Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Oceanside Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Infection prevention and control failures were observed involving water management, EBP, TBP, and hand hygiene. The facility did not monitor hot water tank temperatures as outlined in its water management plan. Staff entered rooms of residents on EBP without the required gown during PICC and PEG-related care, and staff failed to follow contact and enteric precautions for residents with COVID-19, norovirus, and other contact precautions, including improper PPE use and incorrect hand hygiene. During wound care for a resident with pressure injuries, staff did not perform hand hygiene between glove changes and wound care steps as required by policy.
A resident received the wrong Fluticasone product during med pass when an LPN gave nasal spray instead of the ordered inhaler. In a separate issue, another resident with orders for daily weights related to edema and CHF had multiple missed weight entries on the MAR, with no documentation of refusal or provider notification.
Failure to provide ordered hand splint for a resident with limited ROM. A resident who had a stroke and could not move the RUE was observed with the right hand clenched in a fist and no splint or positioning device in the room. The care plan called for a splint or palm protector, but staff reported the resident did not currently have one, while other staff stated it should still be worn as ordered.
A resident with left spastic hemiplegia and contractures was supposed to receive PT/OT after Botox/Dysport injections, but therapy was not provided after the most recent injection. The care plan and consult both referenced therapy for ROM, standing, stretching, and bracing, and the Rehab Director confirmed the resident had not been seen by therapy after the consult.
The facility did not act on grievances from the Resident Council about inconsistent snack availability. Residents expressed concerns during a meeting, and interviews revealed ongoing issues with snack access, particularly at bedtime. One resident reported not receiving a snack when requested, and another noted that staff did not offer alternatives when a requested item was unavailable.
A facility failed to ensure timely physician review of a pharmacist's recommendation during a monthly Pharmacy Medication Regimen Review (MRR). A recommendation to adjust a resident's Gabapentin dosage was made, but the physician did not address it until over 30 days later, contrary to the facility's policy requiring action within 30 days.
The facility did not follow its smoking policy for a resident who was a smoker. The policy requires smoking assessments upon admission, quarterly, and with changes in condition. However, the resident's last assessment was in June, and a quarterly evaluation due in September was missed. This was confirmed by the DON.
A resident identified as an elopement risk left the facility through the front door, triggering an alarm that was deactivated by a recreational assistant without notifying other staff. The resident was later found at a gas station and taken to a hospital after visiting a fire station. The facility's elopement policy, which requires notifying a supervisor and activating a missing patient protocol, was not followed.
The facility failed to provide necessary treatment and services for two residents with pressure ulcers, lacking documentation of weekly assessments and treatment orders. One resident had no treatment orders for pressure injuries until four days after identification, and another resident experienced a 30-day gap between wound evaluations, contrary to facility policy.
A resident with a Stage 3 pressure injury received inadequate infection control during wound care. A nurse failed to disinfect scissors and a wound cleanser bottle, did not change gloves or perform hand hygiene between tasks, and placed contaminated items on a treatment cart without cleaning. The DON confirmed the expected protocols but could not provide a relevant policy.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to implement water management control measures for hot water tanks. The water management plan stated that hot water tanks should be at or above 140 degrees and that biofilm should be checked for, but it did not include a frequency for monitoring hot water tank temperatures. During interview, the maintenance director stated that the facility failed to monitor and document temperatures at the hot water tanks. The facility also failed to implement Enhanced Barrier Precautions for two residents. One resident had an active physician order and care plan for EBP related to a PICC line, and staff entered the room wearing a mask and gloves but without a gown while preparing and administering IV ampicillin through the PICC line. Another resident had an active physician order and care plan for EBP related to a PEG tube, and staff wore gloves and a mask but no gown while replacing the gauze dressing at the PEG tube insertion site. The facility failed to implement Transmission Based Precautions for three residents. One resident tested positive for COVID-19, had a special contact and droplet precautions sign posted, and a housekeeper cleaned the room and bathroom wearing only an N95 respirator, without gloves or a gown, and left without performing hand hygiene. Another resident had enteric contact precautions posted, but an RN left the room and used alcohol-based hand sanitizer instead of washing with soap and water. A third resident was on contact precautions during a norovirus outbreak, but staff entered the room without gown and gloves while giving morning medications, and later another RN entered wearing only a mask, stood close to the resident, assisted the resident back to bed, touched the resident’s back, and used alcohol-based hand rub before exiting. The facility further failed to perform hand hygiene and proper glove use during wound care for one resident with pressure injuries. During dressing changes to sacral and left heel wounds, staff wore gloves and a gown but did not perform hand hygiene when changing gloves between wound care steps, including removing dressings, cleansing wounds, applying treatment, and covering with new dressings. The resident had active physician orders for treatment of the sacral and left heel pressure injuries, and the facility’s wound dressing and hand hygiene policies required hand hygiene before and after glove use and between wound care steps.
Medication Error and Missing Daily Weight Documentation
Penalty
Summary
The facility failed to follow physician orders and medication administration instructions for two residents. During a medication administration observation, Resident #110 had an active order for Fluticasone Propionate 100 mcg/act inhaler to be given one puff orally twice daily, but the LPN obtained Fluticasone Propionate 50 mcg/act nasal spray from the medication cart and handed it to the resident. The resident self-administered the nasal spray under supervision, and the LPN confirmed that the wrong medication had been given. The facility policy required staff to review and confirm each resident’s MAR and compare the medication and dosage scheduled with the medication label before administration. The facility also failed to document daily weights for Resident #100 as ordered. Resident #100 had physician orders for daily weights related to edema and congestive heart failure, with an active order still in place. Review of the January MAR showed that weights were not documented on 6 of 23 days: January 3, 4, 6, 7, 8, and 14. The DON confirmed there was no documentation that the weights had been completed on those days and no record that the resident refused to be weighed or that the physician had been notified of the missing weights.
Failure to Provide Ordered Hand Splint for Resident With Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited ROM had the appropriate equipment to prevent further decrease in ROM. Resident #76, who reported having had a stroke and being unable to move the right upper extremity, was observed sitting in bed with the right hand clenched in a fist, with no hand splint or positioning device present on the right hand or in the room. The resident stated that he/she did not use a hand splint or positioning device for the right hand. Although the care plan, initiated on 8/25/23, identified the resident as at risk for alteration in functional mobility and included an intervention to wear a splint on the affected upper and lower extremity as ordered, Staff J stated the resident did not currently have a hand splint, Staff I stated the resident had a palm protector that should be worn daily when out of bed, and Staff K stated the resident should still have the hand splint applied as per the care plan.
Failure to Arrange Rehabilitative Services After Injection
Penalty
Summary
Provide or get specialized rehabilitative services as required for a resident was not arranged for Resident #25. During interview, Resident #25 stated that he/she was receiving injections for contractures and had been told therapy would follow the injections, but therapy had not been received after the most recent injection. The care plan meeting note dated 12/30/25 stated that Resident #25 would be re-evaluated by PT/OT after a Botox injection. A consultation report dated 1/15/26 documented that Resident #25 was seen for left spastic hemiplegia and recommended Dysport (Botox) injections every three months along with physical therapy for range of motion, standing, stretching, and bracing. The Rehabilitation Director confirmed on 1/29/26 that Resident #25 had not been seen by therapy after the consultation appointment.
Failure to Address Resident Council Grievances on Snack Availability
Penalty
Summary
The facility failed to address grievances raised by the Resident Council regarding the availability of snacks. During a Resident Council meeting facilitated by the Regional Activities Director, residents expressed concerns that snacks were not consistently available when requested. Interviews with residents revealed ongoing issues with snack availability, particularly at bedtime. One resident reported not receiving a snack when requested on a specific evening, and another resident mentioned that staff did not offer an alternative when a requested cookie was unavailable. These grievances were not acted upon, leading to dissatisfaction among the residents.
Delayed Physician Response to Pharmacy MRR
Penalty
Summary
The facility failed to ensure timely review of irregularities identified by the pharmacist during the monthly Pharmacy Medication Regimen Review (MRR) for a resident. The facility's policy requires that recommendations from the MRR be acted upon within 30 calendar days or according to specific protocols. In this case, a recommendation was made on 8/22/24 to adjust the total daily dose of Gabapentin for a resident to stay within recommended dosing guidelines. However, the attending physician did not address this recommendation until 10/2/24, which was more than 30 days after the recommendation was made.
Failure to Follow Smoking Policy for Resident
Penalty
Summary
The facility failed to adhere to its established smoking policy for a resident who was identified as a smoker. According to the facility's policy, residents are to be assessed for their ability to smoke safely upon admission, quarterly, and with any change in condition. However, a review of the resident's medical record revealed that the most recent smoking assessment was conducted several months prior, in June 2024, and a quarterly evaluation due in September 2024 was not completed. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the required quarterly smoking evaluation had not been performed for the resident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision of residents, resulting in an elopement incident involving a resident identified as an elopement risk. On the evening of 7/28/24, the resident left the premises through the front door while wearing a wanderguard. The door alarm was triggered but was deactivated by a recreational assistant, Staff B, who did not notify a nurse or any other staff member about the alarm. The resident was later found at a nearby gas station and had taken a taxi to a homeless shelter an hour away. The resident eventually went to a fire station with abdominal pain and was taken to a hospital before returning to the facility. Interviews with staff revealed that the door alarm had been sounding when Staff B entered the lobby, but the duration of the alarm was unknown. Staff B checked the parking lot for residents, found none, and turned off the alarm without further action. The facility's policy on elopement requires staff to notify a supervisor and activate a missing patient protocol, which was not followed in this instance. The facility had conducted in-service education on the elopement policy and mock elopement drills after the incident, but these actions were not in place at the time of the deficiency.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as evidenced by the lack of documentation of weekly assessments and treatment orders. For one resident, there were no treatment orders for pressure injuries identified on the coccyx and bilateral heels until four days after the initial clinical admission note. Additionally, there were no descriptions or assessments of these wounds documented in the resident's medical record. Another resident had a pressure injury on the left heel, but the facility failed to conduct weekly skin and wound evaluations as required by their policy. There was a significant gap of approximately 30 days between assessments, which was confirmed by the Director of Nursing. The facility's policy mandates complete wound evaluations upon admission, readmission, new in-house acquired wounds, weekly, and with any unanticipated decline in wounds, which was not adhered to in these cases.
Infection Control Lapses During Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the care of a resident with a Stage 3 pressure injury on the left heel. The resident's treatment involved cleansing the wound, applying Betadine, and covering it with an ABD pad secured with Kerlix. During an observation, a registered nurse (Staff C) did not adhere to infection control protocols. Staff C donned a protective gown but left the waist ties dragging on the floor, used surgical scissors from their pocket without disinfecting them, and placed these scissors directly on the resident's bed. Additionally, the nurse placed a multi-use wound cleanser bottle on the bed without disinfecting it after use. Staff C failed to change gloves or perform hand hygiene between handling soiled and clean items during the dressing change. After completing the dressing change, the nurse removed their gloves but did not perform hand hygiene before handling the dirty scissors and wound cleanser bottle again. These items were placed on the treatment cart without disinfection, and the cart was not cleaned afterward. The Director of Nursing (Staff A) confirmed the expectation for glove changes and hand hygiene during dressing changes and the disinfection of multi-use items, but was unable to provide a policy regarding infection control and dressing changes.
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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.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Exeter Center | 4.6 mi | ★★★★★ | 5 | 0 |
| Webster At Rye | 4.6 mi | ★★★★★ | 14 | 0 |
| Riverwoods At Exeter | 8 mi | ★★★★★ | 2 | 0 |
| Mill Town Health And Rehabilitation | 8.4 mi | ★★★★★ | 7 | 0 |
| Maplewood Center | 8.5 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.