Inspection visit

Health inspectionDecember 12, 2025

OCEANVIEW POST ACUTECMS #0553569 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on interviews and record review, the facility failed to ensure three out of 13 sampled residents (Resident 30, Resident 9, and Resident 10) are free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 30 received Depakote (it can be used to treat mood disorders, such as manic episodes in bipolar disorder, as well as seizures and migraines.) without target behavior monitoring, and there was no side effect monitoring. 2. Resident 9 received Trazodone (anti-depressant medication) without monitoring for number of hours of sleep. 3. Resident 10 received Depakote without target behavior monitoring. These failures had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical mental and psychosocial well-being. 1. During a review of Resident 30's clinical record titled, admission Record, dated 12/11/25, indicated Resident 30 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) unspecified and essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition). During a review of Resident 30's order summary report, dated 12/11/25, indicated an order for Depakote sprinkles oral capsule delayed release sprinkle 125 mg (milligram) to give two capsules by mouth at bedtime for mood disorder, dated 8/30/2025. During a review of Resident 30's Medication Administration Record (MAR, a record of medications given) for month of November 2025 and December 11,2025, indicated there was no monitoring for the target behavior of mood disorder and there was no documentation of side effect monitoring for Depakote. During a concurrent interview and record review on 12/11/25 at 3:41 p.m., with the Director of Nursing (DON), the DON reviewed Resident 30's physician's order. The DON confirmed there was no target behavior monitoring and there was no side effect monitoring for Resident 30's Depakote. The DON further stated psychotropic medication (used to treat mental disorders; a medication used to control behavior or to treat thought disorder processes) they need target behavior. 2. During a review of Resident 9's clinical record titled, admission Record, dated 12/11/25, indicated Resident 9 was admitted to the facility with diagnoses including COPD unspecified and essential (primary) hypertension. During a review of Resident 9's order summary report, dated 12/11/25, indicated an order for trazodone (used to treat depression) 50 mg, to give one tablet by mouth in the evening for insomnia (inability to sleep) , dated 6/19/25. During a review of Resident 9's MAR for month of September 18,2025, October 2025, November 2025, and December 11, 2025, it indicated the nursing staff did not monitor the actual number of hours that Resident 9 slept for pm and night shift since 9/18/25. During a concurrent interview and record review on 12/11/25 at 4:05 p.m., with the DON, the DON reviewed Resident 9's physician's order and the MAR. The DON confirmed there was no number of hours of sleep on Resident 9's MAR. The DON stated she would fix it to see the actual hours of sleep. 3. During a review of Resident 10's clinical record titled, admission Record, dated 12/11/25, indicated Resident 10 was admitted to the (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 12 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 12/12/2025 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)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete facility with diagnoses including depression (loss of pleasure or interest in activities for long periods of time) and essential (primary) hypertension. During a review of Resident 10's order summary report dated 12/11/25, indicated an order for Depakote sprinkles oral capsule delayed release sprinkle 125 mg Give 2 capsule by mouth two times a day for mood disorder, dated 8/21/2025. During a review of Resident 10's MAR November and December 11, 2025, it indicated that there was no target behavioral monitoring for use of Depakote. During a concurrent interview and record review on 12/12/25 at 10:34 a.m., with the DON, the DON reviewed Resident 10's physician's order and the MAR for Depakote. The DON stated there was no monitoring for behavior target prior from 12/11/25 and they updated yesterday. During a review of the facility's P&P titled Psychotropic Medication Use, dated 7/2022, indicated, 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications. 11. Residents receiving psychotropic medications are monitored for adverse consequences. 15. Tally/Summarize Behavior at least monthly. Event ID: Facility ID: 055356 If continuation sheet Page 2 of 12 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 12/12/2025 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on observation, interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 33) completed a Level II Mental Health Evaluation as part of the pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). This failure had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions. Findings:1. Review of Resident 33's clinical indicated she was admitted to the facility with diagnoses including bipolar disorder (mental health condition characterized by mood swings that range from the lows of depression to elevated periods of emotional highs). Review of Resident 33's preadmission PASRR Level 1 screening, dated 10/24/25 indicated Resident 33 had a positive Level I screening which indicated she should have a Level II Mental Health Evaluation. Review of Resident 33's letter from the California Department of Health Care Services (DHCS) with a subject, Notice of Attempted Evaluation, dated 10/29/25, indicated a Level II evaluation was not completed. It indicated a Level II evaluation was not scheduled for the following reason: Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. During an interview on 12/11/2025 at 1:44 p.m., Admissions/Marketing (AM) stated Resident 33 Level II evaluation fell through the cracks. Review of the facility's policy, admission Criteria, revised 3/2019 indicated, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) . The facility conducts a Level I PASARR screen . If the level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluations and determination) screening process . The social worker is responsible for making referrals to the appropriate state-designated authority . Event ID: Facility ID: 055356 If continuation sheet Page 3 of 12 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 12/12/2025 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop care plan for two of 13 sampled residents (Resident 30 and Resident 10) when there was no care plan develop for Depakote black box warning (BBW, also known as a boxed warning, is the strongest warning the Food and Drug Administration [FDA-it is a federal agency responsible for protecting and promoting public health by regulating and supervising food safety, medications, medical devices, cosmetics, and other products] gives for prescription drugs). The failures had the potential for the residents not attaining their highest practicable physical, mental, and psychosocial well-being. 1. During a review of Resident 30's clinical record titled, admission Record, dated 12/11/25, indicated Resident 30 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) unspecified and essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition.) During a review of Resident 30's order summary report, dated 12/11/25, indicated an order for Depakote sprinkles oral capsule delayed release sprinkle 125 mg (divalproex Sodium) Give 2 capsule by mouth at bedtime for mood disorder, dated 8/30/2025. During a review of Resident 30's care plan indicated there was no care plan developed for Depakote BBW. During a concurrent interview and record review on 12/11/25 at 4:02 p.m., with the Director of Nursing (DON), the DON reviewed Resident 30's care plan, the DON stated she did found the care plan for Depakote BBW. The DON further stated they should have a care plan for boxed warning. 2. During a review of Resident 10's clinical record titled, admission Record, dated 12/11/25, indicated Resident 10 was admitted to the facility with diagnoses including depression (loss of pleasure or interest in activities for long periods of time) and essential (primary) hypertension. During a review of Resident 10's order summary report, dated 12/11/25, indicated an order for Depakote sprinkles oral capsule delayed release sprinkle 125 mg (divalproex Sodium) to give two capsule by mouth two times a day for mood disorder, dated 8/21/2025. During a review of Resident 10's care plan indicated there was no care plan developed for Depakote BBW. During a concurrent interview and record review on 12/12/25 at 10:40 a.m., with the DON, the DON reviewed Resident 10's care plan, the DON confirmed that there was no care plan from yesterday 12/11/25 for Resident 10's Depakote BBW. During a review of the facility's P&P titled Goals and Objectives, Care Plans, dated 4/2009, indicated, 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . Event ID: Facility ID: 055356 If continuation sheet Page 4 of 12 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 12/12/2025 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 palatability of cooked foods were maintained when five of forty-six facility residents (Residents 7, 32, 4, 41 and 46), receiving food from the kitchen, complained that the food had no taste or tasted bland (lacking taste or flavor) as verified during the test tray meal tasting. This failure of decreased food palatability or no taste could lead to decreased food consumption by residents which could result in decreased nutrient intake for the forty-six facility residents getting foods from the kitchen.1.During an interview on 12/08/2025 at 12:03 p.m., with Resident 7 inside the room, Resident 7 stated the food taste is horrible. Residents Affected - Some During a review of Resident 7's clinical record it indicated Resident 7 was admitted to the facility with diagnosis including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making) unspecified. Review of the order summary report of Resident 7 dated 12/11/25 indicated, Resident 7 had an order of regular texture (standard, unrestricted diet with normal foods), thin consistency (liquids that flow easily, low viscosity and pour quickly from a container), ordered and started on 11/16/23. 2.During an interview on 12/9/2025 at 10:36 a.m., with Resident 32, he stated the food taste was not good. During a review of Resident 32's clinical record, it indicated Resident 32 was admitted to the facility with diagnosis including essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) unspecified. Review of the order summary report of Resident 32 dated 12/11/25 indicated, Resident 2 had an order of Regular diet, SB6 (Soft and Bite Sized) texture, thin consistency, soft bread okay., ordered and started on 12/4/25. 3. During the concurrent observation and interview of Resident 4 on 12/9/25 at 11:42 a.m., Resident 4 was laying in his bed, alert, oriented, calm, comfortable and verbally responsive. Resident 4 stated that his food did not taste good or tasted bland. The cooked rice was hard and did not taste good as well. Review of Resident 4's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 4 was readmitted to the facility on [DATE] with the principal diagnosis of end stage renal disease (also known as kidney failure, is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of the order summary report of Resident 4 dated 12/11/25 indicated, Resident 4 had an order of renal diet (kidney-friendly eating plan for those with kidney disease, focusing on limiting sodium, phosphorus, potassium, and sometimes protein and fluids to reduce waste buildup in the blood), regular texture (standard, unrestricted diet with normal foods), thin consistency (liquids that flow easily, low viscosity and pours quickly from a container), two grams (fundamental metric unit of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055356 If continuation sheet Page 5 of 12 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 12/12/2025 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)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mass) potassium (K, mineral needed by the body that helps nerves to function and muscles to contract), no salt packet and low phosphorus (mineral that is vital for building strong bones and teeth, producing energy and repairing cells), ordered and started on 9/25/25. 4. During the concurrent observation and interview of Resident 41 on 12/8/25 at 12:25 p.m., Resident 41 was in her wheelchair eating lunch in the dining room. She's alert, oriented and verbally responsive. Resident 41 verbalized that the food did not taste good or tasted bland at times. Review of Resident 41's admission record indicated, Resident 41 was admitted to the facility on [DATE] with the principal diagnosis of Parkinson's disease (progressive neurological disorder, primarily affecting movement due to the loss of neurotransmitter or dopamine-producing brain cells) with dyskinesia (involuntary, erratic muscle movements that could not be controlled), with fluctuations (symptoms are unpredictable or changing throughout the day). Review of Resident 41's order summary report dated 12/11/25 indicated, Resident 41 had an order of regular diet (normal, balanced meal without special restrictions), regular texture, thin liquids consistency, ordered and started on 5/28/25. 5. During the concurrent observation and interview of Resident 46 on 12/8/25 at 11:43 a.m., Resident 46 was laying in her bed, alert, oriented, comfortable and verbally responsive. Resident 46 verbalized that the food tasted horrible, did not taste good or tasted bland. Review of the admission record of Resident 46 indicated, Resident 46 was admitted to the facility on [DATE] with the principal diagnosis of nontraumatic intracerebral hemorrhage (ICH, bleeding directly into the brain tissue), in hemisphere, subcortical (refers to brain structures deep within each cerebral hemisphere or the largest part of the vertebrate brain, beneath the cortex or outer layer of the brain). Review of the order summary report of Resident 46 dated 12/11/25 indicated, Resident 46 had an order of regular diet, regular texture, regular consistency (non-restrictive and flows freely), no salt packet with all meals, ordered and started on 10/15/25. During the test tray observation and tasting with kitchen supervisor (KS) and the administrator in-charge (ADMIC) on 12/10/25 from 12:54 p.m. to 1:09 p.m., two test trays were brought and tasted. One of the test trays contained regular potatoes, carrots, rice and fish. The second tray contained mashed potatoes, pureed carrots and pureed fish. Tasted the tray with the regular foods and the regular potatoes and regular carrots did not have taste or tasted bland. The rice was hard and tasted bland as well. Tasted the second tray with mashed potatoes and pureed foods and the mashed potatoes and pureed carrots also tasted bland. During the concurrent interviews with KS and the ADMIC after they tasted the first test tray with regular foods, on 12/10/25 at 1:11 p.m., KS and ADMIC verified that the regular potatoes and carrots did not have taste or tasted bland. They further verified that the rice was hard and tasted bland as well and would check on these concerns. During another concurrent interviews with KS and the ADMIC after they tasted the second test tray with pureed foods, on 12/10/25 at 1:15 p.m., KS and ADMIC verified that the mashed potatoes and pureed carrots also tasted bland and would follow up on that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055356 If continuation sheet Page 6 of 12 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 12/12/2025 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)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the interview with registered dietitian (RD), on 12/10/25 at 2:58 p.m., RD acknowledged that foods served by the facility kitchen should have been palatable, not bland in taste and would check the above concerns. During the interview with the director of nursing (DON) on 12/12/25 from 11:25 a.m. to 11:29 a.m., DON verified the foods should have been palatable to residents and not bland in taste. Review of the facility's policy titled, Food and Nutrition Services, revised October 2017 indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional or special dietary needs, taking into consideration the preferences of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055356 If continuation sheet Page 7 of 12 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 12/12/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food items were stored and prepared in accordance with professional standards for food safety when there were unsanitary baking equipment in the kitchen.This failure had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the forty-six residents who received foods from the facility kitchen.Findings: During the initial kitchen tour observation with kitchen supervisor (KS), on 12/8/25 at 9:51 a.m., observed four baking pans with blackish discolorations and brownish spots in them. During the interview with KS on 12/8/25 at 9:52 a.m., KS acknowledged that the four baking pans had brownish to blackish discolorations, rusty spots, and should have the unsanitary baking pans replaced. During the interview with the registered dietitian (RD), on 12/10/25 at 2:58 p.m., RD verified that the unsanitary baking pans should not be kept in the kitchen and no longer used it. Review of the facility's policy and procedure titled, Sanitation, revised October 2008 indicated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Event ID: Facility ID: 055356 If continuation sheet Page 8 of 12 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 12/12/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when there were no Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes.) signage posted and there was no available PPE (Personal Protective Equipment, refers to specialized gear like gloves, gowns, masks, and eye protection that creates a barrier to shield healthcare workers from infectious materials, preventing disease transmission to themselves, patients, and others by stopping contact with germs, blood, or body fluids) outside Resident 7's room. The failure had the potential to spread infections to residents, staff, and visitors.During an observation on 12/10/2025 at 11:44 a.m., outside Resident 7's entrance door indicated there was no signage of EBP posted and there was no available PPE outside Resident 7's room. During a review of Resident 7's clinical record it indicated Resident 7 was admitted to the facility with diagnosis including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making) unspecified. During a review of Resident 7 physician's order, dated 10/3/2025, indicated an order EBP: FYI (for your information)Enhanced barrier precautions due to risk of MDRO acquisition due to presence of wounds. Every shift. During a review of Resident 7 physician's order, dated 11/25/25, indicated an order for Tx: (treatment) left hip NPCU (non-pressure chronic ulcer): cleanse with normal saline, pat dry apply triad (triad, designed to help maintain an optimal wound healing environment) cream to wound and peri wound every day and evening shift for NPCU. During a concurrent interview and record review on 12/11/2025 at 3:18 p.m., with the Wound Nurse (WN), the WN reviewed Resident 7 physician's order she stated resident 7 had a NPCU to lift hip and another wound on top on the wound on 12/9/25. During an observation outside Resident 7's room on 12/11/2025 at 3:32 p.m., with the WN she confirmed there was no EBP signage posted and there was no PPE cart outside Resident 7's room. During an interview on 12/11/25 at 3:37 p.m., with Director of Staff Development (DSD) and the Director of Nursing (DON), the DSD stated EBP is for residents with pressure injury, blistering and open skin. The DON stated Resident 7 has a chronic wound and needs enhanced barrier precautions. During a review of the facility's policy and procedures titled, Enhanced Standard/Barrier Precautions, updated 6/18/24, indicated, PURPOSE: To provide guidance and recommendations for implementing Enhanced Barrier Precautions (EBP) to include the use of glove and gown during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status. 1. Implementation When implementing EBP, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the required PPE (e.g., gown and gloves). For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055356 If continuation sheet Page 9 of 12 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 12/12/2025 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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five residents (Resident 55) received the appropriate pneumococcal (infections caused by common bacteria that can affect different parts of the body) vaccination. This failure had the potential for residents to have inadequate immunity to pneumococcal infections (caused by bacteria, which can lead to illnesses such as pneumonia [infection in the lung] and meningitis [inflammation around the brain and spinal cord).Findings:Review of Resident 55's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and a foot wound. Review of Resident 55's Informed Consent for Pneumococcal Vaccine, dated 12/3/25 indicated the patient gave the facility permission to administer a pneumococcal vaccination.Review of Resident 55's Immunization Record indicated he had a history of getting the pneumococcal polysaccharide vaccine 23 (PPSV23, one of the two types of pneumococcal vaccines that can prevent pneumococcal disease) on 11/25/2014 and 3/23/2019. There was no documentation that indicated Resident 55 received a pneumococcal conjugate vaccine (PCV, another type of pneumococcal vaccine, which include PCV15, PCV20, and PCV21; each protect against specific types of pneumococcal bacteria)Review of Resident 55's Medication Administration Record for 12/2025 indicated he received PPSV23 on 12/11/25 at 7:31 a.m. During a concurrent interview and record review on 12//2025 at 11:28 a.m., the Director of Staff Development/Infection Preventionist (DSD) reviewed Resident 55's immunization records and clinical record. The DSD confirmed Resident 55 was [AGE] years old and received the PPSV23 on 11/25/2014 and 3/23/2019. The DSD stated they gave him PPSV23 again because that's what he's been getting. The DSD stated the facility followed Centers for Disease Control and Prevention (CDC) guidelines to determine which pneumococcal vaccine to give and at what age.Review of the CDC's Pneumococcal Vaccine Recommendations, dated 10/26/24 indicated, Administer PCV15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine [PCV].Review of the CDC's job aid, Pneumococcal Vaccine Timing for Adults, dated March 2025 indicated for adults 50 years or older who have only received PPSV23, give 1 dose of PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose. If PCV15 is used, no additional PPSV23 doses are recommended. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055356 If continuation sheet Page 10 of 12 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 12/12/2025 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)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to ensure that they maintain the documentation records related to the staffs' coronavirus disease 2019 (COVID-19, an infectious disease caused by the SARS-CoV-2 virus or severe acute respiratory syndrome coronavirus 2) vaccinations for seven out of seven facility staffs reviewed when these staffs did not have records on file regarding their COVID-19 vaccination status. This failure had the potential to jeopardize the health and safety of the staffs and the forty-six residents residing in the facility.Findings: During the concurrent review of the facility's employee files and interview with the director of staff development (DSD) on 12/12/25 from 9:31 a.m. to 1:40 p.m., reviewed the employee files of seven staffs with the DSD. Checked the records of certified nursing assistant (CNA) A, CNA B, CNA C, registered nurse D (RN D), licensed vocational nurse E (LVN E), director of rehabilitation (DOR) and current facility administrator (CFADM). DSD acknowledged that there were no records on file for the seven staffs reviewed regarding their COVID-19 vaccination status and whether the staffs were provided with education regarding the benefits and potential risks associated with COVID-19 vaccine. During the interview with the director of nursing (DON) on 12/12/25 at 1:42 p.m., DON verified the above concern and she further verified that she would have the employee files updated with their COVID-19 vaccination records. Review of the facility's policy titled, Personnel Records revised January 2008 indicated, Our facility maintains certain records for each employee which are directly related to his/her employment. Review of the Centers for Medicare and Medicaid Services (CMS, United States federal agency managing Medicare, Medicaid, Children's Health Insurance Program or CHIP and the health insurance marketplace) State Operations Manual (SOM, provides federal rules, guidelines and procedures from CMS), Appendix PP, Guidance to Surveyors for Long Term Care Facilities, issued 7/3/25 indicated, .The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following: (A) That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; (B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and (C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Event ID: Facility ID: 055356 If continuation sheet Page 11 of 12 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 12/12/2025 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)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and document review, the facility failed to ensure multiple resident rooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.The resident room measurements were as follows:Room Number/ Bed Capacity/ Square Feet Per Resident1 2 72.002 3 66.123 2 79.254 3 68.455 2 74.296 3 75.037 3 75.0310 3 74.2011 2 72.0012 2 72.0014 2 72.0017 4 69.7018 2 72.0019 2 72.0020 2 78.0022 3 76.00During the survey, residents were observed in their rooms. Nursing care and services were not impacted by the shortage of space. The closets and storage were sufficient to accommodate the needs of the residents.Residents were interviewed and stated they did not have any concerns regarding room size, provision of care, or privacy and they can easily navigate inside the room.Staff members were interviewed and stated they were able to safely provide care to the residents, even in rooms with less than 80 square feet per resident.Recommend continuance of room waiver. Event ID: Facility ID: 055356 If continuation sheet Page 12 of 12

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Citations

9 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0605GeneralS&S Epotential for harm
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0883GeneralS&S Dpotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0887GeneralS&S Epotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
0912GeneralS&S Bno actual harm
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the December 12, 2025 survey of OCEANVIEW POST ACUTE?

This was a inspection survey of OCEANVIEW POST ACUTE on December 12, 2025. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OCEANVIEW POST ACUTE on December 12, 2025?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to fun..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 12, 2025