F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure to follow their policy and procedure
(P&P) for activity assessments and preferred activities for one of two sample resident (Resident 1). This
failure had the potential to affect to maintain and improve health, functional, cognitive, and emotional
well-being for Resident 1.
Residents Affected - Few
Findings:
Record review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick
glance) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's FS indicated
diagnoses included schizoid personality disorder (a condition in which people avoid social activities and
interacting with others), depression (a mood disorder that causes a persistent feeling of sadness and loss
of interest in daily activities), anxiety (excessive, and persistent worry and fear about situations) and
cerebral infarction (disrupted blood flow to brain).
Review of Resident 1's assessments for activities-quarterly/annual indicated there were no assessments for
activities for four quarters in a row. Last activities quarterly assessment was completed on 6/25/2023.
Review of this assessment for Resident 1's preferences and participation level with activities indicated,
resident sometimes sits in a chair outside his room and converse with staff and other residents.
Review of Resident 1's activity notes for June 2024 and July 2024 indicated there was no evidence of
documentation for preferred activities were provided to Resident 1.
During multiple observations for Resident 1 on 7/5/2024 between 12:05 p.m., to 3:30 pm., Resident 1
observed sitting on bed, facing ceiling and no inside room or outdoor activities provided to Resident 1.
During an interview with Resident 1 on 7/5/2024 at 1:19 pm, Resident 1 stated I like my activity to sit
outside and get sunlight in the patio. Resident 1 also stated activity staff rarely offering activities to Resident
1.
During an interview with certified nursing assistant A (CNA A) on 7/5/2024 at 1:28 pm., CNA A stated
Resident 1 likes to sit outside in patio and talks to other residents. CNA A also stated activity staff were not
taking Resident 1 out to patio.
During an interview with license vocational nurse B (LVN B) on 7/5/2024 at 1:55 pm., LVN B stated
Resident 1's favorite activity of sitting outside in the patio was not happening as it should be. LVN
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055356
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055356
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oceanview Post Acute
200 Lighthouse Avenue
Pacific Grove, CA 93950
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
B also stated activity staff should have been provided to Resident 1 at least once a week when weather
permits.
During a concurrent interview and record review on 7/5/2024 at 2:05 pm., with director of nursing (DON),
Resident 1's Activities-Quarterly/Annual, assessments and activity notes were reviewed. DON
acknowledged there were no activities quarterly/annual assessments for four quarters since 6/25/2023 for
Resident 1. DON also confirmed Resident 1' preferred activity of sitting outside patio was not happening on
routine basis and there was no documentation for 1:1 room activities for Resident 1. DON stated currently
there were no group activities, only 1:1 in room activity for all residents due to Covid-19 (contagious viral
infection) outbreak (sudden increase) in the facility. DON also stated activity assessments should have
been completed every quarter. DON further stated activity staff should have completed activities
assessment every quarter and Resident 1's preferred activities should have been provided on routine basis.
During a review of facility's P&P titled, Activity Evaluation, revised June 2018, the P&P indicated, The
resident's activity evaluation is conducted by Activity Department personnel, in conjunction with other staff
who evaluate related factors such as functional level, cognition and medical conditions that may affect
activities participation. The completed activity evaluation is part of the resident's medical record and is
updated as necessary, but at least quarterly. The activity evaluation is used to develop an individual
activities care plan that will allow the resident to participate in activities of his/her choice and interest.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055356
If continuation sheet
Page 2 of 2
