Atlantic Shores Rehabilitation & Health Center

F-F602.

Review of Resident R146's clinical record revealed:

3/30/24 - Resident R146 was admitted to the facility with diagnoses, including but not limited to altered mental status.

4/1/24 3:09 PM - Resident R146 signed the facility's Admission Agreement, which included an authorization form to release financial data. The clauses that identified Resident R146's legal representative and responsible party were left blank in this signed document.

The facility's Admission Agreement included information regarding resident's rights, payment obligations, grievance process, advanced directive and other services provided by the facility.

4/2/24 2:59 PM - E5 (Social Work Director) documented in Resident R146's EMR.Her sister [F2] was invited to the meeting (care plan meeting) .SW (social work) was unable to get in contact with her sister .The plan is to have [Resident R146] move in with one of her sisters .[Resident R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit .

4/5/24 - Resident R146's admission Minimum Data Set (MDS) assessment documented a BIMS score of three, which reflected severe cognitive impairment.

4/9/24 9AM - E6 (SW) documented in Resident R146's EMR Update delivered to family and CM (case management)

in phone call.

The facility failed to identify that Resident R146 with a BIMS of 3, did not have the cognitive ability to be her own responsible party and was unable to provide evidence of any intervention on behalf of Resident R146 to address the need for a responsible party with Resident R146's two known sisters.

4/12/24 - Resident R146 was given a Notice of Medicare Non-Coverage (NOMNC) that advised that Resident R146's effective date of last day of Medicare coverage was 4/17/24. The document was signed by E44 (Social Worker) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 4/15/24 10:58 AM - E5 (SW director) documented in Resident R146's EMR, .[Resident R146] received a NOMNC letter with a last cover date of 4/17/24. [Resident R146]'s original discharge plan was to return home alone or to live with one of her Level of Harm - Minimal harm or sisters. [Resident R146] does not feel like she can live on her own. It was reported to the social services department potential for actual harm that she can no longer live with her sister .SW (social work) will work with [Resident R146] and her family to assist with getting her transferred to another facility. Residents Affected - Few 4/17/24 - Resident R146 was cut from Medicare insurance coverage and deemed private pay at the rate of $495 per day, as stated in the Admission Agreement, for her stay at the facility.

4/18/24 4:04 PM - E5 (SW Director) documented in Resident R146's EMR, .[Resident R146] was scheduled for discharge today to her sister, [F3]. SW spoke with both of [Resident R146]'s sisters. [F3], she states that her daughter called this morning and left a message on the admission director's voicemail stating that the resident cannot come and live with her. [F3] also wants to be removed from the electronic medical record as a point of contact for [Resident R146]. SW spoke with the resident's other sister, [F2]. She states that she did not know that the resident could not go home with her other sister. [F3] said that she is home with COVID. F3 will revisit the resident coming home to live with her once she is systematic (sic). SW updated the IDT (interdisciplinary team) that [Resident R146] will not be discharged today.

The facility continued to fail to identify a responsible party for Resident R146 and failed to initiate a referral to the medical staff for a capacity determination.

5/19/24 3:43 PM - E45 (RN) documented in Resident R146's EMR that a family member called and requested that Resident R146 should not sign anything without her family present.

According to the Release of Responsibility for Leave of Absence log, Resident R146 was signed out and left the faciity

on a leave of absence with unrelated persons on 5/20/24, 5/25/24, 6/3/24, 6/21/24, 6/28/24 and 7/12/24.

The facility failed to verify that the persons had authorization to take Resident R146 out of the building.

5/14/24 1:52 PM - E5 documented in Resident R146's EMR,[Resident R146]'s sister called and stated that she wanted referred (sic) to [assisted living] facility program. SW spoke with [Resident R146] and she agreed with a referral to be sent to [assisted living facility]. SW completed the referral and now awaiting a response from [assisted living facility] to see if they will accept [Resident R146].

5/24/24 9:48 AM- E5 (SW) documented in Resident R146's EMR, [Resident R146] visited [assisted living facility] on Monday with her sister. [Resident R146] had been referred to [assisted living facility] for possible placement. [Resident R146] had been accepted by [assisted living facility]. [Resident R146] provided a deposit for [assisted living facility]. There are other documents that need to be filled out by her sister and the n here. There is no set discharge date for [Resident R146] at

this time. IDT team has been made aware.

5/28/24 1:15 PM - E44 (SW) documented in Resident R146's EMR, SW added new contact in PCC (Point Click Care) w/permission of [Resident R146]. Her male friend [F4] xxx-xxx-xxxx.

5/29/24 - E46 (Psychologist) documented in Resident R146's EMR, Her judgment and insight are impaired. At this time, pt is not capable of making her own healthcare decisions.

5/31/24 - The facility made a referral for capacity determination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 This capacity referral was made fifty-six (56) days after the initial BIMS assessment that documented Resident R146 having a severe cognitive impairment. Level of Harm - Minimal harm or potential for actual harm 6/3/24 - E39 (MD) documented in a Physician Affidavit for Guardianship that Resident R146 did not have capacity to function independently including: activities of daily living, pay her own bills, live alone, take medicine Residents Affected - Few appropriately, give consent for medical procedures and resist scams.

6/3/24 10:06 AM - F4 (male friend) signs Resident R146 out of the facility in the Leave of Absence log. Resident R146 was signed back into the facility at 11:35 AM.

6/4/24- The facility petitioned the Court of Chancery to initiate Resident R146's guardianship process.

This petition was initiated one (1) day after Resident R146 was deemed not to have capacity and sixty (60) days after Resident R146 was documented to have a severe cognitive impairment and lacked family/community support.

7/9/24 1:54 PM - During a telephone interview, F2 (Resident R146's sister) stated that she was not informed about Resident R146's last day of Medicare coverage nor was she offered the opportunity to appeal. F2 also confirmed that

she was not asked about allowing Resident R146 to go out the facility with unrelated persons.

7/9/24 - The Court of Chancery filed paperwork that appointed C3 (Esquire) as attorney ad litem of Resident R146, a person with an alleged disability and stated the hearing for guardianship would be on August 15, 2024.

7/10/24 10:24 AM - E5 (SW) documented in Resident R146's EMR, [Resident R146]'s care plan meeting was rescheduled until July 23rd at her request. IDT team was made aware of her meeting being rescheduled.

7/10/24 3:20 PM - A review of Resident R146's face sheet revealed that Resident R146 listed as responsible party and F2 (Resident R146's sister) listed as emergency contact #1 and F3 (Resident R146's other sister) listed as emergency contact #2.

Ninety-six (96) days after Resident R146 was documented as having severe cognitive impairment and thirty-seven (37) days after Resident R146 was deemed not to have capacity, Resident R146's face sheet continued to document that Resident R146 was her own responsible party.

7/12/24 9:31 AM - During an interview, E44 (SWS) stated, When I was explaining about the insurance, she did not understand. She did not understand what she was signing so she did not sign. She would nod her head in agreement, but she did not understand.

7/12/24 10:54 AM - During an interview, F5 (CSA, female friend), I don't have a contract with [Resident R146]. I just really like her and am keeping touch because I like her. I have taken [Resident R146] to Dairy Queen, my grandson's birthday party, out for lunch. She has met my daughter. I have never taken her to the bank. She does not have any money. I heard [F4] and [F3] were trying to get POA (power of attorney).

7/12/24 11:03 AM - During an interview, E1 (NHA) stated, We were trying to get a Medicaid application together. When we got the bounced check, that was when we became aware that there was a problem. That was in May sometime. No, I did not report it to APS.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 7/12/24 1:07 PM - When shown a copy of the facility Release of Responsibility for Leave of Absence log, F5 (CSA, female friend) stated, Yes, that is my chicken scratch (pointing to the dates of 5/20, 5/25, 6/21, 6/28, & Level of Harm - Minimal harm or 7/12 on the release log). F5 then stated that the signature on 6/3 was F4 (male friend). I remember seeing potential for actual harm them here on 6/3; it's my birthday.

Residents Affected - Few 7/12/24 3:13 PM - During an interview, E1 (NHA) stated, We don't have a policy or procedure for residents that have been deemed not to have capacity and don't have a legal guardian or POA (power of attorney).

7/15/24 10:15 AM - During a telephone interview, F2 (Resident R146's sister) reported that Resident R146's roommate F7 alleged that F4 came to the facility and had Resident R146 call the bank to have another debit card mailed to Resident R146's apartment and F4 was the person who picked up Resident R146's mail.

7/15/24 11 AM - The surveyor informed the facility of the allegation against F4 who was listed on Resident R146's face sheet as friend.

7/15/24 12:29 PM - During an interview, E38 (NP) stated, There are no special orders that we place when a patient is deemed not to have capacity. We were not aware that [Resident R146] had been financially exploited.

7/15/24 5:30 PM- After inquiry by the surveyor, E2 (DON) filed a complaint with the [local] police regarding Resident R146's returned check #4483 from 5/23/24 for insufficient funds.

7/16/24 10:10 AM - During an interview, E5 (SW) stated, To my knowledge, there is no policy or precedent regarding when a resident is deemed not to have capacity. I am not aware of any restrictions regarding leaving the facility. I guess you would call her sister. I am not aware of a guardian ad litem.

7/16/24 11:42 AM - During an interview, E1 (NHA) stated, The facility petitioned for guardianship on 6/4/24.

The referral for capacity was made on 5/31/24. [Resident R14]'s need for a capacity determination was discussed and decided at morning meeting so there are no notes from an IDT meeting about it. If [Resident R146} wants to leave the facility with friends, we allow her to go.

7/18/24 - F4 (male friend) remained listed on Resident R146's face sheet as a friend.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 38302

Residents Affected - Some Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include:

7/9/24 11:05 AM - Observation of nourishment refrigerator located at the nurse's station number two (2) revealed a carton of Nutritional Shake that was undated. The instructions on the carton indicate that once opened, any remaining product should be discarded after four (4) days.

7/9/24 11:06 AM - The food storage shelves in the walk-in refrigerator were covered in numerous areas of rust, the floor of the walk-in was wet, and there was some small areas of ice build up in the walk-in freezer.

7/9/24 11:27 AM - During a tour of the kitchen, the surveyor observed E48 (Dining Services Director) and E49 (Assistant Dining Services Director) test the sanitizer level of the solution in two red sanitizing buckets. When E49 tested the sanitizing solution in the bucket from the prep area, the test strip from that bucket indicated that the level of chemical concentration was not at a sufficient level to provide proper sanitization.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 47142

Residents Affected - Few Based on record review and interview, it was determined that for one (Resident R128) out of thirty-three (33) residents

in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation. Findings include:

Cross refer

F-F676.

Review of Resident R128's clinical record revealed:

8/11/23 - Resident R128 was admitted to the facility.

4/23/24 - Resident R128's physicians orders documented Resident R128 to be out of bed for a minimum of two hours every day and nursing to document and notify family of refusals every day shift.

5/16/24 - A quarterly MDS revealed that Resident R128 was dependent for transfer from bed to chair or chair to bed. Resident R128's BIMs score was 13 out of 15 which indicated intact cognition.

7/10/24 at 10:32 AM - 7/11/24 at 2:56 PM - Multiple observations of Resident R128 laying in bed.

7/12/24 9:33 AM - During an interview Resident R128 stated he did not get out of bed at any time on 7/11/24.

A review of the treatment administration record (TAR) revealed a checkmark with E8 (LPN)'s initials for the treatment order that states, Resident to be out of bed for a minimum of 2 hours every day - Nursing to document and notify Sister . of refusals every day shift.

7/12/24 2:29 PM - During an interview, E25 (CNA) confirmed that Resident R128 was not out of bed on 7/11/24 and

they did not offer to get Resident R128 out of bed.

7/12/24 2:31 PM - During an interview E26 (LPN) stated, we have to document about him refusing in the [electronic] notes.

7/17/24 9:19 AM - During an interview E8 confirmed that the checkmark on the treatment administration

record for 7/11/24 means that the task was completed and Resident R128 got out of bed.

There was a lack of facility documentation of any refusals by Resident R128 to get out of bed on 7/11/24.

The facility documented that Resident R128 was out of bed when he was never out of bed on 7/11/24.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Potential for minimal harm 46988

Residents Affected - Many Based on review of facility documentation, review of cited deficiencies from the facility's annual survey of 7/14/23 and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. Findings include:

7/11/24 - A review of the facilities undated policy titled, Medication Regimen Review, lacked information regarding the time frames for a pharmacist response, urgent and non-urgent medication recommendations, or a time frame for a facility response to recommendations.

7/11/24 - A review of the 2567 from Annual and Complaint survey dated 7/14/23 revealed a previous deficiency cited for the facilities MRR policy and lack of time frames for response times.

7/12/24 9:48 AM - An interview with E1 (NHA) confirmed the MRR policy provided was current.

The facility failed to update the MRR policy per the Plan of Correction dated 9/6/23 which indicated the facility would revise and update policy.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on observations, interviews and record review, it was determined that for three (3) (Resident R36, Resident R47 and Residents Affected - Some Resident R461) out of thirty-three (33) reviewed in the investigative sample, the facility failed to ensure a urinary catheter bag was kept off the floor and to ensure staff utilized enhanced barrier precautions (EBP). Findings include:

2023 - A facility policy titled, Enhanced Barrier Precautions- It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions refers to the use of gown and gloves for use (sic) during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices) .

Policy Explanation and Compliance Guidelines:

7. High-contact resident care activities include: .

g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes

1. Review of Resident R47's clinical record revealed:

5/27/16 - Resident R47 was admitted to the facility with diagnoses including: traumatic brain injury and tracheostomy status.

5/22/24 - An annual MDS revealed that Resident R47 required tracheostomy care.

5/5/23 - A careplan for Resident R47 revealed enhanced barrier precautions related to presence of tracheostomy last revised on 3/19/24.

7/16/24 1:55 PM - An interview with E3 (QA and IP) confirmed that supplies for enhanced barrier precautions should be stored in plastic containers in the room and extra supplies are stored in the units linen closets.

7/16/24 2:58 PM - An observation of tracheostomy care completed by E8 (LPN Agency) lacked use of enhanced barrier precautions. E8 failed to utilize a gown or face shield during tracheostomy care with Resident R47. Resident R47's room lacked necessary supplies needed for enhanced barrier precautions.

47621

2. Review of Resident R461's clinical record revealed:

6/13/24 12:18 PM - E33 (MD) documented the successful placement of right upper extremity PICC (peripherally inserted central catheter) line.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 6/13/24 - Resident R461 was admitted to the facility.

Level of Harm - Minimal harm or 6/13/24 - E34 (NP) ordered Assess PICC line site RUE (right upper extremity) area for any signs of infection potential for actual harm and notify MD (medical doctor) every shift in Resident R461's EMR.

Residents Affected - Some 6/13/24 - E39 (MD) ordered Enhanced Barrier precautions: related to PICC line and staph infection 1. Gown. 2. Mask 3. Face shield (if splattering expected to occur) 4. Gloves very shift in Resident R461's EMR.

7/2/24 - E28 (NP) ordered piperacillin sod- tazobactam Intravenous solution 4.5 gm - give 4.5 grams IV four times a day related to infection in Resident R461's EMR.

7/15/24 2:09 PM - During medication administration, E35 (LPN) was observed administering Resident R461's 2 PM Piperacillin IVSS dose wearing only gloves, E35 did not have a yellow gown on.

47142

3. Review of Resident R36's clinical record revealed:

1/26/24 - Resident R36 was admitted to the facility.

2/22/24 - A care plan documented that Resident R36 has an indwelling catheter for neurogenic bladder.

4/3/24 - A physician's order for a foley catheter to straight bag drainage for urinary retention.

7/9/24 - Observations of Resident R36's catheter collection bag lying flat on the floor without a privacy bag while Resident R36 was resting in bed at 10:23 AM and 11:14 AM.

7/10/24 11:31 AM - An observation of Resident R36's catheter collection bag was hooked on the wheelchair and the bottom of the collection bag was dragging along the floor while Resident R36 was being pushed in the wheelchair by E15 (COTA). The catheter collection bag did not have a privacy bag cover. An interview with E15 stated she brought Resident R36 back from the large therapy room located off Resident R36's unit and located near the main facility entrance. E15 immediately got a privacy bag, covered the catheter collection bag and hung it off the floor.

7/12/24 9:44 AM - An observation of Resident R36's catheter collection bag was in a privacy bag but touching the floor. E16 (UM) confirmed the catheter collection bag was touching the floor and stated the privacy bag straps are attached to the bed and it is difficult to keep the catheter collection bag off the floor. E16 then manipulated the privacy bag straps and was able to raise the catheter collection bag off the floor.

7/12/24 12:32 PM - An observation of Resident R36's catheter collection bag lying flat on the floor without the privacy bag straps tied to the bed to keep it raised off the floor. An interview with E16 confirmed the catheter collection bag was on the floor. E16 stated she had the collection bag off the floor, the hooks came off the collection bag earlier and she would try something else.

7/12/24 3:05 PM - An interview with E16 revealed that the collection bag was corrected and they used the hooks on the collection bag to attach to the bed frame.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 7/16/24 12:47 PM - An interview with E3 (QA/IP) revealed that the privacy bags are being evaluated for functionality and they may order different bags. Level of Harm - Minimal harm or potential for actual harm 7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 38302

Residents Affected - Few Based on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment for staff. Findings include:

7/9/24 12:17 PM - Several pipes in the ceiling area of the clean laundry room were dripping onto the floor and into a trash can that had been placed under a portion of the leaking area. All of the leaking pipes had numerous areas of black staining, which appeared fuzzy in some sections. Three wet and stained towels were on the floor under the areas of the leaks.

7/9/24 1:46 PM - During an interview, E50 (Laundry Staff) confirmed the dripping and standing water and stated that the water had been dripping from the pipes and pooling on the floor for several months.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 085037

F-F745.

Review of Resident R146's clinical record revealed:

3/30/24 - Resident R146 was admitted to the facility with diagnoses, including but not limited to altered mental status.

4/2/24 2:59 PM - E5 (Social Work Director) documented in Resident R146's EMR.[Resident R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit .

4/5/24 - Resident R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.

5/29/24 - E46 (Psychologist) documented in Resident R146's EMR, Her judgment and insight are impaired. At this time, patient is not capable of making her own healthcare decisions.

5/31/24 - The facility made a referral for capacity determination.

6/3/24 - E39 (MD) documented in a Physician Affidavit for Guardianship that Resident R146 did not have capacity to function independently including: activities of daily living, pay her own bills, live alone, take medicine appropriately, give consent for medical procedures and resist scams.

6/3/24 10:06 AM - F4 (male friend) signed Resident R146 out of the facility in the Leave of Absence log. Resident R146 was signed back into the facility at 11:35 AM.

6/4/24- The facility petitioned the Court of Chancery to initiate Resident R146's guardianship process.

According to the Release of Responsibility for Leave of Absence log, Resident R146 was signed out and left the faciity

on a leave of absence with unrelated persons on 5/20/24, 5/25/24, 6/3/24, 6/21/24, 6/28/24 and 7/12/24.

7/10/24 3:20 PM - A review of Resident R146's face sheet revealed that Resident R146 listed as responsible party and F2 (Resident R146's sister) listed as emergency contact #1 and F3 (Resident R146's other sister) listed as emergency contact #2.

The facility failed to ensure that Resident R146, a resident with severe cognitive impairment, did not leave the facility without her family's consent.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0563 7/12/24 3:13 PM - During an interview, E1 (NHA) stated, We don't have a policy or procedure for residents that have been deemed not to have capacity and don't have a legal guardian or POA (power of attorney). Level of Harm - Minimal harm or potential for actual harm 7/15/24 12:29 PM - During an interview, E38 (NP) stated, There are no special orders that we place when a patient is deemed not to have capacity . Residents Affected - Few 7/16/24 10:10 AM - During an interview, E5 (SW) stated, To my knowledge, there is no policy or precedent regarding when a resident is deemed not to have capacity. I am not aware of any restrictions regarding leaving the facility. I guess you would call her sister. I am not aware of a guardian ad litem.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Level of Harm - Minimal harm or 47621 potential for actual harm Based on record review and interview, it was determined that for one (Resident R146) out of three residents reviewed Residents Affected - Few for beneficiary notice, the facility failed to provide notification of service changes to Resident R146's authorized representative. Findings include:

Review of Resident R146's clinical record revealed:

3/30/24 - Resident R146 was admitted to the facility.

4/5/24 - Resident R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.

4/12/24 - Resident R146 given a Notice of Medicare Non-Coverage (NOMNC) that advised that Resident R146's effective date of last day of Medicare coverage was 4/17/24. The document was signed by E44 (Social Work) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice .

7/9/24 1:54 PM - During a telephone interview, F2 (Resident R146's sister) stated that she was not informed about Resident R146's last day of Medicare coverage and was not offered the opportunity to appeal.

7/10/24 3:20 PM - A review of Resident R146's face sheet revealed that Resident R146 listed as responsible party and F2 (Resident R146's sister) listed as emergency contact #1 and F3 (Resident R146's other sister) listed as emergency contact #2.

The facility was unable to provide evidence of any attempt to reach either emergency contact for the purpose of receiving the NOMNC notification.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Honor 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 of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on observation and interview, it was determined that for one out of five resident units, the facility failed to provide a clean and homelike environment. Findings include:

7/9/24 10:13 AM - An observation in the 300 hallway of Ocean Gardens unit, revealed a broken handrail with jagged edges not covered. The baseboards in 400 hallway were dirty and dusty, and an area where a dark substance was spilled on wall with a stain. Subsequently the same observation occurred on 7/10/24 and 7/11/24.

7/12/23 1:00 PM - An interview with E13 (Maintenance Director) revealed that the facility has a plan to replace all handrails with new design. E13 stated he will cover the broken handrail for safety concerns for the current time until new rails are installed. E13 also stated that maintenance will clean the base boards and wall of the 400 hallway.

7/15/24 9:51 AM - An observation of a handrail in the 300 hallway of Ocean Gardens unit, revealed a broken handrail with jagged edges not covered. The baseboards in 400 hallway were dirty and dusty, and an area where a dark substance was spilled on wall with a stain.

7/15/24 2:17 PM - An interview with E13 confirmed the handrail should have been fixed over the weekend and it will get taken care of today. Also noted the walls and base boards will be cleaned today.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Protect each resident from the wrongful use of the resident's belongings or money.

Level of Harm - Minimal harm or 47621 potential for actual harm Based on record review and interview, it was determined that for one (Resident R146) out of three residents reviewed Residents Affected - Few for abuse, the facility failed to protect Resident R146 from misappropriation of resident property/funds. Findings include:

Review of Resident R146's clinical record revealed:

3/30/24 - Resident R146 was admitted to the facility.

4/5/24 - Resident R146's admission Minimum Data Set (MDS) assessment documented Resident R146's BIMS score of three, which reflected severe cognitive impairment.

4/12/24 - A Notice of Medicare Non-Coverage (NOMNC) documented that Resident R146's last day of Medicare coverage was 4/17/24. The document was signed by E44 (Social Worker) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice .

5/16/24 - According to a signed and dated statement, F2 (Resident R146's sister) provided the facility with Resident R146's identification, bank statement, other documents and Resident R146's checkbook. F2 had E1 (NHA) and E5 (SW Director) sign the document listing all the documents and belongings that F2 handed over to the facility.

5/17/24 11:05 AM - E43 (Business Office manager) documented a note in Resident R146's EMR that stated Resident R146's checkbook and other documents were secured in the facility safe.

5/19/24 3:43 PM - E45 (RN) documented in Resident R146's EMR that a family member called and requested that Resident R146 should not sign anything without her family present.

5/23/24 - E1 (NHA) and E43 (Business Office manager) obtained Resident R146's checkbook from the facility safe and assisted Resident R146 to write two checks- Check #4483 to the facility in the amount of $6435 for April room/Board and another check as deposit for an assisted living facility that Resident R146 was interested in transferring to.

The facility failed to identify that Resident R146 was not cognitively capable of understanding a financial transaction and failed to safeguard Resident R146's property from inappropriate access.

5/29/24 - E46 (Psychologist) documented in Resident R146's EMR, Her judgment and insight are impaired. At this time, pt is not capable of making her own healthcare decisions.

5/31/24 - E43 received an email from the facility Home Office stating that check #4483 was returned for insufficient funds.

5/31/24 - The facility made a referral for capacity determination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 6/3/24 - E39 (MD) completed a Physician Affidavit for Guardianship which documented that Resident R146 does not have capacity. Level of Harm - Minimal harm or potential for actual harm 7/12/24 9:31 AM - During an interview, E44 (SWS) stated, When I was explaining about the insurance, she did not understand. She did not understand what she was signing so she did not sign. She would nod her Residents Affected - Few head in agreement but she did not understand.

7/12/24 9:55 AM - During an interview, E43 stated, Only the NHA and I have access to the safe. The NHA and I took her checkbook to her to write the checks (to [assisted living facility] and to us). That is when we found out the money was gone because the checks bounced . I told the NHA and Social worker was to report it to APS (Adult Protective Services).

The facility was unable to provide evidence that this allegation of missing resident funds was reported to the State agency.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or 40260 potential for actual harm Based on record review and interview, it was determined that for three (Resident R66 and Resident R146) out of thirty-three Residents Affected - Few residents reviewed in the investigative sample, the facility failed to ensure an accurate assessment. Findings include:

1 Review of Resident R66's clinical record revealed:

5/10/18 - Resident R66 was admitted to the facility.

2/17/24 - Section I of the annual MDS revealed the following: No natural teeth or tooth fragment(s) (edentulous): Yes. Obvious or likely cavity or broken natural teeth was not checked.

7/11/24 11:45 AM - In an interview, E20 (CNA) and E21 (CNA) revealed Resident R66 does not complain of pain with eating and does not wear dentures.

7/11/24 11:50 AM - In an interview, it was revealed that Resident R66 does not have dentures. The surveyor noted that Resident R66 has teeth, but they are in disrepair. Resident R66 stated that although dental exams are offered, Resident R66 declines to attend.

7/12/24 3:35 PM - In an interview, E19 (MDS Coordinator) confirmed that the MDS reflected that resident is edentulous (lack of teeth). Surveyor advised that Resident R66 has broken teeth and Resident R66 confirmed she does not have dentures.

47621

2. Review of Resident R146's clinical record revealed:

3/30/24 - Resident R146 was admitted to the facility.

4/5/24 - Resident R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.

5/8/24 - E38 (NP) ordered a wander guard check placement every shift.

7/3/24 - Resident R146's quarterly MDS documented that Resident R146 did not have a wander/elopement alarm.

7/12/24 9:32 AM - During an interview, E42 (CNA) confirmed that Resident R146 still had a wander guard alarm on her person.

7/12/24 3:42 PM - During an interview, E19 (RNAC) confirmed that Resident R146's 7/3/24 quarterly MDS was modified yesterday to include that Resident R146 did in fact have a wander guard alarm.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on interview and record review, it was determined that for three (Resident R14, Resident R37 and Resident R98) out of three residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed. Findings include:

A review of the facility's policy titled Resident Assessment - Coordination with PASARR Program last revised 6/18/24, documented . 9. A resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

1. Review of Resident R14's clinical record revealed:

5/9/21 - Resident R14 had a level I PASARR completed.

6/7/21 - Resident R14 was admitted to the facility with the following diagnoses: major depressive disorder, adjustment disorder with depressed mood, and delusional disorder.

5/31/23 - Resident R14 was diagnosed with the following diagnoses: unspecified dementia with agitation, violent behavior, and moderate major depressive disorder.

7/16/24 09:52 AM - An interview with E5 (SW Director) confirmed that Resident R14 did not have a level II PASARR completed and one was needed.

40260

2. Review of Resident R37's clinical record revealed:

11/4/18 - Resident R37 was admitted to the facility.

11/5/18 - A level l PASARR was completed and revealed . this patient appears to have: Indicators of mental illness, mental retardation/related conditions, but meets physician's exemption criterion .

12/20/18 - A level 1.5 PASARR was completed and revealed The individual does have a documented serious mental illness (SMI) or a mental illness other than SMI but further review of level of impairment, recent treatment history, or other circumstances demonstrates a full level II is not required .

5/12/23 - Unspecified mood (affective) disorder and unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance and anxiety were added to Resident R37's list of diagnoses.

7/11/24 2:28 PM - In an interview, E1 (NHA) confirmed that given the transition with social workers, there were issues with PASARR's not being completed. E1 stated this situation is being audited and this has been ongoing since May.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 7/11/24 - A request for a Level II PASARR was completed by E5 (SW Director).

Level of Harm - Minimal harm or 7/16/24 - A Notice of a PASARR Level I Screen Outcome was received from Maximus confirming that a potential for actual harm Level II Onsite PASARR was needed.

Residents Affected - Few 47142

3. Review of Resident R98's clinical record revealed:

12/4/20 - Resident R98 had a level l PASARR completed at the hospital with the indication of no level II needed and no suspected or confirmed PASARR conditions.

2/2/21 - Resident R98 was admitted to the facility with diagnoses including cerebral infarction and altered mental status.

4/5/21 - Resident R98 had a level l PASARR completed with the indication of no level II needed and no suspected or confirmed PASARR conditions.

2/2/23 - The electronic medical record documented a new diagnoses of unspecified mild dementia with psychotic disturbance and psychotic disorder with delusions were identified.

6/19/23 - The electronic medical record documented a new diagnoses of unspecified dementia with agitation and violent behavior were identified.

6/20/23 - Resident R98 had psychiatry visits on 6/20/23, 7/5/23, 7/11/23, 1/10/24 and 3/6/24.

7/16/24 9:52 AM - During an interview E5 (SW Director) stated the psych nurse practitioner will screen residents weekly and notify him, the unit manager, or the DON if a resident has any behavioral changes. E5 stated once notified, they will initiate a PASARR review. E5 stated that the facility was without a psych nurse practitioner who had a definitive schedule for a long time and some residents got missed.

7/16/23 12:15 - E5 confirmed a Level II PASARR was not submitted for Resident R98 and one should have been submitted for review.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Some Based on interview and record review, it was determined that for four (Resident R123, Resident R143, Resident R146 and Resident R109) out of thirty-three residents in the investigative sample the facility failed to develop and implement a comprehensive resident centered care plan for an identified care area. Findings include:

1. Review of Resident R123's clinical record revealed:

2/15/24 - Resident R123 was admitted to the facility.

2/21/24 - An admission MDS assessment revealed that Resident R123 was always continent of bowel and bladder.

The MDS revealed that Resident R123 was not indicated for a toileting program at this time.

5/21/24 - A quarterly MDS assessment revealed that Resident R123 was frequently incontinent of bowel and bladder.

The MDS revealed that Resident R123 was not indicated for a toileting program at this time.

7/11/24 9:31 AM - A review of Resident R123's care plan revealed the facility lacked evidence of an incontinence care plan.

7/15/24 10:29 AM - An interview with E27 (LPN UM) confirmed that Resident R123 did not have a care plan for incontinence.

2. Review of 143's clinical record revealed:

4/4/24 - Resident R143 was admitted to the facility.

4/6/24 - An admission MDS assessment revealed that Resident R143 was occasionally incontinent of bowel and bladder. The MDS revealed that Resident R143 was not indicated for a toileting program at this time.

7/11/24 9:42 AM - A review of Resident R143's care plan revealed the facility lacked evidence of an incontinence care plan.

7/15/24 10:29 AM - An interview with E27 (LPN UM) confirmed that Resident R143 did not have a care plan for incontinence.

47621

3. Review of Resident R146's clinical record revealed:

3/30/24 - Resident R146 was admitted to the facility.

4/5/24 - Resident R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 7/15/24 9:45 AM - A review of Resident R146's care plans revealed the facility lacked evidence of a cognitive impairment care plan with interventions. Level of Harm - Minimal harm or potential for actual harm 7/15/24 1:35 PM - During an interview, E3 (QA/IP) confirmed the lack of care plan interventions with regard to Resident R146's cognitive impairment. Residents Affected - Some 4. Review of Resident R109's clinical record revealed:

6/14/24 - Resident R109 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation (Afib), deep vein thrombosis (DVT) and factor V Leiden heterozygous mutation, an inherited disorder that causes abnormal blood clots in legs or lungs.

7/11/24 10:45 AM - A review of Resident R109's care plan revealed no evidence of a care plan or interventions regarding Resident R109's need for anti-coagulation therapy due to the diagnoses of Afib and DVT.

7/15/24 1:35 PM - During an interview, E3 (QA/IP) confirmed the lack of care plan interventions with regard to Resident R109's need for anti-coagulation therapy.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN), and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 40260

Residents Affected - Some Based on record review and interview, it was determined that for six (Resident R25, Resident R37, Resident R47, Resident R66, Resident R68, and Resident R75) out of thirty-three sampled residents for care plan investigations, the facility failed to ensure

that the required interdisciplinary team (IDT) memebers participated in the care plan meetings and for Resident R66's care plan inaccurately includes dentures. Findings include:

A facility policy entitled Comprehensive Care Plans (revised 4/24) states, The comprehensive care plan will be prepared by the interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in

the development of the care plan. B. A registered nurse with responsible for the resident. c. A nurse aide with responsibility for the resident. d. a member of the food and nutrition staff . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

1. Review of Resident R25's clinical record revealed:

9/21/23 - Resident R25 was admitted to the facility.

9/25/23 - A baseline care plan was e-signed.

7/12/24 - E1 (NHA) provided a copy of a quarterly care plan meeting for 4/23/24 that lacked evidence of input from the Physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for

the resident, and a food/nutrition services staff. Additionally, the facility lacked evidence that Resident R25 had a quarterly care plan meeting in December, 2023.

2. Review of 37's clinical record revealed:

11/4/18 - Resident R37 was admitted to the facility.

7/12/24 approximately 11:00 AM - E1 (NHA) provided a copy of a Comprehensive Resident Centered Care Plan Conference sheet for a quarterly meeting, which was undated. The facility lacked evidence that the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for

the resident and a member of food and nutrition services staff provided input. The surveyor also requested documentation for the three previous care plan meetings including the two quarterly meetings and the annual meeting, but the facility was not able to produce evidence that these meetings occurred.

3. Review of Resident R66's clinical record revealed:

5/10/18 - Resident R66 was admitted to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 7/16/24 untimed - E1 (NHA) provided the surveyor with a Comprehensive Resident Centered Care Plan Conference Sheet for Resident R66's annual care plan meeting on 8/28/23, which lacked evidence of input from the Level of Harm - Minimal harm or Physician, a nurse aide with responsibility for the resident, and a food/nutrition services staff. The facility potential for actual harm lacked evidence that a quarterly care plan meeting was held in November, 2023, February, 2024 or May, 2024. Additionally, Resident R66's care plan inaccurately reflected that Resident R66 has an upper and lower dentures. Residents Affected - Some 7/17/24 2:02 PM - In an interview, E14 (staff educator/acting UM) confirmed that Resident R66's care plan inaccurately reflects that this resident had upper and lower dentures. E14 confirmed that resident has broken teeth but does not use dentures.

4. Review of Resident R75's clinical record revealed:

10/9/18 - Resident R75 was admitted to the facility.

7/15/24 approximately 9:45 AM - E1 (NHA) provided the surveyor with a Comprehensive Resident Centered Care Plan Conference Sheet for an annual care plan meeting on 10/26/23 that lacked evidence of from the Physician, a nurse aide with responsibility for the resident, and a food/nutrition services staff. The quarterly care plan meeting sheet also lacked evidence of input from these three IDT members. Additionally, the facility lacked evidence that Resident R75 had a care plan meeting in August, 2023 or January, 2024.

46988

5. Review of Resident R47's clinical record revealed:

5/27/16 - Resident R47 was admitted to the facility with the following but not limited to diagnoses traumatic brain injury and tracheostomy status.

5/29/16 - A review of a careplan for Resident R47's impaired breathing mechanic's last updated 7/25/23 revealed that if Resident R47's tracheostomy dislodges to complete the following interventions: 1. notify supervisor 2. call physician and 911 3. Assess respiratory status, if oxygen saturation is below ninety- two percent apply oxygen by ambu bag or by holding oxygen to the stoma site 4. liscense nurse may reattempt to resinsert trach as per policy.

6/1/16 - An admission MDS revealed that Resident R47 required the following respiratory treatments oxygen, suctioning, and tracheostomy care.

5/22/24 - An annual MDS revealed that Resident R47 required tracheostomy care.

7/15/24 10:29 AM- An interview with E27 (LPN UM) confirmed the care plan did not reflect the current needs related to Resident R47's tracheostomy. The care plan did not reflect Resident R47's current tracheostomy size or current emergency needs if tracheostomy dislodges.

6. Review of Resident R68's clinical record revealed:

11/19/21 - Resident R68 was admitted to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 8/16/23 - A care plan revealed that Resident R68 is resistive and non-compliant with treatment and care related to dementia. The interventions included allow flexibility in ADL routine and if resists care to reapproach. Level of Harm - Minimal harm or potential for actual harm 7/18/24 9:50 AM - An interview with E31 (RN UM) revealed Resident R68 only refuses showers and the following interventions are used: to call daughter, change times, change staff, and change approach. E31 confirmed Residents Affected - Some the current interventions are not reflected on the careplan.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 40260 potential for actual harm Based on record review and interview, it was determined that for six (Resident R25, Resident R37, Resident R47, Resident R66, Resident R68, and Resident R75) Residents Affected - Some out of thirty-three residents in the investigative sample the facility failed to ensure that the required interdisciplinary team (IDT) memebers participated in the care plan meetings and additionally, Resident R66's care plan inaccurately included dentures. Findings include:

State of Delaware Board of Nursing- RN (registered nurse), LPN (licensed practical nurse) and NA (nurses aide)/UAP (unlicensed assistive personnel) Duties 2024 .Admission Assessments - RN, Admission History

Review -RN .Plan of Care: Initial- RN . Updated 4/10/24

1. Review of Resident R160's clinical record revealed:

3/30/24 - Resident R160 was admitted to the facility.

3/30/24 - E8 (LPN) completed the Prestige Admit/Readmit Screener.

4/3/24 - Resident R160's baseline care plan was e-signed by E9 (LPN).

An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission assessment and baseline care plan for Resident R160.

47621

2. Review of Resident R109's clinical record revealed:

6/14/24 - Resident R109 was admitted to the facility.

6/14/24 - E17 (LPN) completed the following admission assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail assessment, Oral/Nutrition assessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.

3. Review of Resident R144's clinical record revealed:

3/21/24 - Resident R144 was admitted to the facility.

3/25/24 - Baseline care plan was generated by E9 (LPN).

4. Review of Resident R148's clinical record revealed:

3/21/24 - Resident R148 was admitted to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 3/21/24 - E23 (LPN) completed the following assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail Level of Harm - Minimal harm or Assessment, Oral/Nutrition Assessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and potential for actual harm IV/Other.

Residents Affected - Some 3/25/24 - The baseline care plan was generated by E9 (LPN).

6/17/24 - Resident R148 was readmitted to the facility.

6/17/24 - E18 (LPN) completed the follwoing assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail Assessment, Oral/Nutrition Asessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.

5. Review of Resident R157's clinical record revealed:

6/19/24 - Resident R157 was admitted to the facility.

6/19/24 - E22 (LPN) completed the following assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail Assessment, Oral/Nutrition Assessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.

6/20/24 - The baseline care plan was generated by E9 (LPN).

6. Review of Resident R461's clinical record revealed:

6/19/24 - E24 (LPN) completed the following assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail Assessment, Oral/Nutrition assessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.

7/17/24 9:19 AM - During an interview, E8 (LPN) stated that she has done admit/readmit screener on the electronic medical record (EMR) for newly admitted residents. The admit/readmit screener was defined as vitals, a skin check and a whole list of questions that we have to ask regarding things like fall and dentures and so on. When asked about the baseline care plan, E8 stated that the unit manager does the care plan.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (corporate RN) and E 7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or 47142 potential for actual harm Based on observation, interview and record review, it was determined that for one (Resident R128) out of seven Residents Affected - Few residents reviewed for ADLs, the facility failed to provide mobility from bed to chair. Findings include:

Cross refer

F-F842.

Review of Resident R128's clinical record revealed:

8/11/23 - Resident R128 was admitted to the facility with diagnoses including cerebral infarction and hemiplegia affecting the nondominant left side.

4/23/24 - A physician order documented that Resident R128 was to be out of bed for a minimum of two hours every day and nursing to document and notify family of refusals every day shift.

5/16/24 - A quarterly MDS revealed that Resident R128 had an impairment on one side for the upper extremities and no impairments for the lower extremities. Resident R128 required substantial or maximal assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed and was dependent for transfer from bed to chair or chair to bed. Resident R128's BIMs score was 13 out of 15 which indicated intact cognition.

7/9/24 - An interview with Resident R128 stated, I stay in bed and they don't get me up.

Observations of Resident R128 laying in bed: 7/10/24 at 10:32 AM, 7/10/24 at 11:14 AM, 7/11/24 at 9:35 AM, 7/11/24 at 10:41 AM, 7/11/24 at 12:11 PM, 7/11/24 at 2:56 PM.

7/12/24 9:33 AM - During an interview Resident R128 stated he did not get out of bed at any time on 7/11/24.

7/12/24 2:29 PM - During an interview, E25 (CNA) confirmed that Resident R128 did not get out of bed on 7/11/24 and that Resident R128 did not refuse. E25 stated, we did not ask if he wanted to get up. He usually tells us that he wants to be up. We did not ask, so he did not refuse.

7/12/24 2:31 PM - During an interview, E26 (LPN) stated, we have to document about him refusing in the [electronic] notes.

There was no facility documentation of any refusals by Resident R128 to get out of bed on 7/11/24.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47621 potential for actual harm Based on record review and interview, it was determined that for one (Resident R146) out of ten resident reviewed for Residents Affected - Few hospitalization , the facility failed to ensure that Resident R146's warfarin dosing was managed in accordance with the professional standards of practice. Findings include:

The acceptable time frame to achieve anticoagulation with warfarin typically ranges from 5 to 7 days. However, it's important to note that the full therapeutic effect may take up to a week due to the long half-life of prothrombin (factor II), which is essential for converting fibrinogen to fibrin12. Warfarin inhibits the production of vitamin K-related factors, and its antithrombotic effect gradually becomes evident as prothrombin levels decrease. During this period, concurrent use of more rapidly acting anticoagulants, such as low-molecular-weight heparin (LMWH) or unfractionated heparin, is recommended. National Library of Medicine, Turkish Journal of Hematology 2016

Warfarin Dosing Guideline- .V. Warfarin dosing nonogram (in medicine, a pictorial representation of a complex mathematical formula) for Maintenance therapy (>1 week of warfarin therapy) of non-bleeding patient

Goal INR 2-3 Dosing Adjustments

INR <1.5 - Consider a one-time dose increase of 1.5-2 times daily maintenance dose

-If adjustment to maintenance dose is needed, increase dose by 10-20%

-Repeat INR in 1 week

INR 1.5-1.7 -Consider a one-time dose increase of 1.5 times daily maintenance dose

-If adjustment to maintenance dose needed, increase by 5-15%

- Repeat INR in 2 weeks

INR 1.8-1.9 -No dosage adjustment may be necessary if the last two INRs were in

Range

-Repeat INR within 8 weeks

-Consider a one-time dose increase of 1.5 times daily maintenance dose

-If adjustment to maintenance dose needed, increase dose by 5-10%

-Repeat INR in 2 weeks

(University of New Mexico Health System June 2020)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of Resident R109's clinical record revealed:

Level of Harm - Minimal harm or 6/14/24 - Resident R109 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation (Afib), potential for actual harm deep vein thrombosis (DVT) and factor V Leiden heterozygous mutation, an inherited disorder that causes abnormal blood clots in legs or lungs. Residents Affected - Few Due to the risk of blood clots, Resident R109 was medically managed with warfarin for anti-coagulation therapy with

the goal INR range of 2.0 to 3.0. (University of New Mexico Health System June 2020)

6/14/24 Friday - E39 (MD) documented in Resident R109's EMR, Warfarin tablet 2 mg (milligram) - give 1 tablet by mouth in the evening every Sat, Sun and Warfarin tablet 2 mg- [NAME] 1.5 tablet (3 mg) by mouth in the evening every Mon, Tues, Wed, Thu, Fri. Total weekly warfarin dosage was 19 mg.

6/15/24 Saturday 11:12 AM - Resident R109's INR was reported as 1.5, which was not at Resident R109's therapeutic goal of 2. 0 to 3.0.

The facility lacked evidence of any intervention for this below goal INR level.

6/18/24 Tuesday 12:06 PM - Resident R109's INR was reported as 1.2, which was not Resident R109's therapeutic goal of 2.0 to 3.0.

6/19/24 - E38 (NP) documented in Resident R109's EMR, Warfarin tablet 2 mg- give 1.5 tablets (3 mg) by mouth in

the evening every Mon, Tue, Wed, Thu, Fri, Sat, Sun. Total weekly warfarin dosage was 21 mg.

This reflected an increase of 2 mg or 10 % of the total weekly warfarin dosage.

6/21/24 Friday 11:45 AM - Resident R109's INR was reported as 1.3, which was below Resident R109's therapeutic goal of 2.0 to 3.0.

This was day 7 of anti-coagulation therapy in the facility and Resident R109 did not reach the desired goal of INR 2.0 to 3.0.

6/21/24 - E38 (NP) documented in Resident R109's EMR, Warfarin tablet 2 mg- give 2 tablets (4 mg) by mouth in the evening every Mon, Fri, Sun and give 1.5 tablets (3 mg) by mouth at bedtime every Tue, Wed, Thu, Sat. Total weekly warfarin dosage was 24 mg.

This reflected an increase of 3 mg or 14.3 % of the total weekly warfarin dosage.

6/25/24 Tuesday 12:23 PM - Resident R109's INR was reported as 1.7, which was still below Resident R109's desired goal of 2. 0 to 3.0.

6/25/24 - E38 (NP) documented in Resident R109's EMR, Warfarin tablet 2 mg- give 2 tablets (4 mg) by mouth in the evening every Mon, Tue, Wed, Fri, Sun and give 1.5 tablets (3 mg) by mouth at bedtime every Thu, Sat. Total weekly warfarin dosage was 26 mg.

This reflected an increase of 2 mg or 7.7 % of the total weekly warfarin dosage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 6/26/24 - Resident R109 was hospitalized for shortness of breath. During this hospitalization , Resident R109 was treated with lovenox, an heparin injection, to help reach the desired anti-coagulation goal as Resident R109's INR was not at goal Level of Harm - Minimal harm or upon admission to the hospital. potential for actual harm 6/30/24 - Resident R109 was readmitted to the facility. Residents Affected - Few 6/30/24 - E38 (NP) documented in Resident R109's EMR, Warfarin tablet 2 mg- give 2 tablets (4 mg) by mouth in the evening every Mon, Tue, Wed, Fri, Sun and give 1.5 tablets (3 mg) by mouth at bedtime every Thu, Sat. Total weekly warfarin dosage was 26 mg.

7/2/24 Tuesday 12:10 PM - Resident R109's INR was reported as 1.2, which was not at Resident R109's desired goal of 2.0 to 3.0.

7/3/24 Wednesday - E38 (NP) ordered in Resident R109's EMR, Warfarin tablet 2 mg- give 2 tablets (4 mg) by mouth

in the evening. Total weekly warfarin dosage was 28 mg. E45 (NP) also ordered, Warfarin tablet 1 mg- give 1 tablet (1 mg) by mouth at bedtime every Wed, Thu for 2 days for a total dose of 5 mg. With the additional 2mg of warfarin, the total weekly dosage was 30 mg.

This one-time dose increase did not meet the professional standard guidelines of a one-time dose increase of 1.5-2 times daily maintenance dose.

This reflected an increase of 4 mg or 15.4 % of the total weekly warfarin dosage.

7/9/24 12:08 PM - Resident R109's INR was reported as 1.4, which was below Resident R109's therapeutic goal of 2.0 to 3.0.

7/9/24 - E38 (NP) ordered in Resident R109's EMR, Warfarin tablet 1 mg- give 1 tablet (1 mg) by mouth at bedtime every Tue, Wed, Thu. Give in addition to 2 mg tabs (total dose= 5 mg). Total weekly warfarin dosage was 31 mg.

This reflected an increase of 3 mg or 10.7 % of the total weekly warfarin dosage.

This was day 9 of anti-coagulation therapy in the facility after Resident R109's re-admission to the hospital and Resident R109's INR remained below therapeutic goal of 2.0 to 3.0.

7/12/24 12:33 PM - Resident R109's INR was reported as 1.2, which did not meet Resident R109's therapeutic goal of 2.0 to 3.0.

7/12/24 - E38 (NP) ordered in Resident R109's EMR, Warfarin tablet 1 mg- give 1 tablet (1 mg) by mouth at bedtime. Give in addition to 2 mg tabs (total dose = 5 mg) and Warfarin tablet 2 mg- give 2 tablets by mouth at bedtime. Give in addition to 1 mg tab. Total dose =5mg). Total weekly warfarin dosage was 35 mg.

This reflected an increase of 4 mg or 12.9 % of the total weekly warfarin dosage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 7/15/24 12:34 PM - During an interview, E38 (NP) stated that he looked up the hospital records from the 6/26/24 admission and reviewed the Hematology consult note. I decided not to bridge with lovenox. There Level of Harm - Minimal harm or was conflicting documentation in the discharge summary regarding whether to bridge or not. I am following potential for actual harm the INR and am increasing the dosage with each INR result.

Residents Affected - Few 7/16/24 - Resident R109's INR was reported as 1.5, which was below Resident R109's desired goal of 2.0 to 3.0.

This was day 16 of anti-coagulation therapy in the facility after Resident R109's re-admission to the hospital and Resident R109's INR did not reach the therapeutic goal of 2.0 to 3.0.

7/16/24 - E38 (NP) ordered in Resident R109's EMR, Warfarin tablet 2 mg- give 3 tablets (6 mg) by mouth at bedtime. Total weekly warfarin dosage was 42 mg. E45 (NP) also ordered, Warfarin tablet 2 mg- give 4 tablet (8 mg) by mouth at bedtime for 1 day. With the additional of the one-time 8mg dosage, the weekly warfarin dosage was 50 mg.

This reflected an increase of 15 mg or 42.8 % of the total weekly warfarin dosage.

7/18/24 12:14 PM - During a telephone interview, E39 (MD) confirmed that Resident R109's INR goal for anti-coagulation therapy was 2-3. With regard to the timeframe that it was taken to achieve this goal, E39 stated, It has taken too long.

Of note, at the time of the survey team exit, the facility was still unable to provide evidence that Resident R109 was therapeutically anti-coagulated with warfarin.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46988

Residents Affected - Few Based on observation, interview and record review it was determined that for two (Resident R123 and Resident R143) out of three residents reviewed for bowel and bladder, the facility failed to respond to or provide services to restore bladder continence. Findings include:

1. Review of Resident R123's clinical record revealed:

2/15/24 - Resident R123 was admitted to the facility.

2/20/24 - A bowel and bladder initial assessment revealed that Resident R123 was continent of bowel and bladder.

2/21/24 - An admission MDS assessments revealed that Resident R123 was always continent of bowel and bladder and not indicated for a toileting program.

April 2024 - A review of the April CNA task flow sheet revealed that Resident R123 was incontinent of bladder sixty-five times out of ninety opportunities.

5/21/24 - A quarterly MDS assessment revealed that Resident R123 was frequently incontinent of bladder and always incontinent of bowel and not indicated for a toileting program.

May 2024 - A review of the May CNA task flow sheet revealed that Resident R123 was incontinent of bladder seventy-two times out of ninety opportunities.

June 2024 - A review of the June CNA task flow sheet revealed that Resident R123 was incontinent of bladder eighty-[NAME] times out of ninety opportunities.

July 2024 - A review of the July CNA task flow sheet revealed that Resident R123 was incontinent of bladder twenty-nine times out of thirty-three opportunities.

7/15/24 12:53 PM - An interview with E40 (CNA) confirmed that Resident R123 is usually incontinent and unable to recall if Resident R123 was on a toileting program. E40 stated that Resident R123 was on a different unit previously and was using a urinal. E40 stated she does not offer a urinal or commode to Resident R123.

7/15/24 1:45 PM - An interview with E41 (COTA) confirmed that therapy assessed Resident R123 for use of urinal and bedside commode. E41 confirmed that Resident R123 is able to utilize both adaptive equipment safely.

7/16/24 12:19 PM - An interview with E14 (RN Staff Educator) revealed that the voiding diary gives them an idea of target times to assist the resident with incontinence. Nursing is able to initiate adaptive equipment such as a urinal but therapy has to initiate a commode. E14 confirmed that Resident R123 is not currently using a urinal or commode.

The facility lacked evidence of responding to decreased continence and failed to provide evidence of services to restore continence for Resident R123.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 7/16/24 1:20 PM - An interview with E3 (QA), E7 (ADON), and E2 (DON) revealed that Resident R123 was offered a urinal trial starting on 7/15/24. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident R143's clinical record revealed:

Residents Affected - Few 4/4/24 - Resident R143 was admitted to the facility.

4/6/24 - An admission MDS revealed that Resident R143 is occasionally incontinent of bowel and bladder and is not indicated for a toileting program.

April 2024 - A review of the April CNA task flow sheet revealed that Resident R143 was incontinent of bladder fifty-nine out of one hundred and one opportunities.

May 2024 - A review of the May CNA task flow sheet revealed that Resident R143 was incontinent of bladder eighty-three out of one hundred and twenty-six opportunities.

June 2024 - A review of the June CNA task flow sheet revealed that Resident R143 was incontinent of bladder fifty-five out of ninety opportunities.

July 2024 - A review of the July CNA task flow sheet revealed that Resident R143 was incontinent of bladder twenty-eight out of thirty-eight opportunities.

7/5/24 - A voiding diary was completed for Resident R143 from 7/3/24 to 7/5/24. The facility lacked evidence of implementing a plan to restore continence for Resident R143.

7/17/24 10:25 AM - An interview with E20 (CNA) revealed that [Resident R143] is independent and will notify staff if

she is incontinent. [Resident R143] is able to clean herself up and I (E20) dont normally have to assist her.

The facility lacked evidence of responding to decreased continence and failed to provide evidence of services to restore continence for Resident R143.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on observation, record review and interview, it was determined that for two (Resident R47 and Resident R121) out of two Residents Affected - Few residents reviewed for respiratory care, the facility failed to provide respiratory care consistent with professional standards of practice. Findings include:

1. Review of Resident R47's clinical record revealed:

5/27/16 - Resident R47 was admitted to the facility with diagnoses including traumatic brain injury and tracheostomy status.

7/7/22 - A physician's order was written for Resident R47 Emergency Trach Supply list - Items are to be kept in a bag together at bedside/head of bed at all times 1. The same size trach 2. next size smaller trach 3. Ambu bag and mask 3. Sterile lubricant (2 packets) 4. Suction Machine with tubing 5. Suction Catheter 6. Oxygen tank/full 7. sterile gloves 8. Trach Ties *check for expiration dates and replace prn *.

5/22/24 - An annual MDS revealed that Resident R47 required tracheostomy care.

7/15/24 9:15 AM - A review of the Resident R47's physician's orders lacked evidence of current tracheostomy size and brand of use.

7/15/24 10:29 AM - An interview with E27 (LPN UM) revealed that all tracheostomy orders would be located

in the EMR under orders. E27 confirmed Resident R47's size and type of trach was not indiciated in EMR. E27 stated Resident R46 is a size 6 based on the emergency equipment.

7/15/24 10:40 AM - A physician's order for Resident R47 revealed that tracheostomy size #4 shiley was the current tracheostomy size and brand.

7/15/24 2:50 PM - An interview with E32 (RN) stated she was unsure of Resident R47's trach size prior to today.

7/16/24 9:58 AM - An observation of a size #6 and size #4 replacement tracheostomy to be hanging at bed side with emergency equipment.

7/17/24 9:30 AM - An interview with E28 (NP) confirmed Resident R47 should be a shiley #4 trach and that the facility does not have the proper equipment at this time to accommodate a smaller size as the emergency order states.

44706

2. Review of Resident R121's clinical record revealed:

10/27/23 - Resident R121 was admitted to the facility with a diagnosis of acute respiratory failure with hypoxia (deficiency in amount of oxygen reaching body tissues).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 11/10/23 - A physicians' order documented continuous oxygen at 2 liters/minute via nasal cannula (tube placed into nostrils to deliver oxygen). Change, date and initial tubing weekly and change humidifier bottle Level of Harm - Minimal harm or weekly and PRN, every night shift on Saturday. potential for actual harm 7/9/24 11:10 AM - During an observation, the oxygen tubing was not labeled with date and initials, this was Residents Affected - Few confirmed with E30 (LPN).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on interview and record review, it was determined that for one (Resident R47) out of two residents reviewed for Residents Affected - Few respiratory care, the facility failed to ensure that the Physician's orders included trach size, type, and accurate emergency orders. Findings include:

Review of Resident R47's clincal record revealed:

5/27/16 - Resident R43 was admitted to the facility.

7/7/22 - A physician's order was written for Resident R47 Emergency Trach Supply list - Items are to be kept in a bag together at bedside/head of bed at all times 1. The same size trach 2. next size smaller trach 3. Ambu bag and mask 3. Sterile lubricant (2 packets) 4. Suction Machine with tubing 5. Suction Catheter 6. Oxygen tank/full 7. sterile gloves 8. Trach Ties *check for expiration dates and replace prn *.

7/15/24 9:15 AM - A review of the Resident R47's physician's orders lacked evidence of current tracheostomy size and brand of use.

7/15/24 10:29 AM - An interview with E27 (LPN UM) revealed that all tracheostomy orders would be located

in EMR under orders. E27 confirmed Resident R47's size and type of trach was not indiciated in EMR.

7/15/24 10:40 AM - A physician's order for Resident R47 revealed that tracheostomy size #4 shiley is current tracheostomy size and brand.

7/17/24 11:50 AM - An interview with E28 (NP) confirmed that the emergency order instructions were not accurate for Resident R47's plan of care.

The facility failed to have a current order for Resident R47's tracheostomy that included type and size and failed to have accurate emergency order's,

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on interview and review of the clinical record, it was determined that for one (Resident R47) out of two residents reviewed for respiratory care, the facility failed to have nursing staff with the appropriate competencies and skill sets to provide nursing and related services to a resident with a tracheostomy. Findings include:

Review of Resident R47's clinical record revealed:

5/27/16 - Resident R47 was admitted to the facility with the following but not limited to diagnoses traumatic brain injury and tracheostomy status.

5/22/24 - An annual MDS revealed that Resident R47 required tracheostomy care.

7/15/24 02:58 PM - An interview with E32 (RN) stated she was unsure of Resident R47's trach size prior to today.

7/17/24 10:30 AM - An interview with E36 (Agency LPN) revealed in an emergency you would insert the smaller size trach if it comes out.

7/17/24 10:45 AM - An interview with E37 (Agency LPN) revealed that E37 was unable to articulate what to do in an emergency with a tracheostomy resident. E37 stated I would call the supervisor for help.

7/17/24 12:30 PM - A review of tracheostomy care competency checklists provided by E14 (Staff Educator RN) revealed that the facility lacked evidence of verifying compentcies with all agency nurses and lacked evidence of all staff being verified for emergency tracheostomy procedures.

7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 085037 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 085037 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or 47621 potential for actual harm Based on record review and interview, it was determined that for one (Resident R146) out of three residents reviewed Residents Affected - Few for abuse, it was determined that the facility failed to provide medically related social services to Resident R146, who was cognitively impaired and did not have a legal decision maker. Findings include:

Cross refer