Other·March 23, 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 an abbreviated survey regarding a complaint investigation conducted on 3/19/2020. For Complaint CA00680278 , regarding Quality of Care/Treatment, a federal deficiency was identified (see F755). For Complaint CA00680362, regarding Admission, Transfer and Discharge, a federal deficiency was identified (see F624). A "G" level deficiency was identified (see

F624). A Class "B" citation was also issued Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 35790, Health Facilities Evaluator Nurse,

F624 SS=G Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 04/10/2020 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: 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: 7K2T11 Facility ID: CA070000078 If continuation sheet 1 of 5 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 03/19/2020 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 provide one of two sampled residents (Resident 2) with a safe and orderly discharge, when Resident 2 who was assessed to be cognitively impaired with at risk for elopement (who is incapable of adequately protecting herself and who departs the health care facility unsupervised), was allowed to leave the facility against medical advice (AMA, resident chooses to leave before the physician recommends discharge) on 2/16/2020 at 3:45 p.m. This resulted in Resident 2 being located four hours later when the police found her on 2/16/2020 at 8:15 p.m., sitting on a bench with complaint of weakness, knee pain, feeling very cold and shaking. Findings: During review of Resident 2's clinical record, Resident 2 was admitted on 3/11/19 with diagnoses included Alzheimer's disease (memory loss and cognitive decline), osteoarthritis (inflammation of joints) and muscle weakness. Review of Resident 2's minimum data set (MDS, resident tool assessment) dated 12/08/19, indicated Resident 2 was severely cognitively impaired and required extensive assistance with one-person physical assist during transfers. Review of Resident 2's elopement - wandering (traveling aimlessly from place to place) risk scale dated 3/11/19, score indicated 9 (at risk to wander). During a review of Resident 2's progress notes dated 2/16/2020, indicated at 3:45 p.m., the licensed nurse heard the alarm go off at the front door and seen Resident 2 exit the facility. The licensed nurse tried to convince her to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7K2T11 Facility ID: CA070000078 If continuation sheet 2 of 5 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 03/19/2020 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 return inside the facility but Resident 2 did not want to return. The nurse asked Resident 2 to sign the AMA form and then allowed Resident 2 to leave the facility as she headed towards the ocean on the sidewalk. At 5:30 p.m., two certified nursing assistants (CNAs) were sent to search for the resident but they could not find her. At 8:15 p.m., the licensed nurse received a telephone call from the police that Resident 2 was found and she was sent to the hospital for an evaluation. Review of Resident 2's hospital history of present illness (H&P) dated 2/16/2020, indicated Resident 2 was admitted for elevated troponin (group of proteins found in skeletal and heart (cardiac) muscle fibers that regulate muscular contraction, measure the level of cardiac-specific troponin in the blood to help detect heart injury), altered mental status which could be from her dementia (memory loss) versus infection. Resident 2 was found wandering in the streets. Apparently, she signed out against medical advice despite having a wander anklet (alarmed anklet, to protect those wander-prone person leaving the facility unattended) on the left. She had no home, and walked 5 miles and became very cold and weak. She was found sitting on a bench complaining of weakness, left knee pain, feeling very cold and shaking. During an interview with the social worker (SW) on 3/12/20 at 1:56 p.m., the SW stated the licensed nurse should not have allowed Resident 2 to sign out AMA because the resident was demented and it was not a safe discharge.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records FORM CMS-2567(02-99) Previous Versions Obsolete

F755 Event ID: 7K2T11 04/10/2020 Facility ID: CA070000078 If continuation sheet 3 of 5 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 03/19/2020 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 CFR(s): 483.45(a)(b)(1)-(3) §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure medications were available for administration for one of two residents (Resident 1). Resident 1 did not have a physician ordered Ativan (a medication used for seizures), which had the potential for the resident's prescribed treatment to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7K2T11 Facility ID: CA070000078 If continuation sheet 4 of 5 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 03/19/2020 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 ineffective. Findings: During review of Resident 1's clinical record, Resident 1 was admitted on 2/06/2020 with diagnoses included malignant neoplasm (cancerous tumor) of brain, cerebral infarction (stroke) and seizures (sudden, uncontrolled electrical disturbance in the brain). Review of Resident 1's physician's order dated 3/09/2020, indicated "Ativan tablet 1 mg (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for seizure activity." Review of Resident 1's progress notes dated 3/9/2020, indicated "...Ativan 0.25 mg Sublingual (under the tongue) given at 6:50 p.m., ineffective. Resident 1's wife called the physician and ordered Ativan 0.75 mg at onetime order, which was given at 7:20 p.m. Resident 1 started to have facial twitching ..." During interview with registered nurse A (RN A) on 3/12/2020 at 12:07 p.m., RN A stated in the evening of 3/9/20, Resident 1 had a seizure activity and the physician ordered to give one and half tablet of Ativan 0.5 mg per tablet but there was no stock available of Ativan for Resident 1 so she had to take it from another resident's supply of Ativan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7K2T11 Facility ID: CA070000078 If continuation sheet 5 of 5