Inspection·August 28, 2024

F 0868 d. Infection Preventionist Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055356 If continuation sheet Page 2 of 4 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 08/28/2024 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 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control practices when: Residents Affected - Few 1. Wet wash cloth (a small,soft and absorbent cloth that used for washing face and body) on sink and dry wash cloth on the floor in bathroom; 2. Medical doctor (MD) did not use required contact precautions (used for infections, diseases, or germs that spread by touching residents or resident's environment) personal protective equipment (PPE: any piece of clothing or equipment that is worn by healthcare workers to mitigate contracting the infections between residents and staff); 3. Laundry aide did not use required contact precautions PPE. These failures had the potential to result in transmission of infection among residents. Findings: 1.During an initial facility tour on 8/5/2024 at 11:50 a.m., observed one wet wash cloth on laying on sink and another dry washcloth on floor in resident room [ROOM NUMBER]'s bathroom. During an interview with certified nursing assistant A (CNA A) on 8/5/2024 at 1:00 p.m., CNA A confirmed wet wash cloth on sink and dry wash cloth on floor in Resident room [ROOM NUMBER] bathroom. CNA A stated wet wash cloth was placed on sink after use, and dry wash cloth was unused and fell on floo. CNA A also stated staff should not have placed used wash cloth on sink after use. CNA A further stated staff should have sent used and unused wash clothes to laundry for washing to maintain infection control practices. 2.During an observation on 8/5/2024 at 11:55 a.m., noted posting on the wall outside Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] for contact precautions. This posting indicated all staff and visitors must put on gloves and gown before room entry, discard gloves and gown before room exit. During an observation along with facility's director of nursing (DON) on 8/5/2024 at 1:22 pm., noted facility's medical doctor (MD) placed gloves, no gown on, walked into Resident room [ROOM NUMBER], and came out to hallway after few minutes with gloves on for both hands. During an interview with MD on 8/5/2024 at 1:26 pm., MD confirmed he did not wear gown before went to Resident room [ROOM NUMBER]. MD stated he should have worn gown along with gloves before entering to room and removed gloves before came out of the room to follow contact precautions. 3.During an observation on 8/5/2024 at 1:30 pm., noted facility's laundry aid (LA) walked into Resident room [ROOM NUMBER] without gloves and gown, and came out of the room after few minutes later. During an interview with LA on 8/5/2024 at 1:35 p.m., LA confirmed she forgot to wear gloves and gown before entered to Resident room [ROOM NUMBER] as posted for contact precautions for this room. LA stated she should have worn gloves and gown before entered to room and removed before came out and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055356 If continuation sheet Page 3 of 4 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 08/28/2024 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 0880 washed hands for infection control. Level of Harm - Minimal harm or potential for actual harm During an interview with license vocational nurse B (LVN B) on 8/5/2024 at 1:40 pm., LVN B stated all staff should have worn gloves and gown before entering into resident rooms with contact precautions posting for infection control. Residents Affected - Few During an interview with DON on 8/5/2024 at 2:15 p.m., DON stated facility following CDC nursing staff should not have left used wash cloth in bathroom sink and on the floor, they both should have sent for laundry for washing. DON also stated MD should have followed contact precautions for PPE before entered to resident room [ROOM NUMBER]. DON further stated all staff should have followed required PPE for contact precautions before entering to resident rooms with contact precautions posting on the wall for infection control practice. During a review of facility's policy and procedure (P&P) titled, Transmission-Based Precautions, revised August 2016, the P&P indicated, Contact Precautions: Wear gloves when contact with resident environment. Wear gown if you anticipate that your clothing may become contaminated. During a review of facility's P&P titled, Personal Protective Equipment, revised October 2018, the P&P indicated, PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055356 If continuation sheet Page 4 of 4