The Pavilion at Ocean Point

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide meatal care (cleaning the area where a urinary catheter [a flexible tube inserted into the bladder to drain urine] enters the body [the meatus] daily using mild soap and water to prevent infections) for four (Resident 3, Resident 4, Resident 6, & Resident 12) of five sampled residents with urinary catheters. This failure had the potential for residents with urinary catheters to not to get assessed and/or cleaned appropriately and could lead to nonfunctional catheters and/or urinary tract infections (an infection caused by bacteria entering the kidneys, bladder, ureters, and urethra) and/or sepsis (your body's extreme, life-threatening response to an infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor intake, initiate weekly weights and implement timely interventions to address significant weight loss for 1 of 3 residents (116) reviewed for nutritional status. This failure resulted in a significant decline in Resident 116's weight from 141.8 pounds (lbs.) in December 2025 to 112.6 lbs. by February 2026.

Inspectors wroteBased on interview and record review, the facility failed to ensure that sufficient staff were available to provide care and services to the residents in a timely manner. As a result, there was a delay in the staff's ability to provide care and services to the resident.

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify areas of improvement and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), the facility's staffing needs identified during the facility's recertification survey and in the Payroll-Based Journal (PBJ- a mandatory , electronic reporting system which tracked hours worked, staff turnover, tenure and census data for long-term care facilities). Cross reference F725 This failure had the potential to affect resident care.

Inspectors wroteBased on observation, interview and record review, the facility failed to use professional nursing standards using when licensed nurse (LN) 23 did not administer Resident 10's medication via gastronomy tube (G-tube - a soft, flexible tube placed directly into the stomach through a small opening in the belly) by gravity (a technique where liquid medication is allowed to flow solely by the force of gravity and not by a syringe plunger or a pump). This failure had the potential to increase the risk of tube clogging, dislodgement, and medication reflux for Resident 10. Per the admission record, Resident 10's was admitted to the facility on [DATE] with diagnoses that included gastrostomy status (means a person has a G-tube placed directly into their stomach through the skin of the belly, creating a permanent or temporary opening for feeding, fluids, and medicine). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, care plan, and implement interventions to address severe hair matting and hygiene refusals for 1 of 2 sampled residents (116). This failure resulted in Resident 116 having severely matted hair with scalp irritation and had the potential to result in further skin breakdown and infection. Resident 116 was admitted to the facility on [DATE] with a diagnosis of anxiety and major depression per the facility admission record. During an observation and interview on 2/24/26 at 10:12 A.M., Resident 116 was observed sitting up in bed. The resident's gray hair was tightly matted across the top and back of the scalp. Yellow crusted material and flaking were present on the right forehead at the hairline. Skin discoloration and red splotching were present on the right and left cheeks. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice when: 1. Insulin injection sites were not rotated for two of six residents (Resident 7 and Resident 16), 2. The facility failed to reassess the vital signs of one of eight sampled residents (Resident 126). This deficient practice had the potential for residents to develop complications such as hardened, scarred skin and unpredictable insulin absorption. In addition, this failure had the potential for Resident 126's condition to decline without proper interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, document, and implement interventions to address contractures affecting the left index and left little fingers for 1 of 2 residents (17) reviewed for mobility limitations. This failure had the potential to result in worsening contractures decreased functional use of Resident 17's left hand. Resident 17 was admitted to the facility on [DATE] with a diagnosis Parkinson's disease (progressive movement disorder of nervous system that causes stiffness and tremors) per the facility admission record. During an observation and interview on 2/24/26 at 11:27 A.M., Resident 17 was observed seated in a wheelchair, propelling down the hallway with his feet. The resident's right hand appeared severely contracted at the wrist. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident (Resident 15) reviewed for dialysis (the process of removing toxic substances from the blood via machine when a person's kidneys no long function adequately) care, received care and treatment that followed the physician's orders and/or the residents' plan of care when fluid restriction was not followed. This deficient practice placed Resident 15 at risk for fluid overload (excessive accumulation of fluid in the body's tissues) which may cause shortness of breath, swelling, rapid weight gain, high blood pressure, fatigue and heart failure.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure two of two residents (Resident 16 and 1) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 16 and Resident 1's diagnosis of post-traumatic stress disorder (PTSD- a disorder that may occur in people who have experienced or witnessed a traumatic event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify Resident 16's and Resident 1's possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a physician's order when licensed nurse (LN) 22 failed to administer a medication as ordered by a physician for a resident (98). This failure had the potential for ineffective medication efficacy (the ability to produce a desired or intended result). Per the admission Record, Resident 98 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disorder (COPD - a treatable lung disease that makes it difficult to breathe). A review of Resident 22's physician's orders indicated an order for Tiotropium Bromide inhaler (medication to treat COPD) - inhale 1 puff daily for COPD. On 2/26/26 at 11:40 A.M., a concurrent observation and interview was conducted with LN 22 during an inspection of medication storage cart (Med cart 5). [...]

Inspectors wroteBased on observation, interview record review, the facility failed to ensure food items were stored and labeled with contents, received dates, and use-by or expiration dates in the walk-in refrigerator, freezer, and dry storage areas for food prepared and served to residents. This failure had the potential to result in residents consuming expired or unidentified food products, increasing the risk of foodborne illness. During a kitchen observation on 2/24/26 at 8 A.M., the facility's walk in refrigerator was inspected. The following items in the refrigerator were found unlabeled with contents, a received date, or a use-by or expiration date: A. One small metal container covered in foil filled with a browned ground meat, unlabeled and undated. B. One small metal container covered in foil filled with a gelatinous tan substance, unlabeled and undated. C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS- a nursing assessment tool) for one of three sampled residents reviewed for MDS accuracy. (Resident 2) This deficient practice resulted in providing inaccurate information to the Federal database (information maintained by the federal government).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure four of seven residents were provided care in a manner that promoted dignity and respect when: 1. Staff did not answer Resident 1's call bell for seven hours;2. Resident 2 waited one hour to have his brief changed; 3. Resident 3 waited all night to have his brief changed; 4. Resident 4 waited one and a half hours for call light to be answered;5. Call light response was an issue verbalized by residents at theResident Council meetings for three consecutive months. These failures resulted in not ensuring residents' rights to be treated with respect and dignity, with the potential to cause psychosocial harm to the involved residents. In addition, this failure had the potential for residents who remained wet for an extended period to develop or worsening of bedsores and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was implemented related to falls for one of two residents reviewed for falls (Resident 1). As a result, Resident 1 was at risk for additional falls.

Inspectors wroteBased on interview and record review, the facility failed to implement strategies to prevent a resident from falling (Resident 1). As a result, Resident 1 sustained a fall with injury.

Inspectors wroteBased on interview and record review the facility failed to provide care in a respectful and dignified manner when an employee showed a soiled linen wipe with bowel movement to Resident 1's face. As a result, Resident 1 was disrespected and had the potential to decrease resident's self-worth.

Inspectors wroteBased on observation, interview and record review the facility did not ensure a TV (television) remote control was provided for 1 of 3 resident's (Resident 1) in a shared room. As a result, Resident 1 was upset and an altercation with another resident occurred/transpired.

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate discharge plan was implemented for 1 of 2 sampled residents (Resident 1) when: Resident 1 was transferred from the skilled nursing facility to a general acute care hospital (GACH) and denied readmission to the skilled nursing facility (SNF) when the GACH medically cleared the resident for return. As a result, Resident 1 did not receive an appropriate discharge notice that included the reasons for the discharge, notification to responsible parties and the right to appeal the discharge decision.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices when the facility: 1.) Did not consistently check water temperature or test the water for germs. 2.) A personal belonging was on top of a clean bed that was intended for a new resident admission. 3.) Licensed Nurses (LNs) did not perform hand hygiene after administering medications between residents (16, 60). These failures had the potential to spread germs and placed residents at risk for infections.

Inspectors wroteBased on interview and record reviews, the facility failed to obtain an informed consent for one of three sampled residents (18), reviewed for unnecessary medication. This failure had the potential for the resident to not be aware of the risks and benefits of taking psychotropic (chemicals which altered brain function) medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (221) had a POLST (physician orders for life sustaining treatment, end of life wishes) signed by the Responsible Party (RP). As a result, there was a potential to not have the resident's end of life wishes honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of six sampled residents (108) when there was a large opening observed in the wall under the sink. This failure had the potential for the resident to feel uncomfortable in their environment.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of discharge to one of three sampled discharged residents (109). As a result, Resident 109 was not fully informed of his discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of the facility's bed-hold policy at the time of discharge to one of three sampled discharged residents (109). As a result, Resident 109 was not fully informed of his bed-hold rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was properly documented in the Minimum Data Set (MDS, resident assessment tool), for one of 24 sampled residents (88). As a result, medical decisions based on the MDS had an increased risk for error.

Inspectors wroteBased on interview and record review, the facility failed to complete the PASARR (Preadmission Screening and Resident Review, a federal requirement to help ensure individuals are not inappropriately placed in a nursing facility) II in a timely manner for one of three residents (67)sampled for PASARR. This failure had the potential to result in Resident 67's mental health needs to be unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed for psychotropic medication (chemical that alters the brain) for two (47, 105) of five residents reviewed for care plan implementation. This failure had the potential for Residents 47 and 105 's current psychotropic drug monitoring to not be communicated to all health care providers. Findings. 1) A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia (problems with reasoning, planning, judgement, memory, and other thought process) and Major Depressive Disorder (a serious mental disorder that affects how a person feels, thinks, and acts). An interview and record review on 10/23/24 at 9:27 A.M., with Licensed Nurse (LN) 1 was conducted. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine nail care to one of three residents (91) reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 91 was at risk for skin injury and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was delivered from the pharmacy in a timely manner for one of 24 sampled residents (88). As a result, Resident 88 did not receive ropinirole (a medication to treat restless leg syndrome [uncomfortable legs]) as ordered for three days.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three residents (47, 105) reviewed for psychotropics (a drug or other substance that affects how the brain works) had specific behavior monitoring in place for the use of psychotropic medications. This failure placed Resident 47 and Resident 105 at an increased risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent when three of 27 medications were not given as ordered by the physician. This failure had the potential for significant medication errors which could have caused residents to experience harmful side effects.

Inspectors wroteBased on observation and interview, the facility failed to ensure medication storage rooms were free from expired medical supplies when: 1. Expired needles and eyewash solutions were found in one of two medication storage rooms. 2. Expired needles were found in one of three medication carts. These failures had the potential to cause infection if the expired items were used on residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of one sampled kitchen staff (Cook 12) properly tested the kitchen disinfectants. As a result, the disinfectant may not have been at the proper strength to disinfect surfaces.

Inspectors wroteBased on observation and interview, the facility failed to ensure frozen meat was thawed appropriately during one of two sampled observations of thawing meat. As a result, there was an increased risk of food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure arbitration agreements (a legal contract) were signed by the Responsible Party (RP) for two of three residents sampled for arbitration agreements (67, 171). As a result, Resident 67 and Resident 171 entered into a legal agreement when they did not have the ability to understand what they were signing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food preparation area was free of insects for one of one sampled kitchens. As a result, there was an increased risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control policies when Certified Nursing Assistant (CNA) 1 and CNA 3 did not wear appropriate personal protective equipment (PPE - gown and gloves) when providing care to one of two residents (Resident 2) who was on Enhanced Barrier Precaution (EBP - a type of precaution indicating the need for PPE when providing care to a resident). This failure had the potential to result in the spread of multidrug-resistant organisms (MDRO - microorganisms, mainly bacteria, that are highly resistant to many types of antibiotics) among the residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable temperature environment for five of seven residents (Residents 3, 4, 5, 6, and 7) interviewed during an air conditioning (AC) malfunction. In addition, the facility failed to document and maintain a temperature log as a proactive maintenance tool. As a result, temperatures were not checked during the AC failure. These failures had the potential to affect the resident ' s comfort, health, and physical well-being related to the building ' s warm internal temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a maintain a hazard free environment when: 1. Liquids (shampoo, body wash, and shaving cream containers) were unsecured in two of three resident showers (west/east hallway and west/south hallway) 2. A red sharps container (a one-way device that contains needles and other sharp devices) was unsecured, and over-flowing with blue used razors, in one of three showers rooms (west/east hall) 3. Water was leaking from an adjacent wall in the west/east hallway, next to the east nursing station. These failures had the potential for confused residents to ingest shampoo, body wash, lotions, shaving cream and to have access to used razors, along with potential for slipping on the wet floor.

Inspectors wroteBased on observation and interview, the facility failed to secure one of two medication carts (cart north), one of two treatment carts (cart north), and one of one intravenous (IV) cart all stored on the east unit, reviewed for safe medication storage. As a result, residents, visitors, and staff had access to unauthorized medications and IV needles.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for one of two resident ' s (Resident 1) for repeated refusals of care and Activities of Daily Living (ADL- basic daily care such as bathing, dressing, brushing teeth, and combing hair). This failure had the potential to result in miscommunication of necessary care, and inconsistent care that could result in delayed wound healing and infections for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide routine showers and/or bed baths to one of two residents (Resident 1) reviewed for Activities of Daily Living (ADL-basic daily care such as bathing, dressing, brushing teeth, and combing hair). As a result, Resident 1 was at risk for skin infections and skin injuries.

Inspectors wroteBased on interview and record review, the facility failed to provide wound treatments as ordered for one of seven residents (Resident 1). As a result, Resident 1 had the potential for delayed healing and worsening of wounds.

Inspectors wroteBased on interview and record review, the facility failed to safeguard one resident's (1) protected health information (PHI). As a result, Resident 1's protected health information was disclosed without a proper authorization.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for two residents (1, 2). Resident 1 was administered Ativan (medication to relieve anxiety) 0.5 milligrams (mg) more times than what the physician ordered. For Resident 2, Cefazolin (medication to treat an infection) 2 grams (gm) was ordered to be administered intravenously (IV; method of administering medication into a vein), every eight hours, but was not administered on four separate times as the IV therapy was ordered. These failures had the potential to affect Resident 1 and Resident 2's well-being and health.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop and implement a baseline nutrition care plan within 48 hours of admission for one reviewed resident (Resident 1) during a complaint investigation. This had the potential for weight loss and a decline in health status due to poor meal intake.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive discharge care plan was completed for one of three sampled discharged residents (Resident 2). This failure had the potential to compromise Resident 2 ' s safety on discharge and delay post-discharge care for Resident 2 ' s ongoing health care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication orders for two of 3 sampled residents (Resident 1 and Resident 2) were administered as ordered. This failure had the potential to affect Resident 1 and Resident 2's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received an anticonvulsant medication (used to treat epilepsy [seizures]; burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements) as ordered by the physician. This failure had the potential for Resident 1 to experience life threatening seizure complications such as increased seizure activity, head trauma, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) was free from physical abuse when activity aid (AA) 1 did not de-escalate and manage Resident 1 ' s inappropriate behavior during a bingo game. As a result, Resident 2 reacted to Resident 1 ' s inappropriate behavior by punching Resident 1 in the face (Cross reference F-656).

Inspectors wroteBased on interview and record review, the facility failed to implement one resident ' s (Resident 1) written care plan interventions to address and de-escalate the resident ' s aggressive behavior. As a result, Resident 1 continued to behave aggressively during a bingo game and was punched in the face by Resident 2 (Cross reference F600).

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a bariatric geriatric chair (geri-chair; a supportive recliner designed to provide more substantial support and comfort than a traditional wheelchair; bariatric geri-chairs are constructed to provide more room and are typically utilized for residents with high body mass index scores) was available for 1 (Resident #42) of 1 resident reviewed for accommodation of needs.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to provide a homelike environment that was well maintained in 4 (Rooms 301, 309, 312, and 314) of 54 resident rooms.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to refer a resident with a newly evident or possible serious mental disorder for a Level II Preadmission Screening and Resident Review (PASARR) for 1 (Resident #83) of 6 sampled residents reviewed for PASARR requirements. This had the potential to cause the resident to not obtain the specialized mental health services needed for quality of life.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to identify major mental illness diagnoses on Level I Preadmission Screening and Resident Reviews (PASARRs) completed on admission for 2 (Resident #62 and Resident #98) of 6 residents reviewed for PASARRs.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #87) of 1 sampled resident reviewed for hospice services, medical record contained pertinent documentation regarding the delivery of hospice care/services.

Inspectors wroteBased on observations, interviews, record review, and review of the Centers for Disease Control and Prevention (CDC) guidance provided by the facility, the facility failed to ensure staff removed their personal protective equipment (PPE) before they left the room of 1 (Resident #28) of 27 residents who tested positive for Coronavirus disease 2019 (COVID-19) during the survey.

Inspectors wroteBased on interview and record review, the facility failed to maintain pharmaceutical clinical records in accordance with accepted professional standards of practices for two of three sampled residents (Resident 1 and Resident 2) when; 1. Schedule II medications (a class of drugs with a high potential for substance abuse) were signed out of a medication cart by licensed nurse (LN) 1 and LN 2 but were not documented as given to Resident 1 in the medication administration record (MAR, a record used to document medication administration). 2. The number of Schedule II tablets documented as removed from the medication cart was different than the total number of Schedule II tablets documented as administered in the MAR. 3. The facility was not able to provide evidence of a controlled substance record for Schedule II medications documented as administered in the MAR. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that all residents were kept safe from hazards when a treatment cart was left unlocked and unattended inside the facility and the external perimeter of the facility property was found to have numerous safety hazards. In addition, the facility did not correctly assess and create care plan risks for residents who smoke and apply personalized strategies for smoking risks (Resident 17, 8, 11, 13, and 4). These failures had the potential for residents to be placed at risk for hazards and could result in inconsistent staff oversight for smoking safety, and inconvenienced other residents in their free use of common areas.

Inspectors wroteBased on observation, interview, and record review the facility failed to contain the spread of COVID-19 infection between staff and residents. This failure allowed an outbreak to occur which affected 59 people who became positive for COVID-19 as of 9/4/23.

Inspectors wroteBased on observation and interview the facility failed to ensure residents were treated with respect and dignity by staff when one resident (Resident 8) expressed concerns, one resident (Resident 14) requested assistance from staff, and other staff and residents overheard personal care concerns for one resident (Resident 12). This failure had the potential for residents to be fearful of making requests and their rights violated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 3 sampled residents (Resident 1, Resident 2 & Resident 3) were not provided a meal or drink substitute of their preference when: Resident 1 & Resident 2 did not receive their preferred choice of soy milk with their meal. Resident 3 received chicken and gravy instead of fish for lunch instead of his documented preference of a hamburger. This deficient practice did not accommodate Resident's 1, 2 & 3's food preferences and placed them at risk of altered nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform a Responsible Party (RP) for one of one sampled residents, (Resident 1) of a change in antipsychotic (a type of prescription psychiatric medication) medication order. This failure violated the rights of Resident 1's RP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to create a comprehensive person-centered care plan for two of two sampled residents (2, 3) reviewed for psychotropic medication care plan. This failure had the potential to not identify and meet the needs of two residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document an appropriate reason for prescribing an antipsychotic medication for two of three sampled residents (1,2). This failure had the potential to harm Resident 1 and 2.