Ocean Gardens Care Center

Inspectors wroteBased on observation, record review, and interviews during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident in one (1) (Resident #1) out of two (2) residents reviewed and sampled for abuse. Specifically, on 04/20/2026 at about 12:45 PM, in the resident's dining room, Resident #1 suddenly grabbed Certified Nursing Assistant #1's left breast when Certified Nursing Assistant #1 was feeding Resident #1. Certified Nursing Assistant #1 reacted to having her breast suddenly grabbed by pushed or slapped Resident #1's hand. Registered Nurse #1 and Certified Nursing Assistants # 2 were in the dining room and provided conflicting statements regarding if Resident #1 was slapped or Resident #1's hand was pushed away.

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility failed to ensure that a resident environment remained free of accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This was evident for one (1) out of five (5) residents (Resident #1) reviewed for accidents. Specifically, Resident #1 who requires two (2)-person assists for bed mobility and transfers, was observed on 02/28/2026 at 10:00 AM with a burn to their left thigh, which was later assessed as a second-degree full thickness burn. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteN.Y. Comp. Codes R. & Regs. Tit. 10 SS 713-1.3 - Nursing units(h) Resident bedrooms shall be designed and equipped for adequate nursing care, comfort and privacy of the residents and shall comply with the following:(1) Placement of residents' beds shall be such that a bed may be approached from at least one side and one end. No bed shall be closer than three feet to a window, radiator, or an adjacent bed. Based on interview and record review conducted during an abbreviated survey, it was determined that the facility failed to ensure compliance with the State and Local Laws. Specifically, resident equipment (bed) is not kept at a minimum of 3 feet from the radiator as referenced in N.Y. Comp. Codes R. & Regs. Tit. 10 713-1.3 - Nursing units. This resulted in harm to a single resident. [...]

Inspectors wroteBased on observation, record review, and interviews during a survey, the facility failed to ensure the Minimum Data Set assessments accurately reflected the resident's status. This was evident in one (1) out of four (4) residents (Resident #1) sampled. Specifically, Resident #1's Comprehensive Care Plan dated 02/03/2026 documented that Resident #1 required two (2) staff to assist them with bed mobility (roll left to right). The Minimum Data Set assessment dated [DATE] did not accurately reflected Resident #1's bed mobility status. The Minimum Data Set inaccurately coded Resident #1 as requiring Partial/Moderate assistance (Helper does less than half the effort).

Inspectors wroteNumber of residents sampled:Number of residents cited:Based on observation, record review, and interviews, the facility failed to ensure that necessary housekeeping and maintenance services were provided to maintain a safe, clean, comfortable and homelike environment for residents. This was evident for four (4) (3rd Floor, 4th floor, 5th floor, and 6th floor) of five (5) resident units observed. Specifically, an accumulation of dust, dirt, and stains were noted on bedside tables, intravenous poles, feeding pumps, oxygen concentrators and suction machines, torn arm rests and soiled wheelchairs were observed in resident rooms, and rust stains were observed in resident shower rooms.

Inspectors wroteNumber of residents sampled:Number of residents cited: Based on observation, interviews and record review, the facility failed to ensure infection control practices and procedures were maintained. This was evident for one (1) of five (5) units (Unit 3). Specifically, shared activity items including but not limited to, plastic building blocks, plastic crayon baskets, incomplete plastic egg toy were observed with brownish stains and an accumulation of dirt and debris. Based on observation, interviews and record review, the facility failed to ensure infection control practices and procedures were maintained. This was evident for one (1) of five (5) units (Unit 3). Specifically, shared activity items including but not limited to, plastic building blocks, plastic crayon baskets, incomplete plastic egg toy were observed with brownish stains and an accumulation of dirt and debris.

Inspectors wroteNumber of residents sampled:Number of residents cited:Based on observations and interviews, the facility did not ensure the physical environment was kept safe, sanitary, functional, and comfortable for residents, staff and the public. Specifically, the outer panels and top end corners of the nurse station was in disrepair, chairs in the nursing station were soiled and had torn bilateral arm rests. In addition, both elevators had graffiti on the walls. This was evident on four (4) of five (5) units (4th floor, 5th floor, 6th floor, and 3rd floor,). 1). During observation from 01/05/2026 to 01/12/2026 between 09:00 AM and 1:00 PM on Unit 4, the following were observed: a). The nursing station room was observed to have two (2) black chairs that were dusty and dirty and one (1) black chair had a large rip exposing brown colored padding. [...]

Inspectors wroteBased on observation, record review, and interviews during the abbreviated survey (607137), the facility did ensure it maintained an effective pest control program to keep the facility free from pests. This was evident on one (1) of sis (6) floors (Floor 1). Specifically, large and small live roaches were observed crawling from under the pushcart in the Recreation staff room on the 1st floor.

Inspectors wroteBased on record observation, record review and interviews conducted during the Recertification and Abbreviated Survey (Complaint #607115 and #2630760), the facility failed to ensure the resident and/or the resident's representative was immediately informed of an accident which resulted in an injury and/or hospitalization. This was evident for two (2) of two (2) residents (Resident #139 & Resident #242) reviewed for Notification of Change out of 38 total sampled residents. Specifically, 1). On 03/25/2024 at 09:30 PM, Resident #139 was found sitting on the floor with a laceration to the left eyebrow that required hospitalization. There was no documented evidence Resident #139's designated representative and/or next of kin was notified of the change in their condition, and 2). On 12/03/2025 at 03:09 PM, Resident #242 was noted with a skin opening to the left dorsal foot. [...]

Inspectors wroteNumber of residents sampled:1Number of residents cited:1 Based on observations, interviews, and record review, the facility failed to ensure that a resident remained free of physical restraints. This was evidenced for one (1) (Resident #9) of one (1) resident reviewed for Physical Restraints out of 38 total sampled residents. Specifically, on 01/07/2026, 01/08/26, and 01/09/2026, Resident #9 was observed seated in a wheelchair in the 3rd floor dining room, with a table in front of them and their back against the wall, and 2 chairs on either side of resident, preventing Resident #9 from moving around.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 2 Based on record review and interviews during the Recertification and Complaint (#2630760 and #607117), the facility failed to ensure all alleged violations involving abuse, neglect, or mistreatment including injuries of unknown origin are reported immediately, but not later than two (2) hours after the allegation is made to the State Survey Agency. This was evident for two (2) of five (5) residents reviewed for Abuse (Resident #126 & Resident #242) out of 38 total sampled residents. Specifically, 1.) On 4/12/2024 at 7:00 AM Resident #126 was observed with facial discoloration/redness to right and left eye and surrounding skin and redness/mild swelling to forehead and eyelids. Resident #126 was unable to explain the injury and the Administrator was first made aware of the incident at 9:00 AM. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00343684 and NY00337964), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse to the administrator of the facility and to other officials (including to the State Agency). This was evident for six (6) out of six (6) residents (Resident #2, #3, #4, # 5, #6 and Resident #7) sampled. Specifically, on 04/18/2024 at 5:50 AM, License Practical Nurse #2 saw Resident #3 wandered into Resident #2's room and sat on the bed. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00323497), the facility failed to protect a resident's right to be free from physical abuse by a nursing home staff. This was evident in one (1) out of three (3) residents (Resident #1) sampled for abuse. Specifically, on 09/07/2023 at approximately 2:15 PM the Occupational Therapist reported to the Director of Nursing that Resident #1 was observed in the dining room with a black eye. Resident #1 reported that they were punched in the eye by a crazy lady and identified Registered Charge Nurse #1 as the person who punched them in the eye on 09/06/2023 during the evening shift. Registered Charge Nurse #1 did not immediately assess Resident #1 after being told Resident was observed with discoloration to their eye.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 9/20/2023 to 9/27/2023, the facility did not ensure residents' right to send and receive mail. This was evident for 9 of 9 attendees (Resident #39, #151, #100, #181, #83, #185, #67, #96, and #147) of the Resident Council meeting conducted on 9/21/2023. Specifically, the facility did not have a system in place to ensure that residents could receive and send mail on Saturdays.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 09/20/23 to 09/27/23, the facility did not ensure that it was free of medication error rate of 5% or greater. This was evident for 2 of 35 medications observed during medication administration. Specifically, medications were not administered as ordered by the physician: 1) Metformin 500mg 1 tablet was administered instead of 2 tablets(1000mg), and 2) Amlodipine 5mg 1 tablet was administered instead of 2 tablets(10mg) to Resident #134, leading to a medication error rate of 5.69%.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey of 9/20/23 through 9/27/23, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during Kitchen observation. Specifically, 1) open produce was stored without a date in the freezer, boxes were stored directly on the freezer floor, and the mixer was observed soiled with grease and grime; and 2) the refrigerator temperature was observed above 41 degrees Fahrenheit (F).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 09/20/23 to 09/27/23, the facility did not ensure infection control practices and procedures were maintained. This was evident for 6 (Resident #171, #21, #38, 134, #191 and #173) of 38 total sampled residents. Specifically, Registered Nurse (RN) #7 was observed using the same Blood Pressure (BP) cuff with Resident #171, #21, #38, and #134 without cleaning and disinfecting the BP cuff in between each resident, and RN #3 was observed using the same the Blood sugar/glucose machine (Glucometer) with Resident #191 and #173 without cleaning and disinfecting the Glucometer in between each resident.

Inspectors wroteBased on observations, interviews, and record reviews during the Recertification/Complaint survey, the facility did not ensure that a resident was provided with appropriate treatment and services to maintain or improve their ability to ambulate. This was evident for 1 (Resident #129) of 4 residents reviewed for Activities of Daily Living (ADLs) out of 38 sampled residents investigated. Specifically, Resident #129 was not provided with floor ambulation program (FAP) as per Rehab assessments, and in accordance with physician's orders.

Inspectors wroteBased on record review and staff interview conducted during the Recertification/Complaint survey, the facility did not ensure that the resident and their representatives were provided with a written summary of the baseline care plan (BCP). This was evident for 3 (Residents #85, #164, and #176) of 38 total sampled residents. Specifically, 1) Resident #85 was not provided with a copy of their BCP, 2) Resident #164 was not provided with a copy of their BCP, and 3) Resident #176 was not provided with a copy of their BCP.

Inspectors wroteBased on observation, record review, and interview during the recertification and complaint survey from 9/20/2023 to 9/27/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 of 38 sampled residents (Residents # 32). Specifically, the MDS assessment for Resident # 32 did not reflect Tracheostomy care.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 9/20/2023 to 9/27/2023, the facility did not develop and implement a comprehensive person-centered care plan (CCP) for a resident. This was evident for 1 (Resident #194) of 38 total sampled residents. Specifically, a CCP related to pain was not developed for Resident #194.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification and Abbreviated (NY00314342) survey from 09/20/23 to 09/27/23, the facility did not ensure adequate supervision and an environment free from accident hazards for a resident. This was evident in 1 (Resident #166) out of 5 residents reviewed for accidents out of 35 total residents sampled. Specifically, Resident #166 was noted to be missing from Unit 2 and was found on Unit 3, which was a locked unit.

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification and complaint survey from 9/20/23 to 9/27/23, the facility did not ensure a resident was provided pain management consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 resident (Resident # 194) out of 3 residents reviewed for Pain Management out of 38 total sampled residents. Specifically, Resident # 194 received Tylenol pain medication without ongoing monitoring of the efficacy of the pain management.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure (1). safe food handling and storage was practiced to prevent food-borne illness, and (2). food was prepared, distributed, and served in accordance with professional standards of food service safety. Specifically, a container of Ricotta Cheese was not discarded on or before the expiration date and hand hygiene was not performed prior to handling food after picking an item up off the floor. This was evident during the Kitchen Observation facility task.

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, (a). 4 residents on oxygen/nebulizer treatment were observed with the tubing not properly labeled and dated to indicate the time the tubing was replaced, (b). 1 resident receiving oxygen therapy was observed with tubing touching the floor on multiple occasions, and (c). the facility did not have a functional site-specific water management plan for Legionella, an annual facility risk assessment for Legionella, a Legionella sampling plan, and the facility did not describe control measures and actions to be taken if control measures were not met. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification and Abbreviated survey, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 183 of 218 residents who maintained personal funds accounts at the facility.

Inspectors wroteBased on record review and staff interviews during the Recertification and Abbreviated survey, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 3 of 4 residents reviewed for Personal Funds out of a sample of 35 residents (Resident #46, #64, and #103).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Abbreviated survey, the facility did not develop and implement a comprehensive person-centered care plan for a resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, a Comprehensive Care Plan (CCP) that included measurable goals and objectives and interventions was not developed to address the resident's diagnoses of Urinary Tract Infection. This was evident for 1 of 2 residents reviewed for Urinary Catheter out of a total of 35 sampled residents. (Resident # 174) The finding is: [...]

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that a Comprehensive Care Plan (CCP) for a resident is reviewed and revised based on changing goals, preferences and needs of the resident. Specifically, the CCP for a resident with an Intravenous Peripherally Inserted Central Catheter (IV PICC) was not reviewed and revised after the catheter was re-inserted. This was evident for 1 of 2 residents reviewed for Infection/Transmission-Based Precautions out of a sample of 35 residents. (Resident #128).

Inspectors wroteBased on observation, record review and staff interviews during the Recertification and Abbreviated survey, the facility did not ensure that care and services are provided according to accepted standards of clinical practice. Specifically, the facility did not ensure that a resident with Intravenous Peripherally Inserted Central Catheter (IV PICC) line for antibiotic is provided with care and services to prevent further infection. This was evident for 1 of 2 residents reviewed for Infection/Transmission-Based Precautions out of a sample of 35 residents. (Resident #128).

Inspectors wroteBased on record review and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that irregularities identified by the pharmacist and forwarded to the facility were acted upon. Specifically, the facility failed to document in the resident's medical record that irregularities identified by the consultant pharmacist had been reviewed and what, if any, action has been taken to address the issues. This was evident for 1 out of 5 residents reviewed for Unnecessary Medications out of a sample of 35 residents. (Resident # 71) The finding is: Resident #71 was admitted to the facility 02/20/2018, with diagnoses that included Non-Alzheimer's Dementia, Seizure Disorder, and Psychotic Disorder. [...]

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification and Abbreviated survey, the facility did not ensure that medication and biologicals were discarded by expiration date. Specifically, a tube of Glucose gel was observed in a cabinet in the medication room past the expiration date. This was evident on 1 of 5 units reviewed for Medication Storage (Unit 6).