The Pavilion at Ocean Point

In the surveyor’s words

From the most serious findings on record at The Pavilion at Ocean Point, in the surveyor’s own words.

• Actual harm, isolatedF692Mar 2, 2026

  Based on observation, interview and record review, the facility failed to monitor intake, initiate weekly weights and implement timely interventions to address significant weight loss for 1 of 3 residents (116) reviewed for nutritional status.This failure resulted in a significant decline in Resident 116's weight from 141.8 pounds (lbs.) in December 2025 to 112.6 lbs. by February 2026.Findings:Resident 116 was admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing) and major depression per the facility admission record.Facility weight records indicated Resident 116 weighed 153.8 pounds (lbs.) on 7/27/25.The nutritional risk assessment (NRA), dated 7/31/25, indicated a goal weight range (GWR) of 145 to 165 lbs. […]

• Actual harm, isolatedF600Sep 14, 2021

  Based on observation, interview, record review and document review, the facility failed to ensure two of five residents (Resident 1 and Resident 2) were free from abuse when: 1. Certified Nursing Assistant 1 (CNA 1) pushed Resident 1 hard and told the resident, Why don't you god damn move, during care. 2. Certified Nursing Assistant 1 (CNA 1) punched and roughly handled Resident 2 during care. These failures resulted in physical and psychological harm to both Resident 1 and Resident 2. Findings: 1. Resident 1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet indicated Resident 1 was her own responsible party. […]

• Actual harm, isolatedF610Sep 14, 2021

  Based on observation, interview, record review and document review, the facility failed to protect one of two residents (Resident 2) from abuse when certified nursing assistant (CNA) 1, who was involved with a previous alleged abuse, was allowed to return to work prior to the completion of the facility's abuse investigation. As result, Resident 2 was punched by CNA 1 which caused the resident pain and also caused the resident to experience anger. This had the potential to affect all residents at the facility. Findings: An unannounced visit to the facility was conducted on 3/15/21 due to allegations of abuse reported by the facility. […]

• No harm, potential for more than minimal, widespreadF725Mar 2, 2026

  Based on interview and record review, the facility failed to ensure that sufficient staff were available to provide care and services to the residents in a timely manner. As a result, there was a delay in the staff's ability to provide care and services to the resident.Findings:Per the PBJ Staffing Data Report CASPER Report 1705D FY Quarter 4 2025 (July 1 -September 30), the report indicated the facility had a one star staffing rating and excessively low weekend staffing.During an interview on 2/25/2026 at 10:00 A.M. with Resident 13, Resident 13 stated there are times when I wait a long time for help, but I can do most things on my own. So that's good. Others can't, I feel bad for them when they have to wait. […]

• No harm, potential for more than minimal, widespreadF865Mar 2, 2026

  Based on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify areas of improvement and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), the facility's staffing needs identified during the facility's recertification survey and in the Payroll-Based Journal (PBJ- a mandatory , electronic reporting system which tracked hours worked, staff turnover, tenure and census data for long-term care facilities).Cross reference F725 This failure had the potential to affect resident care.Findings: During a review of the facility's PBJ Staffing Data Report, Quarter four 2025 (July 1- September… […]