Oceanview Post Acute

Inspectors wroteBased on interviews and record review, the facility failed to ensure three out of 13 sampled residents (Resident 30, Resident 9, and Resident 10) are free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 30 received Depakote (it can be used to treat mood disorders, such as manic episodes in bipolar disorder, as well as seizures and migraines.) without target behavior monitoring, and there was no side effect monitoring. 2. Resident 9 received Trazodone (anti-depressant medication) without monitoring for number of hours of sleep. 3. Resident 10 received Depakote without target behavior monitoring. These failures had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical mental and psychosocial well-being. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure palatability of cooked foods were maintained when five of forty-six facility residents (Residents 7, 32, 4, 41 and 46), receiving food from the kitchen, complained that the food had no taste or tasted bland (lacking taste or flavor) as verified during the test tray meal tasting. This failure of decreased food palatability or no taste could lead to decreased food consumption by residents which could result in decreased nutrient intake for the forty-six facility residents getting foods from the kitchen.1. During an interview on 12/08/2025 at 12:03 p.m., with Resident 7 inside the room, Resident 7 stated the food taste is horrible. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored and prepared in accordance with professional standards for food safety when there were unsanitary baking equipment in the kitchen. This failure had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the forty-six residents who received foods from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that they maintain the documentation records related to the staffs' coronavirus disease 2019 (COVID-19, an infectious disease caused by the SARS-CoV-2 virus or severe acute respiratory syndrome coronavirus 2) vaccinations for seven out of seven facility staffs reviewed when these staffs did not have records on file regarding their COVID-19 vaccination status. This failure had the potential to jeopardize the health and safety of the staffs and the forty-six residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 33) completed a Level II Mental Health Evaluation as part of the pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). This failure had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions.

Inspectors wroteBased on interview and record review, the facility failed to develop care plan for two of 13 sampled residents (Resident 30 and Resident 10) when there was no care plan develop for Depakote black box warning (BBW, also known as a boxed warning, is the strongest warning the Food and Drug Administration [FDA-it is a federal agency responsible for protecting and promoting public health by regulating and supervising food safety, medications, medical devices, cosmetics, and other products] gives for prescription drugs). The failures had the potential for the residents not attaining their highest practicable physical, mental, and psychosocial well-being. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when there were no Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes.) signage posted and there was no available PPE (Personal Protective Equipment, refers to specialized gear like gloves, gowns, masks, and eye protection that creates a barrier to shield healthcare workers from infectious materials, preventing disease transmission to themselves, patients, and others by stopping contact with germs, blood, or body fluids) outside Resident 7's room. The failure had the potential to spread infections to residents, staff, and visitors. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 55) received the appropriate pneumococcal (infections caused by common bacteria that can affect different parts of the body) vaccination. This failure had the potential for residents to have inadequate immunity to pneumococcal infections (caused by bacteria, which can lead to illnesses such as pneumonia [infection in the lung] and meningitis [inflammation around the brain and spinal cord).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure multiple resident rooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive. The resident room measurements were as follows:Room Number/ Bed Capacity/ Square Feet Per Resident1 2 72.002 3 66.123 2 79.254 3 68.455 2 74.296 3 75.037 3 75.0310 3 74.2011 2 72.0012 2 72.0014 2 72.0017 4 69.7018 2 72.0019 2 72.0020 2 78.0022 3 76.00During the survey, residents were observed in their rooms. Nursing care and services were not impacted by the shortage of space. The closets and storage were sufficient to accommodate the needs of the residents. Residents were interviewed and stated they did not have any concerns regarding room size, provision of care, or privacy and they can easily navigate inside the room. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure continuity of care when staff did not provide a transportation driver instructions for dropping off a resident to an appointment for one of three sampled resident (Resident 1). This failure resulted in the resident not being met by a family member at the appointment location and resulted to fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure, they had designated an infection preventionist (IP) that had completed the specialized training in infection prevention and control when the facility did not have an IP with a completion certificate of infection prevention and control training. This failure had the potential for the facility programs and activities to prevent and control infections, not properly implemented that could affect the forty-eight residents currently residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal privacy were provided for three (Resident 1, Resident 2, and Resident 3) out of three sampled residents when privacy curtains were not provided. This failure had the potential to put residents in physical, social and emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety and proper monitoring of resident funds for one of three residents investigated, Resident 1, when Resident 1 lost money in his personal bank account. This failure had the potential to affect the resident's psychosocial and general well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident receive proper foot care and treatment for one of three residents investigated, Resident 2, when Resident 2 did not get an immediate appointment to see a podiatrist. This failure had the potential to affect the resident's foot condition, general health and well-being.

Inspectors wroteBased on an interview and record review the facility failed to ensure to follow their policy and procedure (P&P) for quality assurance and performance improvement (QAPI: a program to enhance the quality of care provided to residents in healthcare facilities) committee meeting attendees. This failure had the potential to result in to identify, monitor, implement and enhance the quality of facility wide system for infection prevention and control practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control practices when: 1. Wet wash cloth (a small,soft and absorbent cloth that used for washing face and body) on sink and dry wash cloth on the floor in bathroom; 2. Medical doctor (MD) did not use required contact precautions (used for infections, diseases, or germs that spread by touching residents or resident's environment) personal protective equipment (PPE: any piece of clothing or equipment that is worn by healthcare workers to mitigate contracting the infections between residents and staff); 3. Laundry aide did not use required contact precautions PPE. These failures had the potential to result in transmission of infection among residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals to their residents) quarterly care conference meeting arranged, conducted, and documented for two out of two sampled residents (Resident 1and 2). This failure had the potential for Resident/resident responsible party (RP: healthcare or financial decision maker for resident) to participate in the development and implement of person-centered plan of care decisions for Resident 1 and 2.

Inspectors wroteBased on an observation, interview and record review, the facility failed to ensure medications were administered as ordered by the medical doctor (MD) for 2 of 2 sampled Residents (Resident 1and 2). This failure had the potential to adversely affects the health and well- being of Resident 1 and 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to follow their policy and procedure (P&P) for activity assessments and preferred activities for one of two sample resident (Resident 1). This failure had the potential to affect to maintain and improve health, functional, cognitive, and emotional well-being for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 12% when three medication errors occurred out of 25 opportunities during the medication administration for two residents (Residents 98 and 41): 1. Licensed vocational nurse A (LVN A) did not give Resident 98 a medication as scheduled; 2. Licensed Vocational Nurse B (LVN B) did not give Resident 41 the full dose of two ordered medications. Also, LVN B crushed a medication for Resident 41 that cannot be crushed. These failures resulted in medications not given according to the physician's orders and had the potential for them not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen when: 1. An undated and unrefrigerated bottle of sauce was found in the dry storage area; 2. Six small packs of sliced apples were beyond the use date; and 3. Potato salad was undated. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure refuse (any disposable materials, which includes recyclable and non-recyclable materials) was disposed properly when garbage bags were not placed inside the garbage disposal bins, garbage bins were overflowing, and garbage bags were on the floor. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy for one of 12 residents (Resident 21) when his body was exposed to public view. This failure had the potential to cause emotional distress to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of post dialysis (a process that filters and purifies the blood using a machine and helps keep fluids and electrolytes in balance) assessments for one of one resident (Resident 19) when numerous post dialysis assessments were not documented. This failure had the potential to result in not identifying post dialysis complications which could affect Resident 19's health.

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis based on Staffing Data Report, Census and Direct Care Service Hours Per Patient Day (DHPPD, a form containing daily staffing information), submitted to Centers for Medicare & Medicaid Services (CMS) for the Fiscal Year (FY) Quarter 1 2024 (October 1 to December 31). This failure had the potential to affect resident's care, health, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate controlled substance (CS, medications that can be easily abused and are under strict government control) accountability for one out of 12 sampled residents (Resident 299), when a CS medication was signed out of the Controlled Drug Record (CDR, an inventory sheet) but was not documented on the Medication Administration Record (MAR) as given to Resident 299. This failure resulted in the facility not having accurate accountability of CS medication and potential for abuse or misuse of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when an expired medication was identified in one of two medication rooms and the temperature was not being monitored daily for two of two medication rooms and medication refrigerators.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection prevention and control policy and procedures when an uncovered nebulizer mouthpiece past its due date was found on Resident 40's bedside table. These failures had the potential for the residents to acquire infection.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure multiple resident rooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement interventions for fall care plan to prevent accidents for one of three sampled residents (Resident 1). The facility failed to initiate a fall care plan when Resident 1 was admitted with high fall risk and did not develop care plan for fall after subsequent falls at the facility. This failure resulted in Resident 1's fall with right wrist fracture (broken bone).

Inspectors wroteBased on observation and interview, the facility failed to ensure a home like environment for three of five sampled rooms (Room A, C, and E) when the floor was not maintained, and the sliding screen doors were off tract. These failures had the potential to place residents at risk for low self-esteem and at risk for insects to come into to resident's room.

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees undergo a criminal background check (process used to check for any previous convictions or claims of crimes, including abuse) prior to start of work for four of six randomly selected employees (Employee 1, 2, 3, and 4). This failure had the potential for the facility to hire employees with criminal backgrounds placing residents at risk for harm, abuse, and exploitation.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 8.57% when three medication errors occurred out of thirty opportunities during medication administration for three out of ten residents (Residents 41,17,29). These failures resulted in medications not given in accordance with the prescriber's orders and or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effects of the medication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There were white substances on the outside of the ice machine and black/brown substances on the inside of the ice machine; 2. The drainage pipe for the kitchen's food sink did not have an air gap (unobstructed vertical space) above the rim (top portion) of the floor drainage pipe. These failures had the potential to cause food contamination and spread illness to residents who received their food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to notify Res 13's responsible party (RP D) of interdiciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) care conference meetings to discuss the plan for Resident 13's well-being. This failure denies RP D the right to accept or deny any treatments or plans for Resident 13. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs were accommodated for one of four sampled residents (Resident 402) when the resident was not provided with a proper call light (a device to call help when needed) and a call light was not within reach. This failure had the potential to put residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the Ombudsman of transfer when Resident 53 was transferred/discharged to the hospital. This failure had the potential for unsafe discharge. Findings Resident 53 was admitted to the facility with diagnoses which included malignant neoplasm (cancer) of colon, pneumonia (infection), moderate protein-calorie malnutrition, and need for assistance with personal care. Resident 53 had been transferred to the hospital on 4/11/22. During a review of Resident 53's electronic record, a notice of transfer to the hospital was not located by surveyor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards for three of four sampled residents (Residents 9, 33, 402 and 48) when: 1. Resident 9's right arm was not elevated as ordered by the physician. 2. Staff did not develop resident-centered care plans regarding communication issues for Resident 33 and Resident 402. 3. The facility failed to monitor one of one residents (Resident 48) for signs and symptoms of bleeding related to the use of Clopidogrel Bisulfate (a blood thinning medications to prevent blood clots or stroke). These failures had the potential to negatively affect the residents' health, safety, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 9) receive proper foot treatment and care when Resident 9 did not received podiatrists (a medical doctor who specializes in treating the feet) referral. This failure had the potential to result to pain and discomfort for Resident 9.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide acceptable parameters of nutritional status when the registered dietician's (RD's) recommendations for nutritional supplements and a fortified diet (a kind of diet the foods with nutrients added to them) were not carried out for one of 5 sampled residents (Resident 18). This failure had the potential to contribute to the risk of further weight loss and decline in health status for Resident 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an ongoing assessment and oversight of the resident after dialysis treatments for one of two sampled residents (Resident 9) when licensed nurses did not provide hemodialysis (a medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) access site assessment and complete the post- assessment report upon resident's return from the dialysis center. These failures had the risk of causing Resident 9's health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled mediations (those with high potential for abuse and addiction) were fully accounted for when: 1. Random controlled medication use audit for one of three sampled residents' (Resident 46) routine pain medications did not reconcile. The medications were signed out of the Medication Administration Records (MAR) but not documented on the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps the record of the usage of controlled medications) to indicate they were given to the resident. 2. An insulin (medication to treat high sugar level in the blood) was not readily available from the emergency kit (E kit, emergency medication). [...]

Inspectors wrote5. Review of Resident 6's clinical record dated 9/4/20 indicated a diagnosis including anxiety disorder (excessive fear about everyday situations), major depressive disorder, and dementia. A review of the physician's order of Resident 6, dated 3/22/21, indicated Seroquel tablet (medication for major depressive disorder) 50 milligram one tablet by mouth in the afternoon and one tablet by mouth at bedtime. During a concurrent record review and interview on 6/9/22, at 2:00 p.m., with DON, she reviewed the last GDR conducted for Resident 6 and she stated that the facility did not have a signed GDR document from Resident 6s physician since 3/22/21. During a phone interview on 6/9/22, at 2:05 p.m., with pharmacy consultant (PC), she stated that she was not aware of a signed GDR document and she validated that the facility should keep records of a GDR. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication storage labeling and discarding of medications when: 1. Four expired medications were not removed from stock. 2. Two opened medications were not labeled. 3. One opened pneumococcal vaccine (medication to prevent pneumonia (Pneumonia an infection of the lungs) vial that was not stored in the refrigerator. The failures had the potential for residents to receive medications with reduced potency from expired medications, improperly stored medications, and/or medication errors due to medications not being labeled

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was disposed properly and a clean environment was maintained for the residents and visitors when garbage bags were not placed in garbage disposal bins located outside, a dumpster was overflowing, and a dumpster was left open. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a staff wore gloves in the hallway and worked on multiple tasks using the same gloved hands, staff also did not perform hand hygiene before and after entering resident rooms. These failures have the potential to result in the spread of infection and disease.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure multiple resident rooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.