Inspection Reports for Oceanside Skilled Nursing and Rehabilitation

The complaint investigation found substantiated issues including unaddressed Resident Council grievances about snack availability, delayed physician response to pharmacist medication review recommendations, and missed quarterly smoking evaluation for a resident.

The facility failed to act on Resident Council grievances regarding snack availability, did not ensure timely physician review of pharmacist medication recommendations for one resident, and failed to follow established smoking policy for one resident.

The complaint investigation found that Resident #1 eloped on 7/28/24 after the front door alarm sounded and was deactivated by staff without notifying nursing personnel. The resident was located at a nearby gas station and later taken to a hospital after going to a fire station with abdominal pain. The facility conducted a Root Cause Analysis and implemented staff re-education and weekly mock elopement drills.

The facility failed to ensure adequate supervision when a door alarm sounded, resulting in a resident elopement. Interviews and record reviews revealed that staff deactivated the alarm without notifying nursing staff, and the resident was found offsite after taking a taxi to a homeless shelter and later hospitalized.

The facility failed to ensure appropriate pressure ulcer care for 2 residents by not providing timely treatment orders and weekly wound assessments. Additionally, infection control practices were not maintained during wound care, including improper glove use, hand hygiene, and equipment cleaning.

The complaint investigation found that the facility failed to provide CPR according to guidelines for one resident who expired. The Director of Nursing was unable to establish a clear timeline for CPR initiation. It was estimated CPR was started 10-15 minutes after the resident was found unresponsive. The facility implemented corrective actions including a full house audit of code status, mock codes, and a QAPI project.

The facility failed to initiate CPR promptly for Resident #1 who had a full code order. Interviews with nursing staff revealed delays in starting CPR, lack of immediate use of the automated external defibrillator (AED), and procedural deficiencies. The facility responded by conducting a house audit of resident code status, implementing mock CPR drills, and starting a Quality Assurance Plan Improvement (QAPI) project focused on CPR.

The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment, failure to follow physician orders for several residents, failure to provide necessary equipment for a resident with limited range of motion, medication security and labeling issues, improper food storage, and incomplete documentation of a resident fall.

The complaint investigation revealed substantiated issues including failure to monitor fluid intake and weights, failure to notify provider of abnormal labs, failure to send resident to hospital when requested, and lack of nursing competencies for IV therapy.

The facility failed to ensure that a resident received treatment and care in accordance with physician orders for intravenous fluid management, failed to monitor and document fluid intake and weights as ordered, did not notify the provider of abnormal lab results, and failed to send the resident to the hospital when requested. Additionally, licensed nurses and nurse aides lacked the appropriate competencies and certifications for intravenous fluid administration.

The facility was found deficient in ensuring weekly documentation of pressure ulcer assessments for a resident, removal of expired medication from medication carts, and proper food storage and sanitation in the kitchen. Several expired food items and unsanitary conditions were observed, and expired medication was found on a medication cart.