Health inspection·September 24, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review the facility failed to ensure continuity of care when staff did not provide a transportation driver instructions for dropping off a resident to an appointment for one of three sampled resident (Resident 1). This failure resulted in the resident not being met by a family member at the appointment location and resulted to fall.Findings:During an interview on 8/28/25 at 1:37 p.m., a family member stated Resident 1 had dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life and had a hard time walking. The family member stated when he arrived at the doctor's office on 8/14/25 at 7:50 a.m. the office was not open and while waiting he received a call from a construction worker who informed him the resident rolled down a hill, hit her head and landed in dirt and bushes. He further stated facility staff said it was the driver's fault and the transportation company said the facility should have sent someone to accompany the resident. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/30/25, indicated the resident's brief interview for mental status (BIMS) scored 5, indicating she had memory problems and severe difficulty in daily-decision making skills.Resident 1 had a physician's order, dated 7/27/25, indicating the resident was not capable of understanding her rights and responsibilities.Review of Resident 1's Physician Certification Statement of Medical Necessity for Non-Emergency Medical Transport form, dated 8/5/25, indicated wheelchair transportation was requested for reasons including the resident was unable to self-transfer into public or private conveyance and her medical condition precluded the resident being able to reasonably ambulate to and from and to board a vehicle. The undated Transportation Services Request Form indicated Resident 1 had a physician's appointment on 8/14/25 at 8 a.m., and specified no attendant and use of a wheelchair. The Alliance Explanation Remarks form, dated 8/6/25, indicated transportation was being arranged for 8/14/25 7:30 a.m. pick up and return at 9 a.m. During an interview on 8/29/25 at 12:50 p.m., the director of nurses (DON) described Resident 1 to have confusion, was able to walk and usually used a wheelchair. The DON stated on the day of appointment a nurse was informed from a telephone call the resident was found down (fallen) by a construction worker, the driver thought the resident was dropped off at the front of the building but it was the back and a family member was waiting at the front.During an interview on 8/29/25 at 1 p.m., the receptionist (RCP) whose duties included arranging resident transportation. RCP stated if a resident had concerns such as confusion she would speak with a nurse but she did not recall what nurse she discussed with.Review of a Nurse's Note, dated 8/14/25 at 8:50 a.m., indicated the facility was informed Resident 1 fell while at the doctor's office and was transported to a hospital emergency department by a family member. During an interview on 9/24/25 at 12:40 p.m., the social services director (SSD) stated when making transportation arrangements the insurance assigns the transportation company and facility staff do not speak with the driver.During a follow-up interview on 9/24/25 at 1:53 p.m., the RCP stated facility staff did not provide any instructions to the driver.During an interview on 9/24/25 at Page 1 of 2 055356 055356 09/24/2025 Oceanview Post Acute 200 Lighthouse Avenue Pacific Grove, CA 93950

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1:10 p.m., the DON stated there was no policy addressing making transportation arrangement or accidents.Review of Resident 1's acute hospital after visit summary, dated 8/14/25, indicated the resident was seen in the emergency department after a fall. The Computed Tomography (CT scan, medical imaging test used to diagnose and monitor a wide range of conditions) did not demonstrate any evidence of traumatic injury. It indicated to please ensure the patient is escorted into the building for any of her appointments. 055356 Page 2 of 2