MILLSBORO, DE - A July 2024 inspection at Atlantic Shores Rehabilitation & Health Center (formerly Ocean Grove Post Acute) documented multiple regulatory violations, including failure to follow physician orders, inadequate infection control practices, and unresolved facility maintenance issues that persisted for months.
Physician Orders Not Followed for Bed-Bound Resident
Inspectors documented a significant lapse in following physician-ordered care for a cognitively intact resident requiring daily out-of-bed activity. The resident, identified as R128, had been admitted to the facility in August 2023 and required assistance with transfers from bed to chair.
On April 23, 2024, physicians ordered that R128 be out of bed for a minimum of two hours daily, with nursing staff required to document and notify family members of any refusals during each day shift. Despite this explicit order, multiple observations between July 10-11, 2024 revealed R128 remained in bed throughout the day.
During an interview on July 12, 2024, R128 confirmed he had not gotten out of bed at any point on July 11. The resident's assessment showed a cognitive score of 13 out of 15, indicating intact mental functioning and the ability to communicate preferences clearly.
The facility's documentation presented contradictory information. The treatment administration record showed a checkmark with staff initials indicating the task had been completed on July 11. However, when interviewed, a certified nursing assistant confirmed R128 had not been out of bed that day and acknowledged staff had not offered to assist him out of bed.
When a licensed practical nurse was asked about documentation procedures, the nurse stated that refusals must be documented in electronic notes. Yet no such documentation of any refusal by R128 existed for July 11. A second interview with the nurse who had initialed the treatment record confirmed that the checkmark indicated the task was completed and R128 had gotten out of bed—contradicting both the resident's statement and the CNA's confirmation.
This situation represents a breakdown in multiple areas: following physician orders, accurate documentation, and ensuring residents receive prescribed mobility activities. Prolonged bed rest can lead to rapid physical deconditioning, increased fall risk when eventually mobilized, pressure injuries, decreased circulation, and potential respiratory complications. Regular out-of-bed activity is medically necessary to maintain muscle strength, joint mobility, cardiovascular function, and overall physical and mental well-being.
Infection Control Failures Put Vulnerable Residents at Risk
Inspectors identified three separate instances where staff failed to follow infection prevention protocols designed to protect residents with medical devices and infectious conditions.
Tracheostomy Care Without Proper Precautions
R47, a resident with a tracheostomy (a surgically created opening in the neck for breathing) since admission in May 2016 following a traumatic brain injury, required enhanced barrier precautions according to facility policy. The facility's 2023 policy explicitly requires gown and gloves during high-contact care activities for residents with indwelling medical devices, specifically listing tracheostomy care.
On July 16, 2024, inspectors observed an agency licensed practical nurse providing tracheostomy care to R47 without wearing a gown or face shield. The nurse used only gloves. Additionally, R47's room lacked the necessary supplies for enhanced barrier precactions, which should have been stored in plastic containers within the room.
Tracheostomy care involves direct contact with respiratory secretions and the opening in the neck, creating opportunities for pathogen transmission in both directions. Enhanced barrier precautions protect both the vulnerable resident from healthcare-associated infections and protect staff from exposure to potentially infectious material.
PICC Line Care Without Required Gown
R461 was admitted to the facility on June 13, 2024 with a peripherally inserted central catheter (PICC line) in the right upper arm and a staph infection. The physician specifically ordered enhanced barrier precautions including gown, mask, face shield (if splattering expected), and gloves for every shift. The resident was receiving intravenous antibiotics four times daily to treat the infection.
On July 15, 2024, inspectors observed a licensed practical nurse administering the 2 PM intravenous antibiotic dose while wearing only gloves—no gown was worn despite the physician's explicit order. PICC lines provide direct access to large central blood vessels and represent a significant infection risk if proper sterile technique and barrier precautions are not maintained.
Catheter Bags Repeatedly Found on Floor
R36, a resident with a urinary retention requiring an indwelling catheter since admission in January 2024, experienced multiple instances where the catheter drainage bag contacted or rested on the floor. Inspectors documented the collection bag lying flat on the floor on July 9 at 10:23 AM and 11:14 AM. The bag was not covered with a privacy bag during these observations.
On July 10, inspectors observed the catheter collection bag dragging along the floor as a therapy assistant pushed R36 in a wheelchair from a therapy room through the facility. The assistant immediately placed the bag in a privacy cover and hung it off the floor after being made aware of the issue.
Additional observations on July 12 found the collection bag touching the floor at 9:44 AM and lying flat on the floor at 12:32 PM without the privacy bag straps secured to keep it elevated. When interviewed, the unit manager confirmed the bag was on the floor and stated the privacy bag straps had come off the collection bag earlier that morning.
Catheter drainage bags must remain below the level of the bladder to ensure proper drainage and prevent backflow, but must never contact the floor. Floor surfaces in healthcare facilities harbor numerous pathogens. When catheter bags contact contaminated surfaces, bacteria can migrate up the drainage tubing into the bladder, causing urinary tract infections. For residents with indwelling catheters, these infections can progress to serious kidney infections or bloodstream infections.
The unit manager acknowledged ongoing difficulty keeping the collection bag off the floor due to issues with the privacy bag strap system. The infection preventionist later stated the facility was evaluating the functionality of the privacy bags and considering ordering different bags.
Quality Improvement Program Failed to Address Previous Citations
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to implement corrections for deficiencies cited during the previous annual survey in July 2023. Specifically, the facility's Medication Regimen Review policy remained unchanged despite a Plan of Correction submitted in September 2023 stating the facility would revise and update the policy.
The policy continued to lack required information regarding timeframes for pharmacist responses to medication recommendations, differentiation between urgent and non-urgent recommendations, and timeframes for facility responses to recommendations. When interviewed, the administrator confirmed the unchanged policy was the current version in use.
Federal regulations require facilities to maintain an effective QAPI program that systematically identifies issues, implements corrections, and monitors to ensure problems are resolved. The failure to update this policy despite a previous citation and written plan of correction demonstrates a breakdown in the quality improvement process.
Additional Issues Identified
Inspectors documented a significant environmental maintenance failure in the clean laundry room. Multiple ceiling pipes were observed dripping water onto the floor and into a trash can placed underneath. The leaking pipes showed numerous areas of black staining with fuzzy growth patterns consistent with mold. Three wet and stained towels were on the floor under the leak areas.
A laundry staff member confirmed the water had been dripping from the pipes and pooling on the floor for several months. This creates both a safety hazard from standing water and potential slip risks, as well as concerns about mold growth in an area where clean linens are processed for resident use.
The inspection findings were reviewed with facility leadership including the administrator, director of nursing, quality assurance/infection preventionist, corporate registered nurse, and assistant director of nursing on July 18, 2024.
These violations highlight the critical importance of staff training, consistent adherence to infection control protocols, accurate documentation practices, and effective quality improvement systems in long-term care settings. Each failure documented represents not merely a paperwork issue but a potential risk to resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Atlantic Shores Rehabilitation & Health Center from 2024-07-18 including all violations, facility responses, and corrective action plans.
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