Oceanview Nursing & Rehabilitation Care Center

Inspectors wroteBased on observation, record review, and interviews conducted during the abbreviated survey (NY00353729), the facility failed to ensure the resident was free of significant medication errors. This was evident for one (1) out of three (3) residents sampled (Resident #1). Specifically, on 09/06/2024, Licensed Practical Nurse #1 administered 150 milligrams of Methadone instead of 35 milligrams of Methadone to Resident #1. Resident #1 was alert and stable with no complaints of pain or discomfort and was escorted for scheduled hemodialysis therapy.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure maintenance services necessary to maintain a sanitary, orderly and comfortable interior were provided to the residents. This was evident during environmental observation. Specifically, resident rooms were observed with mismatched paint, uneven floor, and ripped door kick plate, mattress in disrepair, and broken side tables.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends for the quarter of July- September 2024 which was confirmed by a review of the Weekend Staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on observation, record review, and interviews during Recertification Survey conducted from 03/02/2025 to 03/07/2025 the facility did not ensure safe food storage was practiced. This was evident during Kitchen Observation. Specifically, outdated food items were observed in the kitchen refrigerator.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure the resident's right to be treated with respect and dignity was maintained. This was evident in 2 (Resident #32 and #40) of 23 total sampled residents. Specifically, 1.) Resident #32's urinary drainage bag was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible) and was visible from the hallway, and 2.) Licensed Practical Nurse #2 remained standing while feeding Resident #40.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident in 1 (Resident #41) of 2 residents reviewed for positioning / mobility out of 21 total sampled residents. Specifically, Resident #41 was observed multiple times without a left-hand roll in place as per physician's order.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a therapeutic diet was provided when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident in 1 (Resident #3) of 2 residents reviewed for Activities of Daily Living out of 23 total sampled residents. Specifically, Resident #3, who had a physician's order for thickened liquid, was observed drinking juice without a thickener.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 5 (Residents #6, #41, #48, #88, #92) of 5 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure the daily nurse staffing information included all the required information. This was evident during review of the Staffing Task. Specifically, the daily posting of nurse staffing information did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that the Medical Director consistently participated or attended the Quality Assurance & Performance Improvement (QAPI) meetings. Specifically, the Medical Director had not participated in 2 of the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings.

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case #NY00318543), the facility did not ensure a resident's rights to be free from involuntary seclusion. This was evident for one resident (Resident #1) of three residents reviewed. Specifically, on 07/06/23 at 12:45 AM, the Facility's Administrator observed Resident #1's room door was closed, and a plastic garbage bag was tied from the doorknob to the handrail in the hallway. Resident #1 was in the lock room. The Administrator initiated an investigation and reviewed the Facility's surveillance camera. The camera revealed that starting from 06/23/23, staff members used plastic garbage bags to keep Resident #1's room door locked. The staff members seen on the video were terminated. All staff were re-in-serviced on abuse, neglect, and mistreatment.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey the facility did not ensure an effective infection prevention and control program. This was evident during review of the Legionella Plan and the [NAME] Unit during Medication Administration. Specifically, 1) there were no remediation plan put in place after greater than 30 percent samples tested for legionella were positive, and 2) blood pressure (BP) cuffs were not disinfected after use between Resident #81, #69, and #87.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey of 10/2/23 through 10/11/23, 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 the Kitchen observation. Specifically, items were observed stored undated and with opened packaging, observation of staff not washing hands or changing gloves before handling food after entering and exiting the walk-in refrigerator, and staff were observed not wearing facial hair coverings.

Inspectors wroteBased on interview and record review, during the recertification survey 10/2/23 through 10/11/23, the facility did not ensure the individual financial record was made available to the resident and/or resident representative through quarterly statements. This was evident for 1 (Resident #61) of 2 residents reviewed for Personal Funds out of a sample of 25 residents. Specifically, there was no evidence quarterly statements were provided to a resident or their representative.

Inspectors wroteBased on observations, record review, and interviews during the Recertification survey conducted from 10/02/23 to 10/11/23, the facility did not ensure that a clean, comfortable, and homelike environment was provided to residents. Specifically, rusty brown color, dirty shower wall tiles, build up dirt in the bathroom tiles, were observed in resident's rooms, hallways, a urine odor in the common areas, debris on the floor, and a garbage bin overflowing. This was evident in multiple areas on the [NAME] Side unit.

Inspectors wroteBased on record review, observation, and staff interviews conducted during the Recertification survey of 10/2/23 through 10/11/23, the facility did not ensure that person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's concerns. This was evident for 1 of 4 residents (Resident #304) reviewed for Nutrition and 1 of 5 residents (Resident #36) reviewed for unnecessary medications, out of a sample of 25 total residents. Specifically, 1) a CCP was not developed for Resident #304 with liver cancer and hepatitis C, and 2) a CCP was not developed to address the care needs of Resident #36 with a Foley catheter.

Inspectors wroteBased on record review and interviews conducted during the Recertification and abbreviated survey of 10/2/23 through 10/11/23, the facility did not ensure that the comprehensive care plans (CCP) were reviewed and/or revised after each assessment and as needed. Specifically, a resident with a new order for a positioning device did not have their CCP updated for that intervention. This was evident for 1 of 1 (Resident #44) reviewed for limited range of motion (ROM).

Inspectors wroteBased on observation, record review and staff interview, during the Recertification survey , the facility did not ensure that residents who need respiratory care, including tracheostomy care and suctioning are provided such care including supplies, as consistent with current professional standards of practice, the comprehensive care plan and resident's goal and preferences. It was observed there was no extra tracheal cannula on the resident's bedside. Furthermore, available supplies had an expiration dated of 2005, 2018 and 01/2023 . This was evidenced in 1 of 1 resident investigated for respiratory care in a sample of 25. Resident #56. The finding is : [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification and Complaint survey conducted 10/02/2023 to 10/11/2023, the facility did not ensure the Director of Nursing (DNS) served as a charge nurse/Supervisor, only when the facility has an average daily occupancy of 60 or fewer residents. Specifically, there was documented evidence the DNS worked as a Nursing supervisor on multiple occasions when the facility had no registered Nurse assigned.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey conducted from 10/02/23 to 10/11/23,and complaint (NY00306641 ) survey, the facility did not ensure that a resident was free from financial abuse. This was evident for 1 of 3 residents reviewed for abuse in a sample of 25 (Resident # 155). Specifically, a resident complained that a staff borrowed money and has not paid back the loan. The finding is: The facility Policy and Procedure titled, Prohibition of Residents Abuse/Neglect and Misappropriation of Property with a revised date of 07/2023 documents, Residents have the right to be free from exploitation and misappropriation of property and neglect. [...]

Inspectors wroteBased on record review and interview during the Recertification and Complaint survey (NY 00306641) ,the facility did not ensure all alleged violations involving abuse, neglect , including misappropriation of property were reported in a timely manner to the Department of Health. This was evidenced in 1 of 5 residents reviewed for abuse in a sample of 25. (Resident #155) . Specifically, a resident complained that a staff member borrowed money and has not paid back the loan. The finding is : [...]

Inspectors wroteBased on observations, record review, and staff interview during the recertification survey, the facility did not ensure proper sanitation procedures were followed for the prevention of foodborne illnesses. Specifically, the low temperature dishwasher machine did not meet manufacturer's instructions and regulatory requirements with a wash temperature of 120- to 140- degrees Fahrenheit. The wash temperature on the dishwasher machine read 100- and 90-degrees Fahrenheit during two observations. This was evident during completion of the Kitchen task. The finding is: The facility policy and procedure titled, Low Temperature Dishwasher (Dated 05/15/2020) documented dishes will be sanitized at low temperature between 120- and 140-degrees Fahrenheit. [...]

Inspectors wroteBased on record reviews and interviews during the recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately to reflect the resident's status. Specifically, two (2) residents diagnoses were not accurately coded for mood disorder (Resident #34) and Schizophrenia (Resident #8), one (1) resident was inaccurately coded for having a mechanical ventilator (Resident #8), and one (1) resident was not accurately coded for receiving dialysis services (Resident #3). This was evident for 3 of 27 sampled residents investigated (Resident #3, #8, and #34).