Inspection·April 4, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure personal privacy were provided for three (Resident 1, Resident 2, and Resident 3) out of three sampled residents when privacy curtains were not provided. Residents Affected - Few This failure had the potential to put residents in physical, social and emotional distress. Findings: During a concurrent observation and interview on 2/24/25 at 3:12 p.m. with the Administrator (ADM), the ADM stated, he received a call round 11 p.m. on 2/21/25 about the car crash incident in the facility. The affected room had a signage on the door that indicated, Unsafe to Occupy. A yellow tape labeled with Caution was in the middle of the room. No residents were observed inside the affected room. The ADM stated, the three residents who occupied the affected room were not injured and were transferred to the Day Room (activity/rehab room) due to unavailable other beds/rooms. In the Day Room, three beds were noted. Resident 1 was lying in the bed. There were no privacy curtains in between Resident 1, Resident 2 and Resident 3. There were thin drapes hung to cover the windows to the outside street. There was a uncovered big window on the right side of the Day Room, where the lobby/reception/visitor could seen Resident 1, Resident 2 and Resident 3 inside the room. A review of Resident 1's medical record indicated diagnoses of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety,(the loss of cognitive functioning, thinking, remembering, and reasoning, to such extent that it interferes with a person's daily life and activities) and Other recurrent depressive disorders. (mental health conditions characterized by persistent sadness, loss of interest, and difficulty functioning, impacting daily life and relationships) A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/31/25, indicated a brief interview for mental status score of 4 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 2's medical record indicated diagnoses of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Unspecified hearing loss, Need for assistance with personal care, Mild cognitive impairment of uncertain or unknown etiology. (mild memory or thinking difficulties, but not severe enough to interfere with daily life and cause is unclear) A review of Resident 2's Nurse's Note by Licensed Vocational Nurse (LVN) A dated 2/22/25 at 1:36 (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 04/04/2025 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)