Ocean View Post Acute

In the surveyor’s words

From the most serious findings on record at Ocean View Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689May 12, 2026

  Based on interview, and record review, the facility failed to provide care and services to prevent accidents for one of five sampled residents (Resident 1) who has left sided hemiplegia (paralysis affecting one side of the body) and hemiparesis (one-sided weakness). Resident 1 was left unattended in bed while she was turned on her left side and the bed raised in a high position.As a result, Resident 1 fell off the bed and sustained a femoral neck fracture (fractured hip), which required surgical intervention.Findings:During a record review, the undated Facility admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia (a form of paralysis that causes loss of movement to one side of the body) following… […]

• No harm, potential for more than minimal, patternF880Jun 5, 2025

  Based on observations, interview, and record review the facility failed to ensure infection control procedures were followed when staff did not wear a gown for residents (47, 52 and 306) with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds and medical devices and with history of multidrug-resistant organism- MDROs]). These failures had the potential for cross contamination, spread of infection and residents' decline of health. Findings: 1. Resident 47 was readmitted to the facility on [DATE], with diagnoses which included methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), per the facility's admission Record. […]

• No harm, potential for more than minimal, isolatedF761Aug 27, 2026

  Based on observation, interview and record review, the facility failed to ensure medications were safely secured when Resident 1's medications were left unattended by nursing staff and the medication cart was not locked for 1 of 3 medication carts observed. This failure had the potential to affect residents' safety and may lead to drug diversion (the illegal distribution, transfer, or use of a prescription medication outside its intended medical purpose). Findings:Per the Facility's admission Record, Resident 1 was admitted on [DATE] with diagnoses which included Quadriplegia (a medical condition involving the partial or total paralysis of all four limbs and the torso) and Generalized Anxiety Disorder (a mental health condition defined by constant , excessive worry about everyday things… […]

• No harm, potential for more than minimal, isolatedF627May 12, 2026

  Based on interview and record review, the facility failed to allow one of three sampled residents (Resident 1) to return to the facility following a visit to the emergency department.This failure had the potential for Resident 1 to not receive continuity of care and violated his right to return to the facility per the facility's policy.Findings:According to the facility's admission Record, Resident 2 was admitted to the facility on [DATE] with diagnoses which included aphasia (a disorder which affects a person's ability to speak or understand speech) following cerebral infarction (a stroke).During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/28/26 indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess thinking… […]

• No harm, potential for more than minimal, isolatedF656Jun 5, 2025

  Based on observations, interviews and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to: A. Anticoagulant (blood thinner) therapy for Resident 47, B. Enhanced Barrier Precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds and medical devices]) practices when providing care to residents on EBP (Resident 47 and Resident 52), and, C. […]