Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oceanside Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not serve meals according to the posted menus and standard recipes on two occasions, failing to provide sour cream with baked potatoes and omitting meat from baked ziti without offering a substitute protein. Residents reported dissatisfaction with the meals, and staff interviews confirmed the deviations from the planned menus.
Surveyors identified that food was not served at safe or appetizing temperatures, with cold items like salad, milk, and fruit being served warm, and hot foods such as pasta lacking flavor and expected ingredients. Residents and staff reported dissatisfaction with food temperature, taste, and presentation, including salads being served on the same plate as hot pasta, resulting in unpalatable meals.
A resident with asthma, toe amputation, and depression was found with an inhaler, antacid, and topical steroid at the bedside without staff awareness, assessment, or physician's order for self-administration. The resident was cognitively intact but required ADL assistance. Staff interviews confirmed that medications should not be left at bedside without proper assessment and orders, and facility policy was not followed.
A resident with chronic respiratory failure and COPD did not have their oxygen tubing changed weekly as ordered by the physician, and the tubing was often undated and stored in an unsanitary manner, such as on books and near bird seed. Despite documentation indicating compliance, observations and interviews revealed that staff did not consistently follow the required procedures for changing, labeling, and storing the oxygen tubing.
A resident with multiple documented food allergies, including eggs and peaches, was served food items containing these allergens due to inconsistent documentation and lack of cross-checking between the diet ticket, electronic health record, and physician orders. Staff interviews confirmed that required allergy checks were not consistently performed by kitchen and nursing staff, resulting in the resident being provided with foods they could not safely consume.
The facility failed to store food properly, with a refrigerator consistently above the safe temperature of 41°F, leading to a risk of foodborne illness. Observations revealed unlabeled and expired food items, including red sauce, cooked chicken, and chocolate pudding with mold. The Foodservice Director admitted the refrigerator had been warm for two days and that expired food should have been discarded. The Director of Nursing confirmed that expired food should have been thrown away and food should have been moved from the warm refrigerator.
The facility failed to implement an Antibiotic Stewardship Program as required by CDC guidelines. The ADON admitted that the facility does not regularly discuss infection tracking or trending, and lacks a consistent process for gathering monthly antibiotic use data. The DON, new to the facility, acknowledged the absence of the program and was unaware of current infection control rates, unable to provide related documentation.
A facility failed to maintain proper temperatures in a reach-in refrigerator, storing resident food at unsafe levels. Despite the refrigerator running warm for two days, the Food Service Director did not relocate the food, and the Director of Nursing confirmed that expired food should have been discarded. Observations showed temperatures rising from 50 to 60 degrees Fahrenheit, with the refrigerator feeling warm and musty.
A facility failed to create a comprehensive care plan for a resident with Type 2 Diabetes Mellitus, as required by their policy. Despite having physician's orders for insulin and regular HGB A1C testing, the resident's care plan did not address their diabetes. Interviews with staff confirmed the absence of a diabetes care plan, highlighting a lapse in following the facility's care planning procedures.
A resident with severe cognitive impairment and high risk for pressure ulcers was using an air mattress without a physician's order. Despite hospice recommendations typically being reviewed and approved by the facility's Nurse Practitioner, there was no documentation or order for the air mattress, indicating a lapse in protocol.
The facility failed to provide necessary assistance with ADLs for two residents, leading to deficiencies in care. A resident with severe cognitive impairment and dysphagia was left unsupervised during meals, contrary to care plans and physician orders requiring one-to-one assistance. Another resident with a stage 4 pressure ulcer and dysphagia struggled to eat without the required cueing and assistance, as staff left them alone during meals. Interviews revealed a lack of understanding of care plan requirements among staff.
A resident with a PICC line and foot wounds did not receive care according to professional standards and physician orders. The PICC line dressing was not changed when obscured by blood, and measurements were not taken as required. Additionally, new wound care orders from a hospital discharge were not transcribed or implemented, leading to continued use of previous treatments. Interviews confirmed these lapses in care.
A resident with a stage 4 pressure ulcer had their air mattress set significantly higher than their weight, contrary to manufacturer's guidance. The resident's weight was 164 pounds, but the mattress was set at 280 and 300 pounds. Interviews with staff indicated a lack of adherence to the facility's policy of setting the mattress according to the resident's weight, potentially impacting wound healing.
A resident with severe cognitive impairment and dysphagia was observed eating alone without required one-to-one supervision, despite physician orders for aspiration precautions. The facility's records inaccurately indicated that supervision was provided, as confirmed by nursing staff interviews.
The facility failed to ensure proper hand hygiene during medication administration. A nurse was observed not performing hand hygiene before and after glove use while administering medications, including eye drops and insulin injections. Interviews confirmed that staff were aware of the hand hygiene protocols, but the nurse did not adhere to them.
Failure to Follow Menus and Provide Required Meal Components
Penalty
Summary
The facility failed to follow its posted menus and standard recipes for two consecutive lunch meals, resulting in residents not receiving the food items as planned or appropriate substitutions. On one occasion, residents were served baked potatoes without the required sour cream, despite the menu and recipe specifying its inclusion. Multiple residents expressed dissatisfaction during a group meeting and directly to the surveyor, noting the absence of sour cream and the lack of adherence to the menu. Observations confirmed that the lunch meal did not include the specified condiment, and residents' requests for sour cream went unmet. On another occasion, the facility served baked ziti with plain tomato sauce instead of the required meat sauce, as the meat was not thawed in time and no substitute protein was provided. Residents interviewed during this meal reported the pasta lacked flavor and meat, indicating a deviation from the planned menu and recipe. The Food Service Director acknowledged the failure to provide the correct meal components and did not notify administration or the dietitian in time to arrange for an alternative. The dietitian confirmed the importance of the missing protein and was unaware of the change prior to meal service.
Failure to Serve Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors found that the facility failed to serve food that was palatable and at safe, appetizing temperatures on both units. Thirteen residents voiced dissatisfaction with the temperature and taste of the food, and during a group meeting, residents reported that cold foods were not always served cold, hot foods were not always served hot, menus were not always followed, and condiments were missing. Test trays revealed that cold items such as salad, milk, fruit cup, and juice were served at temperatures above the facility's policy limits, with salads and fruit cups being warm and unappetizing. Hot foods like pasta were served at appropriate temperatures but were described as bland and lacking expected ingredients, such as meat. Bread items were found to be too hard to chew. Additionally, salads were served on the same plate as hot pasta, causing them to become warm and wilted, and residents consistently reported dissatisfaction with the taste and temperature of their meals. Staff interviews confirmed that salads were routinely served on the same plate as hot foods, and that meat was omitted from the pasta due to lack of preparation. The Food Service Director acknowledged not thawing meat for the meal, and both the Administrator and Dietitian stated that salads and cold items should have been served separately to maintain proper temperatures. The facility's own policies require hot foods to be served hot and cold foods cold, with specific temperature guidelines for potentially hazardous foods, but these were not followed during the observed meal service.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including asthma, toe amputation, and depression was observed to have a Primatene mist inhaler, calcium carbonate tablets, and triamcinolone cream on the over-bed table in full view. The resident reported that nursing staff were not aware of the inhaler and that these medications had been at the bedside for some time. The resident was cognitively intact but required assistance with activities of daily living. Review of the medical record revealed no assessment for the ability to self-administer medications, no physician's order for self-administration, and no care plan addressing self-administration of medications. Additionally, there were no physician's orders for the inhaler or calcium carbonate. Multiple staff interviews confirmed that residents should not have medications at the bedside without an assessment and physician's order. The DON acknowledged that the resident had not been assessed for self-administration of medications. Nursing and CNA staff stated that medications should not be left at the bedside and would have removed them if noticed. Facility policy requires an interdisciplinary team assessment and documentation in the medical record and care plan before allowing self-administration, which was not followed in this case.
Failure to Change and Sanitarily Store Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and COPD by not adhering to physician's orders and professional standards. Specifically, the resident's oxygen tubing was not changed weekly as ordered, and the tubing was frequently undated and not stored in a sanitary manner. Multiple observations showed the oxygen tubing resting on unsanitary surfaces such as books and a container of bird seed, and the tubing was not consistently labeled with the date of change. The resident reported that staff had not changed the tubing in several weeks, and this was not the first occurrence of such neglect. Review of the resident's records confirmed a physician's order to change the oxygen tubing weekly, label it with the date and initials, and store it in a respiratory bag when not in use. Documentation in the Treatment Administration Record indicated that the tubing was supposedly changed and labeled as ordered, but direct observations and resident interviews contradicted this. Staff interviews confirmed knowledge of the required procedures, but the Director of Nursing acknowledged ongoing issues with compliance, including a previous grievance regarding the same concern.
Failure to Consistently Accommodate and Document Resident Food Allergies
Penalty
Summary
The facility failed to consistently accommodate and document food allergies for a resident with multiple allergies, resulting in the resident being served food items to which they were allergic. Specifically, the resident, who had diagnoses including diabetes, hypertension, and dementia with moderate cognitive impairment, was observed receiving a breakfast tray containing a hard-boiled egg, despite an egg allergy being listed on their diet ticket. The resident confirmed an allergy to eggs, reporting gastrointestinal symptoms upon ingestion, and stated they would not eat the eggs provided. Additionally, the resident's diet ticket and electronic health record contained inconsistent documentation of allergies, with some allergies such as peaches not being listed on the diet ticket, even though peaches were served multiple times in the facility's menu cycle. Interviews with staff, including CNAs, the DON, the Food Service Director, and the Dietitian, revealed that there were discrepancies between the allergies listed on the diet ticket, the electronic health record, and physician orders. Staff acknowledged that allergies should be checked by both kitchen and nursing staff before food is served, but the process was not consistently followed. The Food Service Director was unaware of the resident's peach allergy due to its omission from the diet ticket, and the Dietitian admitted to not cross-referencing diet ticket allergies with those in the electronic health record during assessments. These lapses led to the resident being at risk of receiving foods they were allergic to.
Improper Food Storage and Labeling in LTC Facility
Penalty
Summary
The facility failed to properly store food items, leading to a risk of foodborne illness. During an initial kitchen walkthrough, a surveyor observed a reach-in refrigerator with a temperature of 50 degrees Fahrenheit, which is above the federal standard of 41 degrees Fahrenheit for refrigerated food storage. The refrigerator contained resident food and emitted a musty smell. Several containers of food, including red sauce, cooked chicken, pinto beans, and chocolate pudding, were found without identification labels and with outdated labels. Additionally, two gallons of milk were past their expiration date. In the dry storage room, a box of potatoes was found with dark, soft spots and green spores, and food boxes were stored directly on the floor. During subsequent visits, the refrigerator's temperature continued to rise, reaching 60 degrees Fahrenheit, and the musty smell persisted. Interviews with the Foodservice Director (FSD) revealed that the refrigerator had been running warm for two days, and the FSD acknowledged that food should have been moved to a different refrigerator. The FSD also admitted that expired food should have been discarded and that the labeling system needed updating. The Director of Nursing and Regional Nurse confirmed that expired food should have been thrown away and that food should have been moved from the warm refrigerator. The FSD was unable to provide evidence that the food in the refrigerator was within a safe temperature range.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program to monitor and promote the appropriate use of antibiotics, as required by the Centers for Disease Control and Prevention (CDC) guidelines. The facility's policy, revised in December 2016, outlined the need for antibiotics to be prescribed and administered under the guidance of the Antibiotic Stewardship Program, with an emphasis on staff training and education. However, the Assistant Director of Nurses (ADON), who also serves as the infection preventionist, admitted that the facility does not meet regularly to discuss tracking or trending of infections and lacks a consistent process for gathering monthly data on antibiotic use. During the survey, the ADON was unable to provide the surveyor with the facility's line listing and antibiotic usage audit tool, indicating that infections are only discussed at Quality Assurance and Performance Improvement (QAPI) meetings quarterly if there is an outbreak. The Director of Nurses (DON), who is new to the facility, acknowledged the absence of an implemented Antibiotic Stewardship Program and was unaware of the current infection control rates. The DON also could not provide any documentation related to the program, highlighting the facility's failure to adhere to its own policy and CDC guidelines.
Improper Refrigerator Temperature Management
Penalty
Summary
The facility failed to ensure that a reach-in refrigerator in the kitchen was functioning properly, leading to improper storage temperatures for resident food. During an initial kitchen walkthrough, a surveyor observed that the refrigerator's thermometer displayed a temperature of 50 degrees Fahrenheit, which is above the federal standard of 41 degrees Fahrenheit for refrigerated food storage. The refrigerator felt warm and had a musty smell, indicating potential spoilage or contamination risk. Subsequent observations showed the temperature rising to 58 and then 60 degrees Fahrenheit, with food still stored inside. Interviews with the Food Service Director (FSD) revealed that the refrigerator had been running warm for two days, yet the food was not moved to a different refrigerator. The FSD acknowledged that the food should have been relocated once the temperature issue was identified. The Director of Nursing and Regional Nurse confirmed that expired food should have been discarded and all food moved from the malfunctioning refrigerator. The FSD was unable to provide evidence that the food temperatures were within a safe range, further highlighting the deficiency in maintaining proper food storage conditions.
Failure to Develop Comprehensive Care Plan for Resident with Diabetes
Penalty
Summary
The facility failed to develop an individualized, comprehensive care plan for a resident diagnosed with Type 2 Diabetes Mellitus (T2DM). According to the facility's policy, a comprehensive, person-centered care plan should be developed within seven days of the completion of the required Minimum Data Set (MDS) assessment and no more than 21 days after admission. This care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. However, upon review, it was found that the resident's active care plans did not include a specific plan addressing their T2DM, despite having physician's orders for insulin administration and regular HGB A1C testing. Interviews with facility staff, including a nurse and the Director of Nursing, confirmed the absence of a T2DM care plan for the resident. The nurse acknowledged that any resident with a T2DM diagnosis should have a corresponding care plan, and the Director of Nursing agreed that the resident should have a person-centered care plan related to their fluctuating blood sugar levels. This oversight indicates a failure to adhere to the facility's policy on developing comprehensive care plans for residents with specific medical conditions.
Failure to Obtain Physician Order for Air Mattress
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice by not obtaining a physician's order for an air mattress for a resident. The resident, who was admitted in June 2023, had diagnoses including unspecified dementia, moderate protein-calorie malnutrition, and polyosteoarthritis. The resident's Minimum Data Set Assessment indicated severe cognitive impairment and a high risk for developing pressure ulcers. Despite these conditions, the resident was observed using an air mattress without a corresponding physician's order documented in their care plans or hospice visitation binder. Observations made by the surveyor on multiple occasions confirmed the resident was using an air mattress set to 80 pounds. Interviews with Nurse #3 and the Director of Nursing revealed that hospice services typically recommend interventions, which are then reviewed and approved by the facility's Nurse Practitioner. However, in this case, there was no documentation or physician's order for the air mattress, indicating a lapse in following the established protocol for implementing hospice recommendations.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, leading to deficiencies in care. Resident #44, who was admitted with a stage 4 pressure ulcer and dysphagia, was observed struggling to eat without the required cueing and assistance. Despite the care plan indicating the need for cueing and occasional assistance, staff left Resident #44 alone during meals, resulting in the resident being unable to properly feed themselves and spilling food and drinks. Interviews with staff revealed a lack of understanding of the care plan requirements, with the CNA unaware of what cueing meant and the Director of Nursing suggesting only intermittent checks rather than continuous supervision. Resident #32, with severe cognitive impairment and dysphagia, was also left unsupervised during meals despite physician orders and care plans requiring one-to-one assistance and supervision. Observations showed Resident #32 eating alone in their room without staff present to ensure adherence to aspiration precautions, such as sitting upright and taking small bites. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the physician's orders for supervision during meals were not being followed. These deficiencies highlight a failure in the facility's adherence to care plans and physician orders, resulting in inadequate support for residents with significant needs. The lack of proper supervision and assistance during meals for both residents indicates a systemic issue in the facility's approach to managing ADLs for residents with severe cognitive and physical impairments.
Failure to Follow PICC Line and Wound Care Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a PICC line, as per professional standards and physician orders. The resident, who was cognitively intact, was readmitted with conditions including osteomyelitis, type 2 diabetes, and cellulitis. The PICC line dressing was not changed when the insertion site was obscured by blood, contrary to the facility's policy and physician orders. Additionally, the PICC line was not measured on admission or during a dressing change, as required. Interviews with nursing staff and the Director of Nurses confirmed that the dressing should have been changed and measurements taken, but these actions were not documented in the resident's medical records. Furthermore, the facility did not transcribe a new treatment order from the resident's hospital discharge paperwork. The discharge summary specified a wound care regimen for the resident's feet, which was not ordered upon the resident's return to the facility. Instead, the resident continued to receive a different treatment that was in place prior to hospitalization. Interviews with the nursing staff and the Director of Nurses revealed that the hospital's wound treatment orders should have been communicated and implemented on the day of admission, but this did not occur.
Improper Air Mattress Setting for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure the air mattress was set at the appropriate setting for a resident with a stage 4 pressure ulcer. The resident, who was admitted with a stage 4 pressure ulcer of the sacral region and dysphagia, was observed with the air mattress set significantly higher than their actual weight. The manufacturer's guidance for the air mattress indicated that the control should be set to the resident's weight, which was 164 pounds, but observations showed the settings at 280 and 300 pounds on different occasions. Interviews with the resident's CNA and nurse revealed that the air mattress settings were supposed to be adjusted according to the resident's weight, but the CNA stated that the settings were never changed. The nurse acknowledged the risk of having the mattress set too firm, which could affect the healing of the wound. The Director of Nursing confirmed that the facility policy required adherence to the manufacturer's guidelines, which were not followed in this case.
Failure to Document Accurate Supervision During Meals
Penalty
Summary
The facility failed to ensure accurate medical records for a resident with severe cognitive impairment and dysphagia, who was admitted with diagnoses including dysarthria following cerebral vascular disease. The resident's physician order required aspiration precautions, including sitting upright at 90 degrees during meals, remaining upright for 30 minutes post-meal, and receiving one-to-one assistance with small bites and sips to ensure slow eating and drinking. However, observations on multiple occasions revealed that the resident was eating alone in their room without the required supervision. Despite the physician's order, the Treatment Administration Record (TAR) for June and July 2024 indicated that staff had signed off on providing one-to-one supervision during meals, which was not observed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the physician's orders should have been followed and accurately documented in the TAR, highlighting a discrepancy between the documented care and the care actually provided.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff performed hand hygiene appropriately during medication administration tasks, as observed by surveyors. Nurse #3 was seen applying gloves without performing hand hygiene beforehand and administering eye drop medication to a resident. After removing the gloves, Nurse #3 touched the contaminated glove with her bare hand and did not perform hand hygiene before touching the resident's bed linens and returning to the medication cart. This pattern of neglecting hand hygiene was repeated when Nurse #3 administered medications in applesauce to another resident and when administering an insulin injection, where she again failed to perform hand hygiene before and after glove use. Interviews with Nurse #3, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) revealed that the staff was aware of the expectations for hand hygiene and proper glove use. Nurse #3 acknowledged the failure to follow protocol, and both the ADON and DON confirmed that staff should perform hand hygiene before entering and after leaving a resident's room, and after glove removal. The DON also stated that staff should not wear gloves in the hallway or place contaminated items on the medication cart.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rockport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seacoast Nursing And Rehabilitation Center | 4.3 mi | — | 0 | 0 |
| Care One At Essex Park | 14.5 mi | — | 0 | 0 |
| Blueberry Hill Rehabilitation And Healthcare Ctr | 14.9 mi | — | 12 | 0 |
| Ledgewood Rehabilitation And Nursing Center | 15 mi | — | 0 | 0 |
| Brigham Health And Rehabilitation Center | 17.1 mi | — | 41 | 0 |
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