Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 19 | 0 |
| Crystal Cove Care Center | 0.3 mi | — | 6 | 0 |
| Mesa Verde Post Acute Care Center | 0.8 mi | — | 24 | 0 |
| Victoria Healthcare And Rehabilitation Center | 1.9 mi | — | 0 | 0 |
| Newport Subacute Healthcare Center | 2.7 mi | — | 7 | 0 |
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