observation and concurrent interview was conducted with Resident 5. Resident 5 was observed sitting up in bed.
When asked about the fracture to her right upper arm, Resident 5 stated she fell at home on [DATE].
When asked if Resident 5 was aware of the physician's order for a sling to be worn on her RUE when out of bed, Resident 5 stated she aware but had not been wearing the sling since the physician told her that she did not need to wear it and Resident 5 decided to stop wearing the sling.
On 2/24/25 at 1453 hours, an interview and concurrent medical record review for Resident 5 was conducted with the ADON.
The ADON verified the physician's order and the care plan for the resident to wear the sling to the RUE.
The ADON had acknowledged Resident 5 should be using the sling to her RUE.
However, the ADON stated Resident 5 had a tendency to remove it.
The ADON verified Resident 5's plan of care should have been updated to show the resident's refusal to wear the sling.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
Review of Resident 45's MAR for February 2025 showed the laboratory tests for CBC, Chem 7, and
was blank.
Further review of the MAR showed the orthostatic blood pressures (sitting, lying and standing) were scheduled to be monitored every Sunday.
However, the blood pressure readings for all positions (sitting, lying and standing) were the same as follows: - on 2/9/25, a blood pressure reading of 126/72 mmHg was documented for the sitting and standing positions; and - on 2/16/25, a blood pressure reading of 126/72 mmHg was documented for the lying, sitting, and standing positions. b.
Further review of Resident 45's medical record did not show any laboratory results for the CBC, Chem 7, and magnesium level scheduled on 2/16/25.
There was no followed up with the laboratory for the results nor any documentation if the laboratory tests were done or not.
On 2/20/25 at 1400 hours, an interview and concurrent medical record review for Resident 45 was conducted with LVN 12.
When asked about the laboratory tests for Resident 45, LVN 12 verified it was not signed in the MAR. LVN 12 was not able to show a requisition paper and the results for the laboratory test for CBC, Chem 7, and magnesium level as ordered by the physician. In addition, LVN 12 was not able to show documented evidence of a follow-up whether the laboratory tests were completed or not.
When asked about the orthostatic blood pressure, LVN 12 stated the CNAs and the therapists assisted the resident to stand up and the LVN checked the blood pressure. LVN 12 verified same blood pressure results were documented for the standing, sitting, and lying positions for Resident 45.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
training with the indwelling urinary catheter was not possible, and the facility could help with the
urology.
c.
Further review of Resident 336's medical record did not show a bladder training was provided for Resident 336 while having the indwelling urinary catheter nor a urology consultation was followed up.
On 2/21/25 at 1008 hours, an interview and concurrent medical record for Resident 336 was conducted with LVN 10. LVN 10 verified the indwelling urinary catheter care and monitoring of the urine output for Resident 336 were only started on 2/21/25, seven days after Resident 336 was admitted at the facility.
When asked about the bladder training for Resident 336, LVN 10 stated the process they followed in the facility included only to remove the indwelling urinary catheter, but there was no bladder training provided at the facility. LVN 10 stated he did not speak to Resident 336 or to Responsible Party 1 about removing the indwelling urinary catheter, so he did not offer a bladder training.
On 2/21/25 at 1416 hours, an interview and concurrent medical record for Resident 336 was conducted with the ADON.
When asked about the bladder training for Resident 336, the ADON stated she spoke to Responsible Party 1 about removing the indwelling urinary catheter but he was upset because he wanted a bladder training while Resident 336 had an indwelling urinary catheter.
The ADON stated she told Responsible Party 1 that a bladder training was not possible, and the facility was not able to do a bladder training.
The ADON stated Responsible Party 1 wanted a urology consultation; however, the ADON could not find documented evidence to show a urology consultation was followed up.
Cross reference to F-F726.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
for shortness of breath.
verified Resident 67's bagged nebulizer mask and tubing had no resident's name and date labeled.
labeled.
On 2/24/25 at 1630 hours, an interview was conducted with the DON.
The DON was informed and acknowledged the above findings.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
Review of the facility's P&P titled Performance Evaluations (undated) showed the performance evaluation would be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.
The performance evaluation meeting will occur at the same time as the employee's compensation review.
On 2/24/25 at 0902 hours, an interview and concurrent facility personnel record review was conducted with the DSD.
Review of LVN 5's personnel record showed LVN 5 was hired on 2/1/21.
The personnel record showed LVN 5's last employee's performance appraisal was on 1/30/24.
Further review of LVN 5's personnel record failed to show LVN 5 was evaluated one year after the last performance evaluation.
The DSD verified the above findings.
The DSD stated the licensed nurses would be evaluated either by a designated RN supervisor or the DON.
On 2/4/25 at 1445 hours, an interview was conducted with the DON.
The DON stated the performance evaluation should be done annually at the minimum.
The DON stated the performance evaluation would be needed to determine the quality of the employee's work performance and to determine if the employee would need an improvement.
The DON was informed and acknowledged the above findings.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
Review of the facility's P&P titled Performance Evaluations (undated) showed the performance evaluation would be completed on each of the employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.
The performance evaluation meeting will occur at the same time as the employee's compensation review.
On 2/24/25 at 0902 hours, an interview and concurrent facility personnel record review was conducted with the DSD.
Review of CNA 7's personnel record showed CNA 7 was rehired on 10/18/22.
Further review of CNA 7's personnel record failed to show the performance evaluations were completed every 12 months for the past two years.
The DSD verified the findings.
The DSD stated it was the responsibility of the DSD to perform the annual evaluation for the CNAs.
The DSD stated she started to work as the facility's DSD only last January 2025 and had not reviewed all the CNAs' personnel records.
On 2/4/25 at 1445 hours, an interview was conducted with the DON.
The DON stated the performance evaluations were done annually at the minimum.
The DON stated the performance evaluations were needed to determine the quality of the employee's work performance and if the employees would need improvement.
The DON was informed and acknowledged the above findings.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
According to the California Department of Public Health, All Facilities Letter (AFL) 24-07 dated
the psychotherapeutic drugs, and consent renewal every six months.
The section for Renewals of Informed Consent showed the facilities must provide the resident with any recommended dosage adjustments and the option of revoking consent. If the resident decides to discontinue using the drug, the prescriber is responsible for planning any necessary, gradual dose reduction, as well as possible behavioral interventions.
Review of Resident 1's medical record was conducted on 2/20/25. Resident 1 was admitted on [DATE].
Review of Resident 1's BIMS dated 2/1/25, showed a BIMS score summary of 12 (moderate cognitive impairment).
Review of Resident 1's Order Summary Report showed a physician's order dated 2/4/25, for clonazepam 1.5 mg by mouth to be given every evening at 1700 hours, for anxiety m/b inability to relax.
Review of Resident 1's MAR for February 2025 showed the following physician's orders: - dated 8/16/24, to administer clonazepam 1.5 mg PO in the evening at 1700 hours, for anxiety and verbalization of anxiousness, discontinued on 2/4/25; and - dated 2/5/25, to administer clonazepam 1.5 mg PO in the evening at 1700 hours, for anxiety m/b inability to relax.
Further review of the MAR showed the clonazepam 1.5 mg medication was administered daily at 1700 hours, on 2/1 to 2/19/25.
Review of Resident 1's Informed Consent-Psychoactive Medication dated 8/6/24, showed an initial consent for the use of clonazepam 2 mg in the evening for anxiety signed by Resident 1 and the physician.
On 2/24/25 at 1435 hours, an interview and concurrent review of Resident 1's informed consent was conducted with RN 3. RN 3 verified and acknowledged Resident 1's latest clonazepam informed consent was obtained on 8/6/24.
On 2/24/25 at 1630 hours, an interview was conducted with the DON.
The DON was informed of Resident 1's clonazepam informed consent was obtained on 8/6/24.
The DON verified the informed consent was not renewed as per the facility P&P and AFL.
The DON acknowledged and verified the above findings.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
During the initial kitchen tour on 2/18/25 at 0833 hours, a concurrent observation and interview was conducted with the RD.
One white basting brush was observed worn out and bristles was frayed.
The RD verified the findings and stated they had a new one and it should have been changed.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
Review of Resident 5's Documentation Survey Report for February 2025 showed the missing documentation for the bowel continence documentation on the following dates and shifts: - 2/16/25, for the day shift; - 2/15, 2/19, and 2/21/25, for the evening shift; and - 2/1, 2/10, and 2/16/25, for the NOC shift.
On 2/24/25 at 1308 hours, an interview was conducted with the ADON.
The ADON acknowledged the missing documentation in Resident 5's bowel and bladder elimination record.
The ADON also acknowledged the CNAs caring for Resident 5 did not document and should have documented the information.
055929 02/24/2025
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
using an oxygen via nasal caula at a rate of 4 liters per minute and the green color nasal cannula
Medical record review for Resident 686 was initiated on 2/18/25. Resident 686 was admitted to the
On 2/18/25 at 1211, 1238, and 1509 hours, a follow-up observation was conducted in Resident 686's room. Resident 686 was observed using her oxygen via nasal canula at a rate of 4 liters per minute and the green color nasal canula tubing was observed touching the floor.
On 2/18/25 at 1513 hours, an observation and concurrent interview was conducted with LVN 6.
When asked if the nasal canula tubing should be touching the floor when the resident was using the oxygen, LVN 6 stated the nasal canula tubing should not be touching the floor as it posed the risk for infection. LVN 6 verified the green color nasal canula tubing was touching the floor while Resident 686 was using her oxygen via nasal canula.
Review of Resident 336's Order Summary Report did not show a physician's order to administer the oxygen.
Review of Resident 336's Plan of Care did not show a care plan problem was developed to address Resident 336's use of oxygen.
On 2/18/25 at 1531 hours, an observation, interview, and concurrent medical record review for Resident 336 was conducted with MDS Coordinator 2. MDS Coordinator 2 verified Resident 336's continuous oxygen was being administered at a rate of 2 liters per minute via nasal cannula, and there was no Oxygen In Use sign posted outside the resident's door. MDS Coordinator 2 also verified there was no physician's order to administer the oxygen to Resident 336, and there was no care plan developed to address Resident 336's oxygen use.
b. On 2/21/25 at 1001 hours, a follow-up observation was conducted for Resident 336. Resident 336 was observed lying in bed with a continuous oxygen being administered at a rate of 2.5 liters per minute via nasal cannula.
Further review of Resident 336's Order Summary Report showed a physician's order dated 2/18/25, to administer oxygen via nasal cannula at a rate of 2 liters per minute.
On 2/21/25 at 1002 hours, an observation, interview, and concurrent medical record review was conducted with LVN 9. LVN 9 verified Resident 336's continuous oxygen was being administered at a rate of 2.5 liters per minute via nasal cannula. LVN 9 verified the physician's order showed to administer continuous oxygen via nasal cannula was at a rate of 2 liters per minute.
50787
055929
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055929 B.
Wing 02/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Cove Care Center 1445 Superior Avenue Newport Beach, CA 92663
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.