Report
TheVardellReport
Oceanview Post Acute
Skilled nursing facility and nursing facility
200 Lighthouse Avenue
Pacific Grove, CA 93950
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The Vardell Report.Oceanview Post Acute
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Pacific Grove, CA
- Record Period
- 2022–2025
- Source Documents
- 13
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 11 inspections from June 2022 to December 2025, state surveyors documented 47 findings at Oceanview Post Acute; 46 have a recorded correction and 1 awaits one; CMS lists 1 enforcement action in the window.
- Inspections
- 11
- 2022–2025, standard and complaint
- Findings
- 47
- Deficiencies cited by state inspectors
- Corrected
- 46
- Of 47 findings, with a recorded correction date
- Penalties
- 1
- 1 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2022 | 1 | 17 | 0 |
| 2023 | 0 | 0 | 0 |
| 2024 | 6 | 18 | 1 |
| 2025 | 4 | 12 | 0 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 46 of 47 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: denial of payment imposed March 20, 2024, ended April 26, 2024.
- 8 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, December 12, 2025, recorded 9 findings (most serious: Level E).
What to Ask About
- Infection Control, Cited in Four Inspections
- Pharmacy Services, Cited in Three Inspections
- Kitchen and Food Safety, Cited in Three Inspections
- Provide appropriate foot care, Cited in Two Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Dialysis Care, Cited in Two Inspections
- Medication Error Rate, Cited in Two Inspections
- Medication Labeling and Storage, Cited in Two Inspections
- Garbage and Refuse, Cited in Two Inspections
- Citation F912, No Recorded Correction
Report at a Glance
- Facility
- Oceanview Post Acute
- Address
- 200 Lighthouse Avenue, Pacific Grove, CA 93950
- CMS Certification Number
- 055356
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 51
- Ownership
- For profit - Limited Liability company
- Record Window
- June 10, 2022 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Standard health inspection
9 findings
- F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level ENo actual harm, potential for moreCorrected Dec 17, 2025
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Dec 17, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Dec 17, 2025
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level ENo actual harm, potential for moreCorrected Dec 17, 2025
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Dec 17, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Dec 17, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 17, 2025
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Dec 17, 2025
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmNo revisit needed
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 6, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level DNo actual harm, potential for moreCorrected Apr 25, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F567Honor the resident's right to manage his or her financial affairs.Level DNo actual harm, potential for moreCorrected Oct 7, 2024
- F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel DNo actual harm, potential for moreCorrected Sep 13, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Sep 13, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Sep 4, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Sep 4, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Aug 21, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
10 findings
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Jun 10, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jun 10, 2024
- F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Jun 10, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jun 10, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 10, 2024
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Jun 10, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 10, 2024
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jun 10, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 10, 2024
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Jun 10, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 26, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2022
Standard health inspection
17 findings
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Jul 9, 2022
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level ENo actual harm, potential for moreCorrected Jul 9, 2022
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Jul 9, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jul 9, 2022
- F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 9, 2022
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Jul 9, 2022
Enforcement Action
Denial of payment imposed March 20, 2024. Status: Closed, April 26, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 10, 2022, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Infection Control, Cited in Four Inspections
Inspectors cited F880 in June 2022, May 2024, August 2024 and December 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F880 across all 11 inspections, oldest to newest - 2
Pharmacy Services, Cited in Three Inspections
Inspectors cited F755 in June 2022, May 2024 and August 2024. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F755 across all 11 inspections, oldest to newest - 3
Kitchen and Food Safety, Cited in Three Inspections
Inspectors cited F812 in June 2022, May 2024 and December 2025. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F812 across all 11 inspections, oldest to newest - 4
Provide appropriate foot care, Cited in Two Inspections
Inspectors cited F687 in June 2022 and October 2024. The agency describes it this way: Provide appropriate foot care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F687 across all 11 inspections, oldest to newest - 5
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in March 2024 and September 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F689 across all 11 inspections, oldest to newest - 6
Dialysis Care, Cited in Two Inspections
Inspectors cited F698 in June 2022 and May 2024. This citation covers care for residents who need dialysis. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F698 across all 11 inspections, oldest to newest - 7
Medication Error Rate, Cited in Two Inspections
Inspectors cited F759 in June 2022 and May 2024. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F759 across all 11 inspections, oldest to newest - 8
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in June 2022 and May 2024. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F761 across all 11 inspections, oldest to newest - 9
Garbage and Refuse, Cited in Two Inspections
Inspectors cited F814 in June 2022 and May 2024. This citation covers whether garbage and refuse are disposed of properly. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2224242424242425252525F814 across all 11 inspections, oldest to newest - 10
Citation F912, No Recorded Correction
F912 was cited in June 2022, May 2024 and December 2025. The agency describes it this way: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The most serious was level B (potential for minimal harm). The December 2025 citation has no recorded correction date; its status reads “No revisit needed.” The record does not show whether the problem was fixed.
2224242424242425252525F912 across all 11 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in four inspections, most seriously at level D.
- 02
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in three inspections, most seriously at level D.
- 03
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level E.
- 04
What changed after F687 was cited, and how do you check it now?
Provide appropriate foot care: cited in two inspections, most seriously at level D.
- 05
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level G.
- 06
How is dialysis care coordinated, and who monitors residents before and after treatment?
Dialysis Care: cited in two inspections, most seriously at level D.
- 07
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level E.
- 08
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level D.
- 09
How is waste handled around the kitchen and resident areas?
Garbage and Refuse: cited in two inspections, most seriously at level E.
- 10
What changed after F912 was cited, and how do you check it now?
Citation F912: cited in three inspections, most seriously at level B. The December 12, 2025 citation has no recorded correction date.
- 11
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in May 2024.
- 12
What led to the 2024 denial of payment, and what would you want a family to know about it?
Denial of payment was imposed March 20, 2024; it ended April 26, 2024.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Jun 10, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Mar 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection May 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Aug 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Aug 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Aug 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Oct 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Apr 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Apr 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Sep 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Dec 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 055356
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowJune 10, 2022 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before June 2022 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.