Crystal Cove Care Center
CRYSTAL COVE CARE CENTER in NEWPORT BEACH, CA — inspection on October 14, 2025.
Found 4 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 3's Order Summary Report showed the following orders:dated 6/11/25, Ambien oral tablet 10 mg, give one tablet by mouth every 24 hours as needed for insomnia manifested by inability to sleep- dated 6/11/25, Ambien oral tablet 10 mg, give one tablet by mouth every 24 hours as needed for insomnia manifested by inability to sleep for 14 days.- dated 6/11/25, oxycodone-acetaminophen oral tablet 10-325 mg, give one tablet by mouth every four hours as needed for moderate pain 4-6 (on the pain scale of 0 to 10 with 0 = no pain and 10 = worst), hold if RR (respiratory rate) less than 12- dated 6/11/25, oxycodone-acetaminophen oral tablet 10-325 mg, give two tablets by mouth every four hours as needed for severe pain 7-10, hold if RR less than 12- dated 6/12/25, Verapamil Extended Release oral tablet 120 mg, give one tablet by mouth two times a day for high blood pressure.
Hold if SBP greater than 110 mmHg.- dated 6/12/25, Verapamil oral tablet 120 mg, give 120 mg by mouth in the afternoon for hypertension.
Review of Resident 3's H&P examination dated 6/12/25, showed Resident 3's diagnoses included PTSD, anxiety, and high blood pressure.
Review of Resident 3's Transfer/Discharge Report dated 6/12/25, showed the following medications were listed on the discharge medication list but not marked as given to the resident upon discharge: - Verapamil 120 mg in the afternoon- Verapamil 120 mg Extended Release 120 mg twice daily- oxycodone-acetaminophen oral tablet 10-325 mg On 10/14/25 at 1709 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 verified Resident 3's Verapamil, Ambien, and oxycodone-acetaminophen medications were not provided to the resident upon the resident's discharge.
Cross reference F-F755.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Cove Care Center
1445 Superior Avenue Newport Beach, CA 92663
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident 3's Current Weights and Vitals dated 6/11/25, showed Resident 3's blood pressure was 142/86 mmHg.
Further review of Resident 3's medical record showed the blood pressure reading on 6/11/25, was the only reading obtained for Resident 3.
According to the National Library of Medicine Website, a normal blood pressure reading is usually 120/80 mmHg.
Readings above 140/90 mmHg are categorized high blood pressure level 2.
Review of Resident 3's H&P examination dated 6/12/25, showed Resident 3's diagnoses included PTSD, anxiety, and high blood pressure.
Review of Resident 3's Order Summary Report showed the following orders:dated 6/12/25, Verapamil Extended Release oral tablet 120 mg, give one tablet by mouth two times a day for high blood pressure.
Hold if the SBP greater than 110 mmHg.- dated 6/12/25, Verapamil oral tablet 120 mg, give 120 mg by mouth in the afternoon for hypertension.
Review of Resident 3's MAR for June 2025 failed to show the Verapamil medication was administered on 6/12/25.
Further review of Resident 3's medical record failed to show documented evidence the resident's physician was notified of the blood pressure reading of 142/86 mmHg on 6/11/25, and the Verapamil medication not administered on 6/12/25.
On 10/8/25 at 1551 hours, an interview and concurrent closed medical record review was conducted with LVN 2. LVN 2 verified Resident 3's blood pressure on 6/11/25 was 142/86 mmHg.
When asked if Resident 3's blood pressure was taken again or if Resident 3's physician was notified of the above normal blood pressure, LVN 2 verified Resident 3's blood pressure was not retaken or rechecked. On 10/10/25 at 1027 hours, a telephone interview was conducted with the DON.
The DON verified there was no documented evidence to show Resident 3's physician was notified of Resident 3's blood pressure on 6/11/25.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Cove Care Center
1445 Superior Avenue Newport Beach, CA 92663
SUMMARY STATEMENT OF DEFICIENCIES
the Roxicodone and oxycodone medications were included in Resident 4's medical record.
The Medical Records Director verified these sheets were not on file and verified the findings.
minimal harm
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Cove Care Center
1445 Superior Avenue Newport Beach, CA 92663
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and facility P&P review, the facility failed to ensure infection control practices were maintained for one of eight sampled residents (Resident 2) reviewed for infection control. * LVN 1's shoe was touching Resident 2's suprapubic catheter urine drainage bag. * LVN 1 failed to perform hand hygiene after removing dirty gloves and before putting on clean gloves. * Resident 2's suprapubic catheter urine drainage bag was touching the floor.
These failures had the potential for cross-contamination and spread of infectious organisms in the facility.Findings:
Review of the facility's P&P titled Handwashing/Hand Hygiene dated 2021 showed hand hygiene was to be performed after touching a resident, after removing a used glove, and before applying a clean glove.
Review of the facility's P&P titled Catheter Care, Urinary dated 2001 showed under infection control, catheter tubing must be kept off the floor. On 10/7/25, at 1400 hours, an observation of urinary catheter care and concurrent interview was conducted with LVN 1.
During the catheter care observation, Resident 2's suprapubic catheter urine drainage bag was observed touching the floor.
Additionally, LVN 1's right shoe was touching Resident 1's suprapubic catheter urine drainage bag. LVN 1 removed the dirty gloves after cleaning Resident 2's suprapubic catheter surgical site and then put on a clean pair of gloves without performing hand hygiene.
LVN 1 acknowledged Resident 2's urine drainage bag should not be touching the floor and verified he did not perform hand hygiene in between changing his gloves.
Facility ID: