Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oceanview Post Acute during CMS and state inspections, most recent first.
Psychotropic medication monitoring was not documented for three residents. A resident receiving Depakote for mood disorder had no target behavior or side effect monitoring, another resident receiving trazodone for insomnia had no documented hours of sleep on the MAR, and a third resident receiving Depakote for mood disorder had no target behavior monitoring. The DON confirmed the missing monitoring during record review, and the facility policy required monitoring for adverse consequences and monthly behavior tallying.
Food Served Was Bland and Unpalatable: Multiple residents reported that meals tasted horrible, bland, or not good, including residents on regular, renal, and modified-texture diets. During test tray tasting, the KS and ADMIC verified that regular potatoes, carrots, rice, mashed potatoes, and pureed carrots were bland, and the rice was hard. The RD and DON acknowledged that foods served by the kitchen should be palatable and not bland.
Unsanitary baking pans were observed in the kitchen with blackish discolorations, brownish spots, and rusty areas. The KS acknowledged the pans were unsanitary and should have been replaced, and the RD verified they should not have remained in the kitchen or continued to be used. The facility policy required utensils and equipment to be kept clean, in good repair, and free from corrosion or other damage that could affect proper cleaning.
Missing COVID-19 Vaccination Documentation for Staff: The facility failed to maintain COVID-19 vaccination records for seven of seven staff files reviewed. The DSD confirmed there were no records showing staff vaccination status or documentation that they received education on the benefits and potential risks of the COVID-19 vaccine, and the DON verified the concern during interview.
PASRR Level II Evaluation Not Completed for a Resident with Bipolar Disorder. A resident with bipolar disorder had a positive PASRR Level I screen indicating the need for a Level II MH evaluation, but the evaluation was not completed. DHCS noted the evaluation was not scheduled because facility staff were unresponsive to repeated communication attempts, and Admissions/Marketing stated the case fell through the cracks.
Failure to develop care plans for Depakote BBW for two residents. One resident had COPD, HTN, and a Depakote order for mood disorder; another had depression, HTN, and a Depakote order for mood disorder. Review of both care plans showed no Depakote BBW care plan, and the DON confirmed the missing care plans during record review.
Missing EBP Signage and PPE Outside a Resident Room: Staff observed no EBP signage and no PPE cart outside a resident's room, despite physician orders for EBP due to wound-related MDRO risk. The resident had type 2 DM, bipolar disorder, and a chronic left hip NPCU, and the WN confirmed the absence of signage and PPE while the DON stated the resident needed enhanced barrier precautions.
Pneumococcal Vaccine Not Given per CDC Guidance: A resident with DM and a foot wound had consent on file for a pneumococcal vaccine and a history of PPSV23, but no documentation of any PCV. The MAR showed PPSV23 was given again, and the DSD confirmed it was administered because that was what the resident had been getting, despite CDC guidance indicating adults with only prior PPSV23 should receive a PCV.
Insufficient square footage was identified in multiple resident rooms after surveyors measured several rooms and found they were below the required 80 square feet per resident, with measurements ranging from 66.12 to 79.25 square feet. Residents were observed in their rooms and stated they had no concerns about room size, privacy, or care, and staff reported they were able to safely provide care despite the limited space. Closets and storage were noted to be sufficient for resident needs.
A resident with dementia and mobility limitations was transported to a medical appointment without an attendant or clear instructions to the driver. The resident was dropped off at the wrong location and left unsupervised, resulting in a fall and subsequent hospital evaluation. Staff interviews and documentation revealed no policy or communication protocol for ensuring safe transport of residents with cognitive and physical impairments.
The facility did not have a designated infection preventionist (IP) who had completed the required infection prevention and control training. Interviews with facility leadership and review of records confirmed that the current IP had not obtained the necessary certification, and no qualified IP had been in place since early February. This failure impacted the implementation of the infection prevention and control program for all residents.
Following an emergency relocation due to a car crash, three residents with dementia and anxiety disorders were placed in a Day Room without privacy curtains between beds or adequate window coverings, resulting in a lack of personal and medical privacy. Facility policy requiring respect for residents' private space was not followed.
A resident reported that a former business office manager took money from his bank account. The facility lacked a checks and balance system to protect resident funds, which was confirmed by the administrator and DON. The resident had moderately impaired cognition and was admitted with COPD, hypertension, and hyperlipidemia. The facility's policy on resident rights was not followed, resulting in the deficiency.
A resident did not receive timely podiatry care due to insurance coverage issues and administrative inaction. Despite having a referral order for a podiatrist, the resident's appointment was delayed for several months, leaving his toenails long and uncut. The facility's policies on physician services and referrals were not followed, leading to this deficiency.
The facility failed to include an Infection Preventionist (IP) in its QAPI meetings, as required by policy. The absence of the IP in meetings held in early 2024 was confirmed by the facility's staff, including the Director of Nursing and the administrator. This omission potentially impacted the facility's infection prevention and control practices.
The facility failed to maintain infection control practices, with a wet washcloth left on a sink and a dry one on the floor in a resident's bathroom. A medical doctor and a laundry aide did not follow contact precautions, entering a resident's room without the required PPE. Both staff members acknowledged their oversight, which was confirmed by the DON and facility policies.
The facility failed to conduct and document quarterly interdisciplinary team (IDT) care conferences for two residents. One resident, responsible for their own decision-making, and another with a family member as the responsible party, both lacked documentation of these meetings for three quarters. Interviews with the Director of Nursing (DON) and Social Service Director (SSD) confirmed the oversight, despite facility policies emphasizing the importance of involving residents and families in care planning.
Two residents did not receive medications as ordered due to unavailability and improper documentation. One resident with dementia missed multiple doses of quetiapine, while another with diabetes and hypertension did not receive tirzepatide and potassium chloride, and had incorrect documentation for rosuvastatin. The facility's DON confirmed the failure to follow up with the pharmacy and adhere to medication administration policies.
A facility failed to conduct quarterly activity assessments and provide preferred activities for a resident with schizoid personality disorder, depression, anxiety, and cerebral infarction. Despite the resident's preference for sitting outside, no activities were documented in June and July 2024. Observations and interviews confirmed the lack of facilitation of preferred activities, and the DON acknowledged the absence of assessments and documentation.
A long-term care facility had a 12% medication error rate during a review, involving two residents. One resident with COPD did not receive a scheduled dose of Dulera Inhalation Aerosol due to an oversight by an LVN. Another resident with liver cancer did not receive the full dose of OxyContin and lorazepam because the LVN crushed a controlled-release tablet, which should not be crushed, and some medication was lost. These actions were against the facility's medication administration policy.
The facility failed to maintain sanitary conditions in the kitchen, as an opened bottle of sauce was found undated and unrefrigerated, six packs of sliced apples were beyond their use date, and potato salad was undated. The Dietary Manager confirmed these observations, which were against the facility's food storage policies.
The facility failed to properly dispose of garbage, with bags of trash found on top of closed bins and on the floor, and some bins overflowing. This was confirmed by the Maintenance Director and Dietary Manager. The facility's policy and the FDA's Food Code require refuse to be stored in a manner inaccessible to pests, which was not followed.
A facility failed to ensure privacy for a resident when a nurse asked him to remove his sleeve for a blood pressure check, exposing his upper body to public view with the room door open and no privacy curtain. The resident felt exposed and preferred more privacy. The nurse acknowledged the oversight, and the facility's policy emphasizes protecting resident privacy during care.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, who received dialysis three times a week. The resident's records showed multiple instances of missing documentation. Interviews with staff confirmed the oversight, and the facility's policy required assessments to be documented upon the resident's return from dialysis.
The facility did not meet the required nursing staff levels, with CNA DHPPD falling below the mandated 2.4 hours and overall DHPPD below 3.5 hours on several occasions. The DON confirmed these deficiencies were due to staff call-ins and illnesses, failing to meet the minimum staffing requirements outlined in AFL 21-11.
A facility failed to maintain accurate controlled substance accountability for a resident when a dose of oxycodone was signed out but not documented as administered. A physician's order prescribed oxycodone for pain management, and a dose was removed from the Controlled Drug Record, but there was no documentation on the Medication Administration Record. A nurse confirmed the lack of documentation and absence of notes on whether the dose was refused or not given, contrary to facility policy.
The facility failed to store medications properly, with an expired Lorazepam found in a medication room. Additionally, temperature logs for medication rooms and refrigerators were incomplete, missing several days of recordings. The DON confirmed that temperatures should be recorded daily, highlighting a lapse in adherence to facility policies.
A facility failed to follow its infection control policy when an uncovered nebulizer mouthpiece, past its due date, was found on a resident's bedside table. An LVN confirmed the mouthpiece should have been changed weekly, as per the facility's policy, which requires equipment to be stored in a plastic bag with the resident's name and date, and changed every seven days.
The facility did not meet the requirement of providing at least 80 square feet per resident in multiple rooms, with some rooms measuring as low as 66.12 square feet per resident. Despite this, care and services were not impacted, and both residents and staff reported no issues with room size or care provision.
The facility failed to develop and implement a fall care plan for a high-risk resident, resulting in multiple falls and a right wrist fracture. Despite being identified as a fall risk upon admission, no interventions were put in place, and staff confirmed the lack of a care plan.
Psychotropic Medication Monitoring Not Documented
Penalty
Summary
The facility failed to ensure three sampled residents were free from unnecessary psychotropic medication use when required monitoring was not documented. Resident 30, who had diagnoses including COPD and essential hypertension, had an order for Depakote sprinkles 125 mg, two capsules at bedtime for mood disorder, but the Medication Administration Record did not show monitoring of target behavior for mood disorder and did not include side effect monitoring. During interview and record review, the DON confirmed there was no target behavior monitoring and no side effect monitoring for Resident 30's Depakote, and stated that psychotropic medication requires target behavior monitoring. Resident 9, who had diagnoses including COPD and essential hypertension, had an order for trazodone 50 mg in the evening for insomnia, but the MAR did not document the actual number of hours slept for the pm and night shifts since 9/18/25. During interview and record review, the DON confirmed the MAR did not include the number of hours of sleep and stated she would fix it to show the actual hours slept. Resident 10, who had diagnoses including depression and essential hypertension, had an order for Depakote sprinkles 125 mg, two capsules twice daily for mood disorder, but the MAR did not show target behavioral monitoring. The DON confirmed there was no behavior target monitoring prior to 12/11/25 and stated it was updated yesterday. The facility's Psychotropic Medication Use policy stated residents receiving psychotropic medications are monitored for adverse consequences and behavior is tallied/summarized at least monthly.
Food Served Was Bland and Unpalatable
Penalty
Summary
The facility failed to ensure that cooked foods were palatable and not bland for residents receiving meals from the kitchen. During interviews, five residents stated that the food tasted horrible, bland, or not good. Resident 7, who had diagnoses including type 2 diabetes mellitus and bipolar disorder and was on a regular texture, thin liquid diet, said the food taste was horrible. Resident 32, with essential hypertension and depression and ordered a regular diet with SB6 texture and thin liquids, said the food taste was not good. Resident 4, who had end stage renal disease and was ordered a renal diet with regular texture, thin liquids, no salt packet, and low phosphorus, stated that the food did not taste good or tasted bland, and that the cooked rice was hard and did not taste good. Resident 41, who had Parkinson's disease with dyskinesia and fluctuations and was on a regular diet with regular texture and thin liquids, said the food did not taste good or tasted bland at times. Resident 46, who had a principal diagnosis of nontraumatic intracerebral hemorrhage and was ordered a regular diet with no salt packet, stated that the food tasted horrible, did not taste good, or tasted bland. During test tray observation and tasting with the kitchen supervisor and administrator in-charge, regular potatoes and carrots did not have taste or tasted bland, and the rice was hard and tasted bland. On the second tray, mashed potatoes and pureed carrots also tasted bland. The kitchen supervisor and administrator in-charge verified these findings during the tasting, and the registered dietitian and director of nursing acknowledged that foods served by the kitchen should have been palatable and not bland. The facility policy stated that each resident is to be provided a nourishing, palatable, well-balanced diet that meets daily nutritional or special dietary needs and takes resident preferences into consideration.
Unsanitary Baking Pans Found in Kitchen
Penalty
Summary
Food items were not stored and prepared in accordance with professional food safety standards when four baking pans in the kitchen were observed with blackish discolorations, brownish spots, and rusty areas. During the kitchen tour, the kitchen supervisor acknowledged that the pans had brownish to blackish discolorations and rusty spots and stated they should have been replaced. The registered dietitian later verified that the unsanitary baking pans should not have remained in the kitchen or continued to be used. The facility policy titled Sanitation stated that utensils, counters, shelves, and equipment must be kept clean, maintained in good repair, and free from breaks, corrosions, open seams, cracks, and chipped areas that may affect use or proper cleaning.
Missing COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to maintain documentation records related to staff COVID-19 vaccinations for seven out of seven staff files reviewed. During a concurrent review of employee files with the DSD, records for CNA A, CNA B, CNA C, RN D, LVN E, the DOR, and the current facility administrator were checked, and the DSD acknowledged that there were no records on file showing their COVID-19 vaccination status or whether they had been provided education about the benefits and potential risks of the COVID-19 vaccine. During interview, the DON verified the concern and stated that the employee files would be updated with the COVID-19 vaccination records. The facility policy on Personnel Records states that the facility maintains certain records for each employee directly related to employment, and the CMS SOM Appendix PP guidance cited in the report states that staff COVID-19 vaccination documentation must include education provided, vaccine offer or information on obtaining the vaccine, and staff vaccination status and related information as indicated by NHSN.
PASRR Level II Evaluation Not Completed for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that one of 13 sampled residents, Resident 33, completed a Level II Mental Health Evaluation as part of the PASRR process. Resident 33’s clinical record showed diagnoses including bipolar disorder. Her PASRR Level I screening, dated 10/24/25, was positive and indicated that she should have a Level II Mental Health Evaluation. A letter from the California Department of Health Care Services, dated 10/29/25, stated that the Level II evaluation was not completed and was not scheduled because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. During an interview on 12/11/2025 at 1:44 p.m., Admissions/Marketing stated that Resident 33’s Level II evaluation “fell through the cracks.” The facility policy stated that new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders, and that the social worker is responsible for making referrals to the appropriate state-designated authority.
Failure to Develop Care Plans for Depakote BBW
Penalty
Summary
The facility failed to develop care plans for Depakote black box warning (BBW) for two sampled residents, Resident 30 and Resident 10. Resident 30’s record showed admission diagnoses of COPD and essential hypertension, and an order for Depakote sprinkles 125 mg, 2 capsules by mouth at bedtime for mood disorder. Review of Resident 30’s care plan showed no care plan developed for Depakote BBW. During interview and record review with the DON, the DON reviewed Resident 30’s care plan and stated she did not find the care plan for Depakote BBW, and that there should have been a care plan for boxed warning. Resident 10’s record showed admission diagnoses of depression and essential hypertension, and an order for Depakote sprinkles 125 mg, 2 capsules by mouth two times a day for mood disorder. Review of Resident 10’s care plan showed no care plan developed for Depakote BBW. During interview and record review with the DON, the DON reviewed Resident 10’s care plan and confirmed that there was no care plan from the prior day for Resident 10’s Depakote BBW. The facility policy titled Goals and Objectives, Care Plans stated that care plan goals and objectives are defined as the desired outcome for a specific resident problem and are entered on the resident’s care plan so all disciplines have access to the information and can report whether the desired outcomes are being achieved.
Missing EBP Signage and PPE Outside Resident Room
Penalty
Summary
The facility failed to ensure infection control practices were implemented when Enhanced Barrier Precaution (EBP) signage was not posted and PPE was not available outside Resident 7's room. During an observation on 12/10/2025 at 11:44 a.m., there was no EBP signage at the entrance door and no available PPE outside the room. Resident 7's clinical record showed diagnoses including type 2 diabetes mellitus without complications and bipolar disorder, unspecified. Resident 7 had a physician order dated 10/3/2025 for EBP due to risk of MDRO acquisition because of wounds, to be followed every shift. A later physician order dated 11/25/25 directed treatment for a left hip NPCU with cleansing, pat dry, and triad cream every day and evening shift. During a concurrent interview and record review on 12/11/2025 at 3:18 p.m., the Wound Nurse reviewed the orders and stated Resident 7 had an NPCU to the left hip and another wound on top of the wound on 12/9/25. During an observation outside the room on 12/11/2025 at 3:32 p.m., the Wound Nurse confirmed there was no EBP signage posted and no PPE cart outside the room. The DON stated Resident 7 had a chronic wound and needed enhanced barrier precautions, while the DSD stated EBP is for residents with pressure injury, blistering, and open skin.
Pneumococcal Vaccine Not Given per CDC Guidance
Penalty
Summary
The facility failed to ensure that one resident received the appropriate pneumococcal vaccination. Resident 55 was admitted with diagnoses including diabetes and a foot wound. His informed consent for pneumococcal vaccine, dated 12/3/25, showed he gave the facility permission to administer a pneumococcal vaccination. His immunization record showed a history of PPSV23 on 11/25/2014 and 3/23/2019, but there was no documentation that he received a pneumococcal conjugate vaccine (PCV). The medication administration record for 12/2025 showed Resident 55 received PPSV23 on 12/11/25 at 7:31 a.m. During a concurrent interview and record review, the DSD/Infection Preventionist confirmed the resident was [AGE] years old and had previously received PPSV23 on 11/25/2014 and 3/23/2019. The DSD stated the facility gave him PPSV23 again because that was what he had been getting and stated the facility followed CDC guidelines to determine which pneumococcal vaccine to give and at what age. The CDC guidance reviewed indicated adults 50 years or older who had never received a PCV should receive PCV15, PCV20, or PCV21, and adults 50 years or older who had only received PPSV23 should receive one dose of PCV15, PCV20, or PCV21 at least 1 year after the last PPSV23 dose.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
Multiple resident rooms did not meet the required square footage per resident. Surveyors observed and measured resident rooms and found that rooms 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 14, 17, 18, 19, 20, and 22 were below the minimum of 80 square feet per resident for multiple-occupancy rooms, with measurements ranging from 66.12 to 79.25 square feet per resident. During the survey, residents were observed in their rooms, and nursing care and services were not impacted by the shortage of space. Residents stated they had no concerns regarding room size, provision of care, or privacy and reported they could easily navigate inside the room. Staff stated they were able to safely provide care to residents even in rooms with less than 80 square feet per resident. The closets and storage were sufficient to accommodate resident needs.
Failure to Provide Adequate Supervision During Resident Transportation
Penalty
Summary
Facility staff failed to ensure continuity of care and adequate supervision for a resident with dementia and mobility issues during transportation to a medical appointment. The resident, who had a history of memory problems, severe difficulty in daily decision-making, and required a wheelchair for mobility, was sent to a physician's appointment without an attendant or specific instructions provided to the transportation driver. The transportation request form indicated no attendant was needed, despite the resident's inability to self-transfer or ambulate safely. Upon arrival at the appointment location, the resident was dropped off at the back of the building while a family member was waiting at the front, resulting in the resident being left unsupervised. As a result of this lack of supervision and miscommunication, the resident fell, rolling down a hill and sustaining a head injury before being found by a construction worker. The facility's records and staff interviews confirmed that no instructions were given to the driver regarding the resident's needs, and there was no policy in place for making transportation arrangements or addressing accidents during transport. The resident was subsequently transported to the emergency department, where no traumatic injury was found, but the after-visit summary emphasized the need for the resident to be escorted into buildings for future appointments.
Failure to Designate a Qualified Infection Preventionist with Required Training
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) who had completed the required specialized training in infection prevention and control. Multiple interviews with facility leadership, including the interim director of nursing, director of staff development, former administrator, and the current designated infection preventionist, confirmed that the individual currently serving as the IP had not completed or obtained a certificate for infection prevention and control training. Documentation provided by the acting administrator further indicated that there had been no IP with the required training or certification since early February 2025. The facility's own policy and procedures, as well as state guidance, require that the designated IP complete initial infection prevention and control training within 30 days of designation. Despite this, the current IP, who began working in the role in February 2025, had not yet completed the necessary training as of the time of the survey. This lapse affected the facility's ability to ensure that its infection prevention and control program was properly implemented for the forty-eight residents residing in the facility.
Failure to Provide Resident Privacy After Emergency Relocation
Penalty
Summary
The facility failed to provide personal privacy for three residents after a car crash rendered their original room unsafe to occupy. The residents, who had diagnoses including dementia, anxiety disorders, and cognitive impairments, were relocated to the Day Room due to a lack of available beds or rooms. In the Day Room, three beds were set up for the residents, but there were no privacy curtains between them. Additionally, thin drapes only partially covered the windows to the outside street, and a large uncovered window allowed visibility from the lobby, reception, and visitor areas into the room where the residents were housed. Observations and interviews confirmed that the residents remained in this arrangement without privacy curtains, and their personal and medical privacy was not maintained as required. Facility policy states that residents' private space and property are to be respected at all times, but this was not upheld during the period following the incident. The lack of privacy measures had the potential to cause physical, social, and emotional distress to the affected residents.
Failure to Safeguard Resident Funds
Penalty
Summary
The facility failed to ensure the safety and proper monitoring of resident funds, specifically for one resident who lost money from his personal bank account. During an observation and interview, the resident, who was alert and verbally responsive, reported that the previous business office manager had taken money from his account. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, hypertension, and hyperlipidemia, and had a BIMS score indicating moderately impaired cognition. The facility's investigation confirmed that the business office manager was arrested by police, and the facility had forwarded the resident's account information to law enforcement. Interviews with the facility's administrator and director of nursing revealed that the facility lacked a checks and balance system for business office practices to safeguard resident funds. Both the administrator and the director of nursing acknowledged that resident funds should be protected and that the absence of such a system contributed to the incident. The facility's policy on resident rights, which includes protection from misappropriation of property and exploitation, was not adhered to, leading to the deficiency.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to ensure that a resident received proper foot care and treatment, as evidenced by the resident not receiving an immediate appointment to see a podiatrist. The resident, who was calm, alert, oriented, and verbally responsive, expressed to the nursing staff a few months prior that he wanted to see a podiatrist for his toenails, which were long and uncut. Despite this request, the resident was not seen by a podiatrist until several months later. The delay in the resident's podiatry appointment was attributed to the fact that the service was not covered by the resident's insurance, and the previous administrator did not approve the facility to cover the cost. The resident had a referral order for an in-house podiatrist dated several months prior, but the appointment was not scheduled until much later. The facility's policies on physician services and referrals were not adhered to, resulting in the resident's delayed care.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to adhere to its policy and procedure for the Quality Assurance and Performance Improvement (QAPI) committee meetings by not ensuring the presence of an Infection Preventionist (IP) during the quarterly meetings. The QAPI Committee Minutes for meetings held on January 24, 2024, and April 24, 2024, lacked the signature of an IP under the list of attendees. This absence was confirmed during interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON), who both acknowledged that the IP or a designee did not attend these meetings. The facility's administrator also confirmed the absence of the IP's signature in the QAPI Committee Minutes and stated that the IP should have been present to discuss infection control concerns. The facility's policy, revised in March 2020, mandates that the IP is a required member of the QAPI committee. The failure to include the IP in these meetings potentially hindered the facility's ability to identify, monitor, and enhance infection prevention and control practices.
Infection Control Deficiencies in PPE Usage and Washcloth Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as observed during a survey. In one instance, a wet washcloth was found on a sink and a dry washcloth on the floor in a resident's bathroom. A certified nursing assistant confirmed that the washcloths were not handled according to infection control practices, as used washcloths should have been sent to the laundry for cleaning. Additionally, the facility's medical doctor and a laundry aide did not adhere to required contact precautions. The medical doctor entered a resident's room with only gloves, neglecting to wear a gown as required by the contact precautions posted outside the room. Similarly, the laundry aide entered a resident's room without wearing gloves and a gown, despite the contact precautions notice. Both staff members acknowledged their failure to follow the necessary precautions, which were confirmed by the director of nursing and supported by the facility's policy and procedure documents.
Failure to Conduct and Document Quarterly IDT Care Conferences
Penalty
Summary
The facility failed to ensure that interdisciplinary team (IDT) quarterly care conference meetings were arranged, conducted, and documented for two sampled residents. Resident 1, who was self-responsible for daily decision-making, had no documented evidence of quarterly IDT care conferences for three quarters. Similarly, Resident 2, whose significant family member was the responsible party, also lacked documentation of IDT care conferences for three consecutive quarters following their admission. Interviews with the facility's Director of Nursing (DON) and Social Service Director (SSD) confirmed the absence of quarterly IDT care plan meetings and documentation for the residents. The SSD acknowledged the facility's non-compliance and stated that the social service department was responsible for arranging and documenting these meetings. The facility's policy and procedure documents indicated the importance of involving residents and families in care planning, but these were not adhered to in the cases of Resident 1 and Resident 2.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the medical doctor for two residents. Resident 1, who was admitted with dementia and anxiety, had a physician's order for quetiapine, an antipsychotic medication, to be administered daily. However, the electronic medication administration record (EMAR) indicated that 19 out of 31 doses were not administered as documented by the code '9', which signifies 'Other/See Progress Notes'. This was due to the unavailability of the medication, as confirmed by the licensed vocational nurse (LVN) and the registered nurse (RN). Resident 2, admitted with diabetes type 2, hypertension, and atrial fibrillation, had orders for potassium chloride, tirzepatide, and rosuvastatin. The EMAR showed that rosuvastatin was documented as administered for six doses, but only four doses were actually given. Additionally, tirzepatide and potassium chloride were not administered at all due to the medications not being available. During an interview, Resident 2 confirmed not receiving the medications and was informed by the charge nurse that they were waiting for the pharmacy delivery. The facility's director of nursing (DON) confirmed that the medications were not administered as ordered and acknowledged that the licensed staff should have followed up with the pharmacy to ensure the availability of medications. The facility's policy and procedure for administering medications, revised in April 2019, requires medications to be administered according to prescriber orders and documented accurately, which was not adhered to in these cases.
Failure to Provide Preferred Activities and Conduct Assessments
Penalty
Summary
The facility failed to adhere to its policy and procedure for conducting activity assessments and providing preferred activities for a resident diagnosed with schizoid personality disorder, depression, anxiety, and cerebral infarction. The resident had not received activity assessments for four consecutive quarters, with the last assessment completed on June 25, 2023. Despite the resident's preference for sitting outside on the patio and conversing with staff and other residents, there was no documentation of these activities being provided in June and July 2024. Observations on July 5, 2024, revealed the resident sitting on their bed without any activities being offered. Interviews with the resident, a CNA, an LVN, and the DON confirmed that the resident's preferred activity of sitting outside was not being facilitated regularly. The DON acknowledged the lack of quarterly activity assessments and the absence of documentation for 1:1 room activities. The facility's policy, revised in June 2018, required activity evaluations to be conducted quarterly and used to develop an individualized activities care plan. However, due to a COVID-19 outbreak, only 1:1 room activities were being provided, and the resident's preferred activities were not being routinely offered.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility experienced a medication error rate of 12% during a medication administration review, with three errors occurring out of 25 opportunities. The first error involved a Licensed Vocational Nurse (LVN A) who failed to administer a scheduled dose of Dulera Inhalation Aerosol to a resident diagnosed with respiratory failure and chronic obstructive pulmonary disease (COPD). The medication was supposed to be given at 9 a.m., but the nurse did not administer it after the resident returned from the bathroom, despite having initially prepared it. The second and third errors involved another Licensed Vocational Nurse (LVN B) who did not administer the full dose of two medications to a resident with liver cell carcinoma. LVN B crushed an OxyContin CR tablet, which should not be crushed, and some of the medication was lost during the process. Additionally, the resident did not receive the full dose of lorazepam and OxyContin due to spillage. The facility's policy requires medications to be administered according to prescribers' orders, which was not followed in these instances.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. An opened bottle of sauce was found in the dry storage area without an open date, despite the label indicating it should be refrigerated after opening. The Dietary Manager confirmed the bottle was open and undated. Additionally, six small packs of sliced apples were found beyond their use date, and the Dietary Manager acknowledged they should have been discarded. Furthermore, eight pounds of potato salad were found open and undated, which was also confirmed by the Dietary Manager. The facility's policy and procedure titled 'Food Receiving and Storage' was reviewed and indicated that foods should be stored in compliance with safe food handling practices, including labeling and dating. The policy specified that dry foods should be labeled and dated, and refrigerated foods should be stored at or below 41 degrees Fahrenheit. The failure to adhere to these policies had the potential to cause food contamination and spread food-borne illness to residents receiving food from the kitchen.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. On two separate occasions, garbage disposal bins located in the facility's parking lot near the basement entrance were found with bags of trash placed on top of closed bins, and some bags were on the floor. Additionally, one bin was overflowing with a black plastic bag, and another bin's cover was open. These observations were confirmed by the Maintenance Director and Dietary Manager, who acknowledged that the garbage should not be on top of the bins or overflowing. The facility's policy and procedure for food-related garbage and refuse disposal, revised in October 2017, stated that garbage and refuse containing food wastes should be stored in a manner inaccessible to pests, and outside dumpsters should be kept free of surrounding litter. The United States Food and Drug Administration's 2022 Food Code also requires refuse to be stored in receptacles with tight-fitting lids to prevent access by insects and rodents. The facility's failure to adhere to these guidelines resulted in an environment that could potentially attract pests and spread diseases.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure privacy for Resident 21, leading to a deficiency in maintaining the resident's dignity and privacy. During an observation, Resident 21 was in his room with two roommates, wearing a long-sleeved shirt and sitting in a wheelchair. Licensed Vocational Nurse A asked Resident 21 to remove his sleeve to take his blood pressure, which resulted in his upper chest and abdomen being exposed to public view, including his roommates, as the door to the room was open and there was no privacy curtain in use. Resident 21 expressed feeling exposed and preferred to have privacy, such as having the door closed or being behind a privacy curtain. LVN A acknowledged during an interview that she should have closed the door when asking Resident 21 to remove his sleeve. The facility's policy on Quality of Life - Dignity, revised in February 2020, indicates that staff should promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure proper documentation of post-dialysis assessments for a resident with end-stage renal disease, who received dialysis at a dialysis center three times a week. The clinical records for this resident showed multiple instances where the post-dialysis assessment was not documented on specific dates. During interviews, a registered nurse and the director of nursing confirmed the missing documentation and acknowledged that nurses were expected to assess the resident's access site and complete the dialysis form upon the resident's return from dialysis. The facility's policy required a communication form to be initiated before sending residents to the dialysis center and for assessments to be documented upon their return.
Insufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on a 24-hour basis, as evidenced by the Staffing Data Report, Census, and Direct Care Service Hours Per Patient Day (DHPPD) submitted to CMS for the Fiscal Year Quarter 1 2024. The DHPPD for Certified Nursing Assistants (CNAs) fell below the required 2.4 hours on multiple dates between October and December 2023. Additionally, the overall DHPPD requirement of 3.5 hours was not met on several occasions. During an interview and record review, the Director of Nursing confirmed these deficiencies, attributing them to staff call-ins and illnesses. The All Facilities Letter (AFL) 21-11 mandates that the 3.5 DHPPD staffing requirement, with 2.4 hours by CNAs, is a minimum standard for Skilled Nursing Facilities (SNFs), and additional staff should be employed to meet patient needs.
Controlled Substance Accountability Failure
Penalty
Summary
The facility failed to ensure accurate accountability of controlled substances for one resident, Resident 299. A physician's order dated April 26, 2024, prescribed oxycodone, a controlled substance, for pain management to be administered as needed. On May 19, 2024, a dose of oxycodone was signed out from the Controlled Drug Record by licensed nursing staff, but there was no corresponding documentation on the Medication Administration Record indicating that the dose was administered to Resident 299. During an interview and record review on May 22, 2024, Registered Nurse D confirmed the absence of documentation for the administration of the oxycodone dose on May 19, 2024, and verified that there was no note indicating whether the dose was refused or not given. The facility's policy requires that the individual administering medication must document it on the MAR after administration and before the next medication is given.
Medication Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by the presence of an expired Lorazepam Oral Concentrate in one of the medication rooms. During an observation with an LVN, the expired medication was identified, and the LVN confirmed the expiration date. The facility's policy and procedures require that discontinued, outdated, or deteriorated drugs be returned to the dispensing pharmacy or destroyed, which was not adhered to in this instance. Additionally, the facility did not consistently monitor and record the temperatures of medication rooms and refrigerators. Temperature logs for two medication rooms were found to be incomplete, with several days missing temperature recordings. The DON acknowledged that the temperatures should have been recorded daily and confirmed the missing entries for March, April, and the current month. This lack of documentation indicates a failure to comply with the facility's requirement to complete temperature logs regularly.
Infection Control Breach with Nebulizer Equipment
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy and procedures when an uncovered nebulizer mouthpiece, which was past its due date, was found on Resident 40's bedside table. During an observation, it was noted that the nebulizer mouthpiece was exposed and had a date label of 5/9/24, indicating it was overdue for replacement. Licensed Vocational Nurse (LVN) C confirmed during an interview that the mouthpiece should have been changed weekly, as per the facility's policy. The facility's policy, titled 'Administering Medications through a Small Volume (Handheld) Nebulizer' dated October 2010, specifies that equipment should be stored in a plastic bag with the resident's name and date, and changed every seven days or according to facility protocol.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that multiple resident rooms met the required minimum of 80 square feet per resident. The survey revealed that several rooms, including those with two to four residents, had less than the mandated space per resident, with measurements ranging from 66.12 to 79.25 square feet per resident. Despite this deficiency, observations during the survey indicated that nursing care and services were not impacted by the shortage of space. Residents expressed no concerns regarding room size, care provision, or privacy, and staff reported being able to safely provide care even in the smaller rooms. The facility's closets and storage were deemed sufficient to meet residents' needs.
Failure to Implement Fall Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement interventions for a fall care plan to prevent accidents for one of the sampled residents. The resident was admitted with a high fall risk and had multiple diagnoses, including multiple fractures, head injury, and dementia. Despite being identified as a high fall risk upon admission, no fall risk care plan was developed, and subsequent falls occurred without any care plan interventions being implemented. The resident experienced multiple falls during their stay at the facility. On one occasion, the resident was found on the floor without injury, but no fall care plan interventions were developed. On another occasion, the resident was found sitting on the floor beside their bed, unable to describe what happened, and again, no fall care plan interventions were developed. The resident had another fall, resulting in a right wrist fracture, and was sent to the emergency room for evaluation and treatment. Interviews with facility staff confirmed that the resident was a fall risk upon admission and that no fall risk care plan was developed. Staff acknowledged the importance of developing and updating fall care plans to prevent further injuries. The facility's policy and procedure for managing falls and fall risk were not followed, as no interventions were implemented to prevent subsequent falls or address the risks of clinically significant consequences of falling.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 179 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pacific Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Hill Manor Health Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Canterbury Woods | 0.6 mi | ★★★★★ | 11 | 0 |
| Cypress Ridge Care Center | 1.8 mi | ★★★★★ | 4 | 0 |
| Monterey Post Acute | 1.9 mi | ★★★★★ | 4 | 0 |
| Westland House | 2.8 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.