Oceanview Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 20, 2024

  Based on interview, and record review, the facility failed to develop and implement interventions for fall care plan to prevent accidents for one of three sampled residents (Resident 1). The facility failed to initiate a fall care plan when Resident 1 was admitted with high fall risk and did not develop care plan for fall after subsequent falls at the facility. This failure resulted in Resident 1's fall with right wrist fracture (broken bone). Findings: Review of Resident 1's Admission Record, it indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, right side, unspecified injury of head, wedge compression fracture of thoracic vertebra (bone at the midback), paroxysmal atrial fibrillation (an irregular and often very rapid heart… […]

• No harm, potential for more than minimal, patternF605Dec 12, 2025

  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. […]

• No harm, potential for more than minimal, patternF804Dec 12, 2025

  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. […]

• No harm, potential for more than minimal, patternF812Dec 12, 2025

  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. […]

• No harm, potential for more than minimal, patternF887Dec 12, 2025

  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. […]