Other·March 17, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 3/5/2020. The facility was licensed for 51 beds. The census at the time of the survey was 46. The sample size was 12. A "G" level deficiency was identified (see

F689). A Class "B" citation was issued (see F689). A Class "B" citation was also issued (see Title 22, 72528(c)). Representing the California Department of Public Health: 37409, Health Facilities Evaluator Nurse; 35157 Health Facilities Evaluator Nurse; 35790, Health Facilities Evaluator Nurse.

F636 SS=D Comprehensive Assessments & Timing CFR(s): 483.20(b)(1)(2)(i)(iii)

F636 04/03/2020 §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 1 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 2 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to comprehensively analyze the use of merry walker (enclosed walking and sitting safety device) for one of one resident reviewed (Resident 2). This placed the resident at risk for unidentified changes in mood, behaviors and decreased physical function status related to the use of the device. Findings: During review of the admission minimum data set (MDS, resident assessment tool) dated 12/01/19, indicated Resident 2 was admitted on 11/26/19, with diagnoses included dementia (memory loss), cerebrovascular disease (stroke) and Parkinson's (movement disorder). The MDS indicated the resident was severe cognitively impaired and required limited assistance with one-person physical assist for transfers and supervision with one-person physical assist for walk-in corridor, locomotion on and off unit. "Wheelchair" was the only one marked in section G0600 (Mobility devices). Resident 2 had not used a merry walker and had no history of falls. In multiple observations on 3/02/2020 at 10:24 a.m., 3/03/2020 at 10:00 a.m., and 3/04/2020 at 11:30 a.m., Resident 2 was seen in his merry walker in the hallways of the unit. The resident had lack of socialization with peers, staff, activities, engagement and supervision. He walked in his merry walker as needed. He FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 3 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE would stand, take one to two steps and sit down. This repeated several times throughout the day. Resident 2 presented with a furrowed brow and with bruise on left hand. Staff did not offer him to sit in a standard chair. During review of Resident 2's MDS record, there was no comprehensive assessment done to reflect if Resident 2 had improved or worsened in functional status. In an interview with the MDS Coordinator (MDS-C) on 3/04/2020 at 9:05 a.m., the MDSC confirmed the lack of comprehensive assessment done for Resident 2 other than physical therapy (PT) evaluation on 12/09/19. The MDS-C also stated it was unclear to her how the merry walker had improved Resident 2's functional status and she would not even know if she would code it as restraint or mobility device till the interdisciplinary team discuss this.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 04/03/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 4 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement a comprehensive, collaborative care plan (directs the nursing care of the resident) for one of two hospice residents (Resident 12), when there was a 18 day delay for an order of a low air loss mattress (LAL,mattress designed to prevent and treat pressure ulcer). This failure could potentially not provide the resident the necessary care and comfort necessary in hospice care (care of terminally ill residents with focus on comfort). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 5 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Review of Resident 12's Physician Summary report dated 3/3/2020, Resident 12 was admitted to the hospice program on 12/4/19 with terminal diagnosis of cerebral vascular accident (CVA, stroke). Resident 12 was also a bilateral knee amputee related to complications of diabetes (high blood sugar). An order dated 2/14/2020, indicated "LAL mattress for comfort." During an observation of Resident 12 on 3/2/2020 at 9:09 a.m., Resident 12 was lying on a regular foam mattress. During an follow-up observation on 3/3/2020 at 8 a.m., Resident 12 had a regular foam mattress. During an observation on 3/4/2020 at 9 a.m., Resident 12 was lying on a LAL mattress. He stated it was delivered late last night. He stated it felt comfortable especially on his spine. Review of Resident's comprehensive care plan did not indicate use of the LAL mattress for resident's comfort. During an interview with the director of nursing (DON) on 3/4/2020 at 9:19 a.m., she stated the LAL mattress was ordered through hospice services. She stated the facility called hospice services for a follow-up but confirmed there was no documentation of a follow-up. She acknowledged nursing should have followed up more since it was a collaborative plan of care between the facility and hospice. During a telephone interview with the director of care services for hospice (DCSH), on 3/5/2020 at 8:49 a.m., she stated hospice received the order request on 2/20/2020. It was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 6 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE originally not approved. The DCSH stated on 3/3/2020, the facility contacted hospice services and stated Resident 12 would benefit highly from the LAL mattress. The DCHS stated it was approved and delivered the same day. Review of the facility's revised policy, "Hospice Program", indicated... In general, It is the responsibility of the hospice to manage the resident's care as it relates to terminal illness and related conditions including .. providing medical supplies, durable medical equipment (DME), and medications for the palliation of pain and symptoms... Responsibility of the facility includes... Communicating with the hospice provider to ensure the needs of the resident are addressed and met 24 hours per day... Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being.

F661 SS=D Discharge Summary CFR(s): 483.21(c)(2)(i)-(iv)

F661 04/03/2020 §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 7 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE release to authorized persons and agencies, with the consent of the resident or resident's representative. (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-thecounter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any postdischarge medical and non-medical services. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure discharge summaries were completed for two of three residents' closed records reviewed (Residents 1 and 48), which had the potential to result in missed health information related to unmet care needs. Findings: 1. Review of Resident 1's Admission Record indicated she was admitted to the facility on 11/3/19 and discharged to another facility on 12/11/19. Review of Resident 1's clinical record indicated she did not have a discharge summary from the physician for her discharge to another facility. During an interview with the director of nursing (DON) on 3/5/2020 at 10:05 a.m., she confirmed Resident 1 did not have a discharge summary from the physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 8 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility's 4/2009 policy, "Discharge Summary and Plan", indicated "When the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment."2. During review of Resident 48's closed record, Resident 48 was admitted on 8/23/19 with diagnoses included cerebral infarction (stroke), muscle weakness and dementia (memory loss). During review of Resident 48's progress notes dated 12/17/19, indicated "Resident expired 1950. No signs of respiratory effort, no heart sounds. Hospice agency was notified. Family member called facility shortly after and was informed of resident passing". During review of Resident 48's clinical record, there was no discharge summary noted on the electronic medical record. During interview with medical record director (MRD) on 03/04/2020 at 4:10 p.m., the MRD confirmed there was no discharge summary done because she missed the follow-up with the physician. During a review of the facility's 4/2009 policy and procedure (P&P), "Discharge Summary and Plan", indicated "6. A copy of the postdischarge plan and summary will be provided to the resident and receiving facility, and a copy will be filed in the resident's medical records."

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 04/03/2020 Facility ID: CA070000078 If continuation sheet 9 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement care plan to prevent fall for one of two residents reviewed (Resident 49) who was assessed for fall high risk. Resident 49 had a fall on 12/19/19, hit her head and sustained a hematoma (blood leaks from blood vessel). Findings: During review of Resident 49's clinical record, indicated Resident 49 was admitted on 12/17/19, with diagnoses included Alzheimer's disease (memory loss and cognitive decline), muscle weakness and hypertension (high blood pressure). During review of Resident 49's minimum data set (MDS, resident tool assessment) dated 12/20/19, the MDS indicated Resident 49 was severely cognitively impaired and required supervision with two-person physical assist during transfer. During review of Resident 49's fall risk assessment dated 12/18/19, score indicated 22, which means high risk for fall. During review of Resident 49's situation, background, assessment and, recommendation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 10 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (SBAR, form of prompt communication) note dated 12/19/19, indicated "at 12:32 a.m., three staff witnessed Resident 49 got out of bed and fell while walking in the hallway near other resident's room, with no apparent injury noted. Recommendations: landing mat in place and resident to monitor closely with one to one person". During review of Resident 49's SBAR note dated 12/19/19, indicated "Unwitnessed fall at 7:45 p.m., the Nurse Practitioner (NP) heard a thump (as in was hit heavily), then found Resident 49 on floor on her knees next to her bed. The NP and another staff assisted transfer Resident 49 back to bed, sustained 3 X (by) 3 centimeters (cm, metric unit of length) hematoma on right forehead. During review of Resident 49's transfer to hospital summary note dated 12/20/19, Resident 49's daughter requested transfer Resident 49 to hospital for further evaluation due to Resident 49's history of head injury. The Physician (MD) was notified and Resident 49 was sent to hospital at noon time. During an interview with certified nursing assistant B (CNA B) on 03/04/2020 at 3:00 p.m., CNA B stated she did not provide one to one close monitoring with Resident 49 because she had other residents assigned with her to care for. During review of the facility's CNA assignment sheet dated 12/19/19, indicated there was no CNA assigned to provide one to one close monitoring for Resident 49. During an interview with the administrator (Admin) and licensed vocational nurse A (LVN A) on 03/05/2020 at 9:02 a.m., they stated they were not able to provide close monitoring for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 11 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 49. During review of Resident 49's fall care plan dated 12/18/19, indicated "Monitor closely with one on one possibly male orderly if available. Provide assistance as identified in transfer and mobility." During a review of the facility's policy and procedure (P&P), "Falls and fall Risk, managing", revised 2007, the P&P indicated "4. If falling recurs, despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant."

F726 SS=E Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 04/03/2020 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 12 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure competent staffing to care for residents' needs for two of five residents reviewed (Residents 38 and 40) when: 1. Licensed nurses (LN) did not know Resident 38 had a pacemaker (a small device that's placed in the chest or abdomen to help control abnormal heart rhythms) and did not know how to assess the resident with a pacemaker as ordered by the physician; 2. Registered nurse F (RN F) did not follow physician order for Resident 40's wound treatment; and 3. LN did not complete Resident 40's weekly skin assessments. These failures had placed the residents at risk of being improperly assessed and unmet care needs. Findings: 1. Review of Resident 38's Admission Record indicated she was admitted on 1/30/2020 with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 13 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE diagnosis of presence of cardiac pacemaker. Review of Resident 38's physician orders dated 2/4/2020, indicated she had orders for LN to observe and document signs and symptoms of pacemaker malfunction such as dizziness, syncope (loss of consciousness resulting from insufficient blood flow to the brain), difficulty breathing, short of breath, chest pain, and weakness, and signs and symptoms of infection on the pacemaker site such as pain, swelling, redness, and discoloration every shift. During an interview with licensed vocational nurse C (LVN C) on 3/3/2020 at 1:50 p.m., she stated she monitored the malfunction of Resident 38's pacemaker by checking Resident 38's heart rate and monitored the pacemaker site for bleeding. During an interview with LVN D on 3/4/2020 at 9:16 a.m., she stated she monitored the pacemaker site to see if it was there, but she did not know where Resident 38's pacemaker was located. LVN D stated she monitored Resident 38's pacemaker malfunction by checking Resident 38's vital signs (pulse rate, respiratory rate, body temperature, and blood pressure). During an interview with LVN E on 3/5/2020 at 1:15 p.m., she stated she was not sure if Resident 38 had a pacemaker or not. LVN E stated she did not know what to monitor at the pacemaker site, and she monitored Resident 38's pacemaker malfunction by checking Resident 38's heart rate.2. During an observation on 03/03/2020 at 1:30 p.m., RN F removed the old dressing to Resident 40's buttocks with her gloved hand, cleansed the wound with saline, applied wet gauze soaked with Puracyn (wound cleanser) for five minutes, then applied the antibiotic powder with her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 14 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE gloved hand towards the wound. RN F did not apply sure prep before covering with gentle foam. During an interview with RN F on 03/03/2020 at 3:00 p.m., RN F stated she forgot to apply sure prep on the wound edges before covering with gentle foam to protect the skin. Review of Resident 40's physician order dated 3/2020, indicated "Stage 4 pressure injury to sacrum: .... Apply sure prep before covering with gentle foam dressing". 3. During review of Resident 40's clinical record, there was lack of weekly skin assessment for the following periods: 12/30/19 to 1/03/2020; 1/13/2020 to 1/17/2020; 1/20/2020 to 1/24/2020; 1/27/2020 to 1/31/2020; and 2/24/2020 to 2/28/2020. During an interview with the director of nursing (DON) on 03/03/2020 at 3:45 p.m., she confirmed the lack of weekly skin assessments on those period dates because the designated licensed nurses missed to do it.

F758 SS=E Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 04/03/2020 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 15 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure 6 of 9 residents (5, 6, 27, 29, 43, and 49) were free from unnecessary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 16 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychotropic medications when 1. Resident 5 did not have the physician's rationale for maintaining the same dose for Remeron (a drug used to treat depressive disorder which is a medical illness that causes feelings of sadness and/or a loss of interest in activities once enjoyed); 2. Resident 6's manifested behaviors were not monitored; 3. Resident 29's recommendation from psychologist for gradual dose reduction (GDR) for buspirone (used to treat anxiety) was not presented to the physician; 4. Resident 43 did not have the physician's rationale for maintaining the same dose for Remeron; 5. Resident 27 did not have the physician's rationale for maintaining the same dose for Lexapro; and 6. There was no stop date for Resident 49's use of Zyprexa (as needed) within 14 days duration. Findings: 1. Review of Resident 5's Admission Record indicated he was admitted with diagnosis of depressive disorder. Review of Resident 5's physician order indicated he had an order for Remeron 30 milligrams (mg, a metric unit of mass) at bedtime for depressive disorder, started on 8/28/19. Review of Resident 5's Note To Attending Physician/Prescriber, dated 12/29/2019, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 17 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated the consultant pharmacist recommended to consider a dose reduction for Resident 5's Remeron. The physician responded to maintain the same dose but did not provide the rationale. During an interview with the director of nursing (DON) on 3/5/2020 at 10:07 a.m., she confirmed there was no rationale provided for maintaining Resident 5's Remeron at the same dose. 2. Review of Resident 6's physician order, dated 6/5/19, indicated she had an order for Celexa (used to treat depression) 15 mg in the morning for depressive disorder as manifested by refusal of care such as not changing clothes, not taking medications. But there was no monitoring for the manifested behaviors. During an interview with the DON on 3/4/2020 at 3:20 p.m., she reviewed Resident 6's clinical record and was unable to find the monitoring for refusal of care such as not changing clothes, not taking medications. 3. Review of Resident 29's Admission Record indicated he was admitted with diagnosis of anxiety disorder (people with anxiety disorders frequently have intense, excessive and persistent worry and fear about everyday situations). Review of Resident 29's physician order, dated 5/4/19, indicated he had an order for buspirone 15 mg two times a day for anxiety disorder. Review of Resident 29's Psychological Consultation Report, dated 1/10/2020, indicated the psychologist recommended to consider GDR for Resident 29's buspirone. But there was no document that the psychologist's recommendation was presented to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 18 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physician. During an interview with the DON on 3/5/2020 at 10:10 a.m., she stated GDR needed to have the order from the physician, but the psychologist's recommendation for GDR for Resident 29's buspirone was not presented to the physician for review. 4. Review of Resident 43's Admission Record indicated she was admitted on 10/22/15 with diagnosis of depressive disorder. Review of Resident 43's physician order, dated 2/5/19, indicated she had an order for Remeron 7.5 mg at bedtime for depressive disorder. Review of Resident 43's Note To Attending Physician/Prescriber, dated 1/23/2020, indicated the consultant pharmacist recommended to consider a dose reduction for Resident 43's Remeron. The physician responded to maintain the same dose but did not provide the rationale. During an interview with the director of nursing (DON) on 3/5/2020 at 10:14 a.m., she confirmed there was no rationale provided for maintaining Resident 43's Remeron at the same dose5. Review of Resident 27's clinical record indicated she was admitted on 12/31/16 with diagnoses to include major depressive disorder (a mental disorder with feelings of sadness, and loss of interest in activities). Review of Resident 27's physician order, dated 7/20/18, indicated an order for Lexapro 20 mg. by mouth one time a day for depression. Review of the consultant pharmacist's note, dated 7/24/19, indicated to evaluate the current dose and consider a dose reduction as Resident 27 was on the same dose since 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 19 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The physician's response was a check marked "condition stable" but did not provide a specific rationale for maintaining the dose. During a concurrent interview and record review with the DON on 3/5/2020 at 3:25 p.m., she acknowledged there was no specific rationale from the physician for maintaining the current dose. 6. During review of Resident 49's physician order dated 12/17/19, indicated "Zyprexa solution. Inject 2.5 mg intramuscularly every six hours as needed related to dementia. Zyprexa tablet 5 mg (Olanzapine). Give 1 tablet by mouth three times a day related to dementia". There was no stop date within duration of 14 days. During interview with LVN A on 03/05/2020 at 9:15 a.m., LVN A stated confirmed there was no stop date for the order and acknowledged that it should be limited to 14 days.

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 04/03/2020 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility had a 13.3% medication error rate when four medication errors out of 30 opportunities were observed during medication pass observation, for three of three randomly selected residents (Residents 27, 38, and 41). These failures could potentially jeopardize the residents' health. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 20 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. During a medication pass observation on 3/2/2020 at approximately 4:55 p.m., registered nurse G (RN G) had four oral medications for Resident 27. The medications were Namenda 5 milligram (mg. a metric unit of mass) 1 tablet for Alzheimer's, a progressive disease that destroys memory; Quetiapine 50 mg. (an antispychotic, drug to treat psychosis, mental disorder where there is a disconnection from reality); Calcium 600 mg. Vitamin D3 400 U 1 tablet (a Vitamin supplement); and Carbidopa levodopa ER 50-200 mg.(extended release) 1 tablet for Parkinson's disease ( central nervous system disorder that affects causes tremors). RN G crushed all the medications and mixed them all in one cup with applesauce and administered it to Resident 27. During a concurrent interview with RN G, she stated she had to crush and mix the drugs with applesauce, as Resident 27 had trouble swallowing the pills. When informed that Carbidopa was an ER (drugs formulated so the drug is released over time providing a more consistent level of drug in the body), she acknowledged that it should have not been crushed. Review of Resident 27's physician order, dated 12/7/19, indicated an order of CarbidopaLevodopa 50-200 mg. Give one tablet by mouth three times a day related to Parkinson's disease. Should be taken at least 30-60 minutes prior to any meals including protein. A physician's order, dated 11/9/18, indicated " May crush all crushable medications together and give with applesauce". According to the website," http:// online.lexi.com/lco/action/home",(online reference for clinical drugs), indicated Carbidopa-levodopa tablet should be swallowed whole; do not crush, or chew. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 21 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the facility's revised policy, dated 4/2007, " Crushing medications", indicated... one of the guidelines to crushing a medication was... The medication administration record (MAR) or other documentation must indicate why it was necessary to crush the medication. 2. During a medication pass observation on 3/2/2020 at approximately 5 p.m., (RN G) stated she forgot to give one more medication to Resident 27. The medication was buspirone HCL (medication for anxiety, a nervous disorder characterized by a state of excessive uneasiness and apprehension) 15 milligram (mg., a metric unit of mass) orally. RN G crushed the medication, mixed it with applesauce and gave it to the resident. Review of Resident 27's physician order dated 12/19/19, indicated buspirone HCL tablet,15 mg. three times a day related to anxiety disorder. Review of Resident 27's medication administration (MAR) for March 2020, indicated it was scheduled for 0900 (9 a.m.), 1500 (3 p.m.), and 2000 (8 p.m.). During an interview with the day shift licensed vocational nurse H (LVN H), on 3/3/2020 at 2:30 p.m., she stated she gave the 3 p.m. dose on 3/2/2020 at 2 p.m. (one hour before) as 3 p.m. was not a good time since it was change of shift. The MAR indicated it was given at 3 p.m. During an interview with RN G on 3/3/2020 at 3:45 p.m., she stated she thought the buspirone was not yet administered because the e-mar (electronic MAR ) was yellow for the time indicated, which meant it was not yet given. However, she confirmed she did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 22 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE check the MAR that indicated it was already given at 3 p.m. and that the next scheduled dose was at 8 p.m. RN G documented the medication as given at 8 p.m. 3. During a med pass observation on 3/3/2020 at 7:57 a.m., licensed vocational nurse C (LVN C) had 11 oral medications and 1 oral inhaler to administer to Resident 41. One of the oral medications to be administered was Gabapentine (a nerve pain medication and medication also for seizure) 600 mg, one tablet, which was not available at that time. During a concurrent interview with LVN C, she stated the nurse would usually send a refill request to pharmacy with enough time (i.e. three days before it runs out) for pharmacy to send the refill. LVN C peeled the sticker form the bubble pack (medication individually packed in a plastic bubble). She stated the pharmacist would usually send it through same day delivery and usually in the afternoon. Review of Resident 41's physician's order, dated 1/9/2020, indicated an order of Gabapentin 600 mg. one tablet by mouth two times a day related to other chronic pain. The resident missed the 9 a.m. medication and not given as documented in the MAR. 4. During a medication pass observation on 3/3/2020 at approximately 8:35 a.m., LVN C stated she had a nasal spray medication for Resident 38. She stated Resident usually administered her own nasal spray under her supervision. LVN C showed this surveyor "Azelastine 0.1% nasal spray (medication used to relieve nasal symptoms such as runny/itching/stuffy nose, sneezing, and post nasal drip caused by allergies)," Use 2 sprays in each nostril twice daily". Resident 38 stated she was a retired RN and administered 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 23 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE separate nasal sprays in each nostril". Review of Resident 38's physician's order, dated 1/20/2020, indicated " Azelastine HCL Solution 137mcgs/spray, 1 spray in both nostrils two times a day. During an interview and concurrent record review with LVN C on 3/4/2020 at 9:30 a.m., she stated the label indicated ''2 sprays". She stated she knew it was a new order as Resident 38 had requested for two sprays. LVN C confirmed the order and acknowledged she did not check the physician's order and based it solely on the the label. She also confirmed there was no order clarification made from the physician. Review of the facility's revised policy, dated 12/2012, indicated...Medications must be administered in a safe and timely manner and as prescribed... Medications must be administered in accordance with the orders, including any required time frame.

F770 SS=D Laboratory Services CFR(s): 483.50(a)(1)(i)

F770 04/03/2020 §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 24 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to follow physician's orders for two of 12 residents (Residents 6 and 12) when 1. Resident 6's hepatic function panel (a blood test to check how well the liver is working) and serum creatinine (a waste product that forms when creatine, which is found in the muscle, breaks down) and electrolytes panel (measures the blood levels of sodium, potassium, chloride, and carbon dioxide; creatinine and electrolytes levels are factors in determining the kidney health) were not done in 9/2019; and 2. Resident 12's hemoglobin A1C (HgA1C, blood test that indicate average level of blood sugar (BS) over a period of two-three months) every three months was not done in 12/2019. These failures had the potential to jeopardize the health and safety of the residents by causing a delay in appropriate treatment. Findings: 1. Review of Resident 6's Admission Record indicated she was admitted on 7/31/16 with diagnoses including depressive disorder (a medical illness that causes feelings of sadness and/or a loss of interest in activities once enjoyed) and delusional disorder (a disorder where a person has trouble recognizing reality; a person with this illness holds a false belief firmly, despite clear evidence or proof to the contrary). Review of Resident 6's physician order indicated she had orders for Depakote (a drug used to treat manic-depressive illness; it may cause serious allergic reactions affecting multiple body organs such as liver or kidney) 250 milligrams (mg, a metric unit of mass) in the morning for depressive disorder, started on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 25 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3/1/19, and 500 mg in the evening for delusional disorder, started on 4/3/19. Resident 6 also had physician orders for hepatic function panel every six months, started on 3/19/19, and serum creatinine and electrolytes panel every six months, started on 3/28/19. Review of Resident 6's clinical record indicated hepatic function panel was done on 3/20/19, but it was not done in 9/2019, and serum creatinine and electrolytes panel was done on 3/29/19, but it was not done in 9/2019. During an interview with the director of nursing (DON) on 3/4/2020 at 4:58 p.m., she reviewed Resident 6's clinical record and was unable to locate 9/2019 laboratory results for hepatic function panel and serum creatinine and electrolytes panel.2. Review of Resident 12's clinical record, indicated he was originally admitted to the facility on 1/21/13 with diagnoses to include hemiplegia (paralysis of one side of the body) and hemeparesis (muscle weakness or partial paralysis on one side of the body) related to cerebrovascular disease (stroke), and diabetes (high blood sugar). Review of Resident 12's physician order dated 12/4/19, indicated an order for hemoglobin A1C (HgA1C, blood test that indicate average level of blood sugar (BS) over a period of twothree months) every three months related to diabetes. Resident 12 was on insulin medication (insulin, a hormone which regulates the amount of glucose in the blood. A lack of insulin causes a form of diabetes). Review of Resident's laboratory results for HgA1C, indicated results for the following months: 3/6/19 = 6 (H high), 6/6/19 = 6.3 (H), and 9/7/19 = 6.5 (H). There was no result for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 26 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE December. During an interview with licensed vocational nurse A (LVN A) on 3/5/2020 at 9 a.m., she confirmed the finding. She stated she would review the medical records. During an interview with the medical record director (MDR) on 3/5/2020 at 12: 29 p.m., she confirmed there was no HgA1C done for the month of December. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 04/03/2020 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: 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. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 27 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The resident room measurements were as follows: Room Number Bed Capacity Square Feet Per Resident 1 2 3 4 5 6 7 10 11 12 14 17 18 19 20 22 2 3 2 3 2 3 3 3 2 2 2 4 2 2 2 3 72.00 66.12 79.25 68.45 74.29 75.03 75.03 74.20 72.00 72.00 72.00 69.70 72.00 72.00 78.00 76.00 During 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. 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PSGQ11 Facility ID: CA070000078 If continuation sheet 28 of 29 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: PSGQ11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA070000078 (X5) COMPLETE DATE If continuation sheet 29 of 29