Ocean Park Healthcare

Inspectors wroteBased on interview and record review, the facility failed to report an unusual occurrence to the state survey agency (SSA) within 24 hours for one of two sampled residents (Resident 1), who was diagnosed with a right humerus fracture and right scapular fracture one month after falling on 4/12/2026. Resident 1 continued to have pain weeks after the fall and an magnetic resonance imaging (MRI - a non-invasive scan that uses a giant magnet and radio waves to take 3D pictures inside of the body) completed on 5/5/2026 (3 weeks after the fall) indicated Resident 1 had a right nondisplaced humeral fracture and a right nondisplaced scapular fracture. This deficient practice had the potential to result in a delay of an investigation by the SSA to determine if abuse or neglect had occurred for Resident 1.

Inspectors wroteBased on interview and record review and interview, the facility staff failed to promptly check the magnetic resonance imaging (MRI-a noninvasive medical test that uses a strong magnetic field, radio waves, and a computer to produce detailed, cross-sectional images of the body's internal organs, tissues, and skeletal system) scan results and immediately notify the ordering physician of the MRI scan results for one (1) of two sample residents (Resident 1). On 4/12/2026 Resident 1 suffered an unwitnessed fall and complained of pain to the right shoulder pain., Xray completed at a general acute care hospital (GACH) showed no fracture/s. On 5/5/2026, Resident 1's MRI scan results indicated Resident 1 had suffered right humerus (is the long bone located in the upper arm) and scapula (shoulder blade) fractures (broken bones). The MRI results were emailed the facility on 5/11/2026 at 1:34 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an effective discharge with a safe and orderly discharge planning for one of three sampled residents, (Resident 1) by failing to:1. Implement the facility's policy and procedures (P&P), titled, Transfer or Discharge, Facility-Initiated to ensure Resident 1's discharge criteria was met with required orientation and documentation as specified in the policy. 2. Ensure a post-discharge plan was developed, documented and reviewed in discharge summary/post discharge plan of care at least 24 hours before resident's discharge or transfer from the facility. These deficient practices placed residents in an unsafe and ineffective discharge.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one out of three sampled residents (Resident 1), who has a diagnosis of dysphagia (difficulty swallowing), was provided with nutritional and hydration care and services consistent with resident's comprehensive assessment by failing to:Ensure Resident 1 was closely monitored and evaluated when Resident 1 refused to eat. Ensure Resident 1's weight was closely monitored according to Resident 1's comprehensive care plan. Ensure Registered Dietitian (RD-is a credentialed, regulated healthcare professional authorized to provide medical nutrition therapy, counselling, and and evidence-based dietary planning to threat disease) followed-up when Resident 1 refused to eat. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the nursing staff met the skills and staff competency evaluation requirements. This deficient practice had the potential for knowledge, training, and certification deficit among the nursing staff, leading to inadequate or delayed care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual nursing hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for three of three sampled days (5/2/2025, 5/3/2025, and 5/4/2025). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedures for medication storage by failing to ensure proper disposal expired medical supplies from intravenous (IV, a method of administering fluids, medications, or nutrients directly into a vein) medication cart by failing to disposed of: 1. One StatLock catheter stabilization device (device that adheres to the skin where the tubing of the catheter is locked in preventing accidental removal), 2. Nine (9) StatLock PICC (Peripherally Inserted Central Catheter, a long, thin tube inserted into a vein in the arm and threaded upwards through the vein into a larger vein near the heart) Plus catheter stabilization devices (device the adheres to the skin locking in the PICC tubing preventing accidental removal), and 3. Four (4) IV start kits (contains items for starting an IV line). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure proper sanitation and food handling practices by failing to ensure: 1. Juice gun (also known as a bar gun, is a device used to dispense various types of carbonated and non-carbonated drinks, including juices) tubing was free of grime build up, 2. Two bulk juices were not labeled with use by dates and, 3. One dry food scoop was being stored on top of a dry food bin in the dry food storage room. This deficient practice had the potential to result in unsafe food management, and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one out of three sampled residents (Resident 10) was free from physical restraint by failing to ensure the use of bed siderails and geriatric chair with lap tray informed consent was completed per individualized assessment. This deficient practice violated resident's right to be treated with respect and dignity with the use of physical restraints.

Inspectors wroteBased on observation, and interview, the facility failed to maintain a clean, odor-free, well-kept environment for one of five sampled residents (Resident 1), by failing to ensure the resident's room and adjacent hallway were odor free. This failure resulted in a foul-smelling environment in Resident 1's room and the adjacent hallway.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of three sampled residents reviewed for restraints (Residents 3 and 10) were free from physical restraint by: A. Failing to ensure the physician's order for bed siderails was in place and geriatric chair (geri chair - a large, padded, often wheeled chair designed to help seniors or individuals with limited mobility) with lap tray were properly assessed and evaluated for Resident 10. B. Resident 3 was observed with a geri chair parked alongside Resident 3 while she was in bed that restricted the resident's movement. These deficient practices had the potential to result in entrapment and injury with the use of restraints for Residents 3 and 10.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' notice of proposed transfer/discharge notification was sent to the Office of the State Long-Term Care Ombudsman (public advocate) on a timely manner for one of three sampled discharged residents reviewed (Resident 39) as indicated in the facility's policy. This deficient practice had the potential to deny Resident 39's protection from being inappropriately discharged .

Inspectors wroteBased on interviews and record review, the facility failed to ensure the assessment entries were accurate for one of one sampled resident reviewed for resident's assessment (Resident 12) by failing to appropriately assess residents' diagnosis in the Minimum Data Set (MDS - resident assessment tool). This deficient practice had the potential to result in a negative effect on residents' plan of care and delivery of services.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Pre-admission Screening Resident Review level II (a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) was obtained and maintained in the residents chart for two of three sampled residents (Residents 1 and 25). This deficient practice had the potential to negatively affect the appropriate care and services rendered to Residents.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of 12 sampled residents (Resident 10) by failing to develop a comprehensive (CP) with the use of bilateral bed siderails for Resident 10. This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality of care for one of three sampled residents reviewed for behavior, (Resident 12 ) by failing to ensure failed to ensure the assessment entries were accurate for one of three sampled residents (Resident 12) by failing to appropriately assess residents' diagnosis in the Minimum Data Set (MDS - resident assessment tool). This deficient practice had the potential to result in a negative effect on residents' plan of care and delivery of services.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure that the resident was safe during mobility using a geri chair (a large, padded, often wheeled chair designed to help seniors or individuals with limited mobility) for one of two sampled residents (Resident 25). This deficient practice had the potential to cause harm/injury and possible hospitalization for Resident 25.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure that the resident's feet did drag on the floor during mobility using a geri chair (a large, padded, often wheeled chair designed to help seniors or individuals with limited mobility) for one of two sampled residents (Resident 25). This deficient practice had the potential to cause harm/injury and possible hospitalization for Resident 25.

Inspectors wroteBased on interview and record review, the facility failed ensure the medical record for two of five sampled residents (Residents 32 and 40) was accurate and compete for: 1. Resident 32's Advance Directive Acknowledgement form was filled out completely, 2. Resident 40's Physician's progress note was accurately dated. This failure resulted in an incomplete and inaccurate forms in the medical record and had the potential to effect the delivery of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 11 out of 12 rooms met the 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) was free from significant medication errors by failing to transcribe all prescribed medications. The facility failed to transcribe apixaban/Eliquis (an anticoagulant or blood thinner medication used to prevent blood clots to prevent stroke and harmful blood clots in the blood vessels) which was part of Resident 1 ' s General Acute Care Hospital (GACH) physician transfer orders. This deficient practice resulted in Resident 1 missing the mediation doses as prescribed and had the potential to a serious harm to the resident causing blood clots that can lead to life threatening complications. Cross Reference: F842.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) medical record was complete and accurate by failing to transcribe the prescribed medication apixaban/Eliquis (an anticoagulant or blood thinner medication used to prevent blood clots to prevent stroke and harmful blood clots in the blood vessels) which was part of Resident 1 ' s General Acute Care Hospital (GACH) physician transfer orders. This deficient practice resulted in Resident 1's medical record to be incomplete and inaccurate. Cross Reference: F760.

Inspectors wroteBased on interview and record review, for one of five sampled resident (Resident 1), Resident 1 who fell in the facility on 1/15/2025, the facility failed to ensure: 1) Certified Nurse's Aide (CNA) 2, closely monitored and supervised Resident 1 while assigned as Resident 1's one to one (1:1- a caregiver provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) sitter on 3/02/2025 on the 11 PM to 7 AM shift. 2) CNA 2 immediately notified a licensed nurse that Resident 1 fell on 3/03/2025 at 4:30 AM to ensure timely assessment and intervention(s) for the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three (Resident 2) received care and support through informed, deliberative decision making that promote respect for the values, needs, and interests through bioethics committee (crucial advisors, assisting with ethical decision-making in complex situations) by serving as decision makers on behalf of Resident 2 and providing psychoactive medication without consent. This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately separate residents after a report allegation of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled Abuse, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Revised 4/2021, by failing to protect resident from possible further abuse for a resident-to-resident altercation. This deficient practice had the potential to place Resident 1 at risk for further elder abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Certified Nursing Assistants (CNA 6 and CNA 5) carried out activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) services and implemented interventions in accordance with the resident's assessed needs for one of three sampled residents (Resident 1) per facility's policy and procedure (P&P). This deficient practice resulted in Resident 1's toileting, bathing needs not being met, which could negatively affect the resident's health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 who required maximal assistance with repositioning had been turned and repositioned according to the resident's care plan (CP). 2. Ensure Resident 1 who was incontinent of bladder had been kept clean to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) to the extent possible and prevent skin injury. These deficient practices resulted to failure in the delivery of necessary care and services including repositioning and incontinence care for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to permit Resident 1 to return back to Skilled Nursing Facility 1 (SNF 1) from a general acute care hospital (GACH) for one of three sampled residents (Resident 1). As a resulted, GACH transferred Resident 1 to SNF 2 which was not the resident's preference.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for vision for one of two sampled residents (Resident 32). This deficient practice resulted in Resident 32's decline in activities of daily living (ADL - activities related to personal care such as bathing or showering, dressing, getting in and out of bed or chair, walking, using the toilet, and eating) and enjoying hobbies including watching television (TV), and socializing with the other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 32) received proper treatment and assistive devices to maintain vision abilities. Resident 32 has been missing corrective (prescription) eyeglasses since 03/18/2024. This deficient practice resulted in Resident 32's decline in physical and psychosocial needs, as the resident was not able to enjoy hobbies including reading, watching television (TV), and socializing with the other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two training records years (2022) on mandated reporter on abuse, was completed. Facility failed to validate that training documentation on mandated reporter on abuse by facility's staff was completed in 2022. This deficient practice had the potential for staff members not to understand/be educated/be informed on the rights of the resident and the responsibilities of a facility to properly care for its residents regarding mandated reporter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its' policy titled, Care Plans, Comprehensive Person-Centered by failing to ensure the floor mat was in place for one of three sampled residents (Resident 2) who assessed as a high risk for falls. This deficient practice resulted in Resident 2 having multiple falls in the last three months and episodes of rolling or sliding out of bed, when not monitored closely.

Inspectors wroteBased on observations, interviews, and record revies the facility failed to provide necessary services to maintain good personal hygiene and grooming to 4 out of 7 sampled residents (Resident 1, 3, 6, and 7), by failing to provide scheduled showers. This deficient practice placed Residents 1, 3, 6, and7 at risk for skin infections, skin breakdown, and poor self-perception.

Inspectors wroteBased on observation, interview, and record review that facility failed to obtain an order and initiate a care plan for a pressure sensitive alarm while on bed to alert staff when the resident gets up unassisted for one of one sampled resident (Resident 1). This deficient practice could have resulted in inappropriate care and treatment for Resident 1.

Inspectors wroteBased on observation, interview, and record review that facility failed to obtain an order and initiate a care plan for a pressure sensitive alarm (An alarm designed to alert the caregiver when the resident gets out of bed) while on bed to alert staff when the resident gets up unassisted for one of two sampled residents (Resident 1). This deficient practice could have resulted in inappropriate and delayed care and treatment for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff supervised and did not leave a resident unattended in the restroom and develop a plan of care for one of three sampled residents (Resident 1). Resident 1 was a high risk for fall, needed a walker (Walking frame- is a device that gives support to maintain balance or stability while walking) for mobility. Resident 1 had cognitive impairment (When a person starts to have problems with their memory or thinking). As a result, Resident 1 experienced unwitnessed fall on 12/30/2023. Resident 1 experienced a change in condition (COC- A sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. [...]

Inspectors wroteBased on interview, and record review, the facility failed to meet professional standards of quality for one of five sample residents (Resident 1) by failing to monitor and document Resident 1 ' s blood pressure while administering nifedipine (medication to treat high blood pressure and chest pain) to Resident 1 according to physician ' s order. These deficient practices had the potential to result in unintended complications related to the management of blood pressure such as hypotension (abnormally low blood pressure) and can lead to falls and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policies on Administering Medications, Documentation of Medication Administration, and Resident Rights to one of three sampled residents (Resident 4) by failing to: 1. Ensure Resident 4 was informed and educated on what medications she was taking. 2. Ensure proper medication administration documentation was performed for Resident 4. These deficient practices violated Resident 4 ' s right to know about her care and treatment and had the potential for Resident 4 to miss her medication.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan on risk for falls after a fall for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were updated to indicate that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) information was provided and discussed residents and/or responsible parties for four of19 sampled residents (Residents 1, 33, 84 and 235). These deficient practices violated the rights of Residents 1, 33, 84, and 235 and/or their representatives to be fully informed of the option to formulate advance directives and had the potential for conflict with the Residents 1, 33, 84 and 235 health care wishes.

Inspectors wroteBased on interview and record review, the facility failed to Develop and implement a person-centered care plan for anti-depressant Medication to treat depression [a mood disorder that causes persistent feeling of sadness and loss of interest], anti-anxiety (medication to treat/reduce anxiety [intense, persistent worry and fear], and sedative [medication to aid with sleep] medications for two of two sampled residents (Residents 24 and 33) These deficient practices had the potential for Residents 24 and 33 to not receive/benefit from necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased an interview and record review, the facility failed to ensure that a Registered Nurse (RN) was designated to work onsite in Facility 1 for at least eight consecutive hours a day, 7 days a week, and was not shared between two sister facilities for 41 of 41 in house residents. This deficient practice had the potential for the facility to not manage, oversee nursing services and, deliver high-quality and effective health care services to achieve positive clinical outcomes, and resident/family satisfaction for 41 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide portion sizes as indicated on the menu for residents on mechanical soft and pureed diet as indicated on the menu. This deficient practice had the potential for inadequate and or over adaequate protein and caloric intake for residents on mechanical soft and pureed diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at appetizing temperatures and as recommended per facility's policy and procedures. This deficient practice had the potential to result in decreased food intake for residents who eat at the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure Certified Nurse Assistants 2 and 4 ( CNAs 2 and 4) performed hand hygiene before and after direct contact with Resident 185, and before and after distributing residents' meal. These deficient practices had the potential to spread infection and food borne illness from staff to among residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA 1) did not stand when feeding two of two sampled residents (Residents 1 and 31). This deficient practice violated the right to be treated with dignity and respect, enhance the quality of life and individuality, and had the potential to compromise the safety of Residents 1 and 31.

Inspectors wroteBased on observation, interview, and record review, for one of one sampled resident (Resident 22), the facility failed to: Ensure bilateral (one each side) full side rails were not pulled up while Resident 22 was in bed Obtain physician's order to use bilateral full bed side rails for Resident 22 Conduct Interdisciplinary Team (IDT-A team of primary care providers, specialist, and professionals who plan, coordinate, and deliver a person's health care) assessment for Resident 22. These deficient practices resulted in physical restraint (any manual method, physical or mechanical device, equipment, or material, that is attached or adjacent to the resident's body; and cannot be removed easily by the resident) and had the potential to result in entrapment (state of being caught in), injury, and or death for Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and care, based upon current standards of practice and the resident's care plan for the prevention of a urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) to the fullest extent possible for Resident 185 This deficient practice had the potential to result in UTI for Resident 185

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) immediately and accurately documented Ativan (sedative medication that can relieve anxiety) medication on the Controlled Medication Count sheet (CMCS-accountability record log record for medications considered to have strong potential for abuse) after administration to one sampled resident. This deficient practice increases the risks medication diversion (transfer of a medication from legal to an illegal use) and delayed Ativan refill for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that: 1. Unopened insulin (medication to treat high blood sugar) vials and pens were refrigerated. 2. Opened fluphenazine (anti-psychotic medication) vial, ketoconazole (anti-fungal medication) 2% cream, nystatin-triamcinolone (anti-fungal and yeast medication) cream and Lotrisone (anti-fungal medication) cream was labeled with date. 3. Ointments and creams were placed separated with the oral medications in the medication cart. 4. Temperature logs for medication and specimen fridge were monitored and recorded twice daily per facility policy. These deficient practices had the potential to compromise the safety and effectiveness of medications, resulting in possible medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Direct Care Service Hours Per Patient Day (DHPPD) staffing information posted was updated with the actual hours daily for each shift and signed by the Director of Nursing or designee for four of four sampled days (1/24/2022, 1/25/2022, 1/26/2022 and 1/27/2022) per facility's policy and procedures and All Facilities Letter (AFL) 21-11. This deficient practice had the potential to prevent residents and visitors from knowing the number of staff available for direct resident care and residents' needs to go unmet.