Oceanside Rehabilitation and Nursing Center

Inspectors wroteBased on observation, record review and interview, the facility failed to follow the facility menus for three of the four observed meals on two of two units.

Inspectors wroteBased on interviews and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve palatability and are at appetizing temperatures on the Seaside Unit, [NAME] Unit, and for Residents eating in the dining room.

Inspectors wroteBased on observation and interview, the facility failed to properly follow food storage and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically:1. The facility failed to properly store food items in the kitchen and kitchenette to prevent the risk of foodborne illness.2. The failed to properly follow food handling and hand hygiene practices on the tray line to prevent the risk of foodborne illness in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a wound treatment was completed as ordered for one Resident (#4), out of a total of 17 sampled Residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing therapy services were provided for one Resident (#38) out of a total of 17 sampled Residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to serve what was listed on the menu or provide a substitution for two lunch meals. Specifically, on 6/8/25 the facility failed to serve sour cream with the baked potato during the lunch meal and on 6/9/25 the facility failed to add meat to the baked ziti according to the facility's recipe during the lunch meal.

Inspectors wroteBased on observations and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on two of two units.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure one Resident (#36) out of a total sample of 18 residents did not self-administer medication without an assessment or physician's order.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#27) out of sample of 18 residents. Specifically, for Resident #27, the facility failed to change oxygen tubing as indicated in the physician's orders and the facility failed to ensure staff consistently stored oxygen tubing in a sanitary manner when not in use.

Inspectors wroteBased on observation, record review and interview, the facility failed to consistently accommodate resident food allergies for one Resident (#26) out of a total sample of 18 residents. Specifically, for Resident #26 a. the facility failed to ensure the kitchen did not serve the Resident eggs which were listed as an allergy on his/her diet ticket, and eggs are served/offered 17 times during a 28 day menu cycle and b. the facility failed to consistently document food allergies in the medical record and on the diet ticket, including an allergy to peaches on his/her diet ticket which is offered as a dessert five times during a 28 day menu cycle.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to properly store food items to prevent the risk of foodborne illness and in accordance with professional standards for food service safety.

Inspectors wroteBased on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program.

Inspectors wroteBased on observations, interview and policy review, the facility failed to ensure that equipment in the kitchen was functioning properly. Specifically, the facility failed to ensure that a reach-in refrigerator was operating at the proper temperature while resident food was being stored inside of it.

Inspectors wroteBased on record review, interview and policy review, the facility failed to develop an individualized, comprehensive care plan for one Resident (#43) out of a total sample of 18 residents. Specifically, the facility failed to develop a comprehensive care plan for Resident #43 related to Type 2 Diabetes Mellitus .

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow professional standards of nursing practice for one Resident (#10) out of a total sample of 18 residents. Specifically, the facility failed to obtain a physician order for an air mattress prior to the resident using one.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for two dependent Residents (#44 and #32) out of a total sample of 18 residents. Specifically: 1. For Resident #44, the facility failed to ensure assistance was provided with bed mobility and eating as indicated in the plan of care. 2. For Resident #32, the facility failed to ensure supervision with meals was provided as indicated in the plan of care.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that one Resident (#13) received treatment and care in accordance with professional standards of practice out of a total sample of 18 residents. Specifically, for Resident #13 the facility failed to: 1a. Change the Residents' PICC (A peripherally inserted central catheter (PICC), is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) line dressing when the insertion site was unable to be visualized, 1b. Measure the PICC line on admission and with the dressing change on 7/10/24 as ordered, 2. Transcribe a new treatment order from the hospital discharge paperwork. Findings Include: [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the air mattress was set at the appropriate setting for one Resident (#44) with a stage 4 pressure ulcer out of a total sample of 18 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure accurate medical records for one Resident (#32) out of a total sample of 18 residents. Specifically, for Resident #32, the facility failed to accurately document the level of supervision received during meals. Findings Included: Resident #32 was admitted to the facility in February 2024 with diagnoses including dysarthria (poor articulation of words) following other cerebral vascular disease and dysphagia (difficulty swallowing). Review of Resident #32's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. [...]

Inspectors wroteBased on observations, policy review and interviews the facility failed to ensure nursing staff performed hand hygiene appropriately during the medication administration task.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia and was known by staff to wander the hallways and had exhibited exit seeking behaviors, the Facility failed to ensure that Resident #1 was provided with an adequate level of supervision in an effort to maintain his/her safety to prevent an elopement. On 02/15/24, at some point during the evening shift, unbeknownst to staff, Resident #1 exited the Facility, staff only became aware of the elopement after he/she was found outside by a staff member who was returning to the facility from a break, and saw him/her sitting on the pavement in the front parking lot. Resident #1 was brought back onto the facility, he/she was noted to be shivering as it was cold outside and was assessed to have abrasions on his/her toes.