Health Inspection

Ocean Grove Post Acute

July 18, 2024 · Millsboro, DE · 231 South Washington Street

Citations 29

CMS Rating 2/5

Beds 181

Provider ID 085037

Healthcare Facility

Ocean Grove Post Acute

Millsboro, DE · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

OCEAN GROVE POST ACUTE in MILLSBORO, DE — inspection on July 18, 2024.

Found 29 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise

Review of R36's clinical record revealed: 1/26/24 - R36 was admitted to the facility. 2/22/24 - A care plan documented that R36 has an indwelling catheter for neurogenic bladder. 4/3/24 - A physician's order for foley catheter to straight bag drainage for urinary retention. 7/9/24 - Observations of R36 lying in bed with the catheter collection bag was visible from the hallway and not in a privacy bag at 10:23 AM, 11:14 AM and 1:56 PM. 7/10/24 11:31 AM - An observation of R36's being pushed back to the room in a wheelchair where the catheter collection bag was not in a privacy bag and hooked onto the wheelchair. An interview with E15 stated she brought R36 back from the large therapy room located off R36's unit and located near the main facility entrance. E15 confirmed that the catheter collection bag did not have a privacy cover and immediately got a privacy bag and covered the catheter collection bag. 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.

085037 07/18/2024

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

FF0561

Honor the resident's right to and the facility must promote and facilitate resident self-determination

Review of R143's clinical record revealed: 4/4/24 - R143 was admitted to the facility. 4/6/24 - An admission MDS revealed that R143 was not assessed for shower or bathing preferences. 4/10/24 - An admission recreation assessment revealed that for R143 it was very important to choose between a tub bath, shower, bed bath or sponge bath. 7/9/24 - R143 was readmitted from hospital. 7/9/24 12:31 PM - A physician's order revealed shower days were Wednesday and Saturday on the 3 -11 shift with skin check on Saturday and to document refusals every Wednesday and Saturday. 7/10/24 12:58 PM - An interview with R143 revealed that the facility did not give R143 a choice of shower day or time. R143 stated that she prefers showers in the morning. 7/17/24 11:00 AM - An interview with E12 (Activities Assistant Director) revealed that the initial recreation assessment is completed upon admission and is shared with the MDS coordinator and nursing to help establish what's important to the resident. 7/17/24 11:15 AM - An interview with E11 (LPN) revealed that shower schedule is based on room assignment. 7/17/24 11:20 AM - An interview with E10 (LPN UM) confirmed that shower scheduled is based on room assignment for day and time. 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.

085037 07/18/2024

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

FF0563

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

when a patient is deemed not to have capacity .

precedent regarding when a resident is deemed not to have capacity. I am not aware of any

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.

085037 07/18/2024

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

FF0582

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

Review of R146's clinical record revealed: 3/30/24 - R146 was admitted to the facility. 4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment. 4/12/24 - R146 given a Notice of Medicare Non-Coverage (NOMNC) that advised that 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 (R146's sister) stated that she was not informed about R146's last day of Medicare coverage and was not offered the opportunity to appeal. 7/10/24 3:20 PM - A review of R146's face sheet revealed that R146 listed as responsible party and F2 (R146's sister) listed as emergency contact #1 and F3 (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.

085037 07/18/2024

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

FF0584

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.

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.

085037 07/18/2024

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

FF0602

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

nod her head in agreement but she did not understand.

NHA and I took her checkbook to her to write the checks (to [assisted living facility] and to us).

That

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.

085037 07/18/2024

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

FF0623

Provide timely notification to the resident, and if applicable to the resident representative and

The facility failed to provide the Office of the Ombudsman notification of R130's 3/15/24 and 3/25/24 transfers to an acute care hospital. 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.

085037 07/18/2024

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

FF0625

Notify the resident or the resident?s representative in writing how long the nursing home will hold the

Review of R130's clinical record revealed: 10/26/23 - R130 was admitted to the facility's locked dementia unit with diagnoses including: dementia with agitation. 1/31/24 - R130's quarterly MDS documented a BIMS score of five, which reflected severe cognitive impairment. 3/15/24 - R130 was transferred to the hospital for three episodes of coffee-ground emesis (vomit) and was diagnosed with a gastrointestinal bleed. R130 returned to the facility on 3/17/24. 3/25/24 - R130 was transferred to the hospital for a syncopal (fainting) episode. R130 returned to the facility on 3/27/24. 7/17/24 - Review of R130's EMR revealed F1 (R130's son) was listed as Emergency contact # 1 and R130 was listed as responsible party. 7/17/24 - Review of R130's Bed-hold Policy Notices, dated 3/15/24 and 3/25/24, both revealed R130 listed as the responsible party to whom the notice was presented.

The facility failed to notify an appropriate resident representative of the facility's bed-hold policy for R130's hospitalizations. 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.

085037 07/18/2024

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

FF0641

Ensure each resident receives an accurate assessment.

The surveyor noted that R66 has teeth, but they are in disrepair. R66 stated that although dental exams are offered, 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 R66 has broken teeth and R66 confirmed she does not have dentures.

Review of R146's clinical record revealed:

3/30/24 - R146 was admitted to the facility. 4/5/24 - 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 - R146's quarterly MDS documented that R146 did not have a wander/elopement alarm. 7/12/24 9:32 AM -

During an interview, E42 (CNA) confirmed that R146 still had a wander guard alarm on her person. 7/12/24 3:42 PM -

During an interview, E19 (RNAC) confirmed that R146's 7/3/24 quarterly MDS was modified yesterday to include that 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.

085037 07/18/2024

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

FF0644

Coordinate assessments with the pre-admission screening and resident review program; and referring

mental status. 4/5/21 - 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 - 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 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.

085037 07/18/2024

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

FF0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and

Review of 143's clinical record revealed: 4/4/24 - R143 was admitted to the facility. 4/6/24 - An admission MDS assessment revealed that R143 was occasionally incontinent of bowel and bladder.

The MDS revealed that R143 was not indicated for a toileting program at this time. 7/11/24 9:42 AM - A review of 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 R143 did not have a care plan for incontinence.

085037 07/18/2024

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

FF0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared,

and E7 (ADON) at the exit conference.

085037 07/18/2024

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

FF0658

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

Review of 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.

085037 07/18/2024

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

FF0676

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

Review of R128's clinical record revealed: 8/11/23 - 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 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 R128 had an impairment on one side for the upper extremities and no impairments for the lower extremities. 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. R128's BIMs score was 13 out of 15 which indicated intact cognition. 7/9/24 - An interview with R128 stated, I stay in bed and they don't get me up.

Observations of 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 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 R128 did not get out of bed on 7/11/24 and that 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 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.

085037 07/18/2024

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

FF0684

Provide appropriate treatment and care according to orders, resident?s preferences and goals.

4 tablet (8 mg) by mouth at bedtime for 1 day.

With the additional of the one-time 8mg dosage, the

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 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 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.

085037 07/18/2024

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

FF0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate

offered a urinal trial starting on 7/15/24.

4/6/24 - An admission MDS revealed that 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 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 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 R143 was incontinent of bladder fifty-five out of ninety opportunities.

July 2024 - A review of the July CNA task flow sheet revealed that R143 was incontinent of bladder twenty-eight out of thirty-eight opportunities. 7/5/24 - A voiding diary was completed for R143 from 7/3/24 to 7/5/24.

The facility lacked evidence of implementing a plan to restore continence for R143. 7/17/24 10:25 AM - An interview with E20 (CNA) revealed that [R143] is independent and will notify staff if she is incontinent. [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 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.

085037 07/18/2024

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

FF0695

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

Review of R47's clinical record revealed: 5/27/16 - 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 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

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 R47 required tracheostomy care. 7/15/24 9:15 AM - A review of the 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 R47's size and type of trach was not indiciated in EMR. E27 stated R46 is a size 6 based on the emergency equipment. 7/15/24 10:40 AM - A physician's order for 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 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 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.

Review of R121's clinical record revealed:

10/27/23 - R121 was admitted to the facility with a diagnosis of acute respiratory failure with hypoxia (deficiency in amount of oxygen reaching body tissues). 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 weekly and PRN, every night shift on Saturday. 7/9/24 11:10 AM - During an observation, the oxygen tubing was not labeled with date and initials, this was confirmed with E30 (LPN).

085037 07/18/2024

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

FF0710

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

Review of R47's clincal record revealed: 5/27/16 - R43 was admitted to the facility. 7/7/22 - A physician's order was written for 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

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 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 R47's size and type of trach was not indiciated in EMR. 7/15/24 10:40 AM - A physician's order for 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 R47's plan of care.

The facility failed to have a current order for 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.

085037 07/18/2024

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

FF0726

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a

Review of R47's clinical record revealed: 5/27/16 - 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 R47 required tracheostomy care. 7/15/24 02:58 PM - An interview with E32 (RN) stated she was unsure of 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.

085037 07/18/2024

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

FF0745

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

to R146's apartment and F4 was the person who picked up R146's mail.

7/15/24 11 AM - The surveyor informed the facility of the allegation against F4 who was listed on 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 [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 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. [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 [R146} wants to leave the facility with friends, we allow her to go. 7/18/24 - F4 (male friend) remained listed on 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.

085037 07/18/2024

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

FF0812

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

serve food in accordance with professional standards.

stored, prepared, and served in a manner that prevents food borne illness to the residents.

Findings

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.

085037 07/18/2024

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

FF0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are

Review of R128's clinical record revealed: 8/11/23 - R128 was admitted to the facility. 4/23/24 - R128's physicians orders documented 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 R128 was dependent for transfer from bed to chair or chair to bed. 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 R128 laying in bed. 7/12/24 9:33 AM -

During an interview 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 R128 was not out of bed on 7/11/24 and they did not offer to get 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 R128 got out of bed.

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

The facility documented that 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.

085037 07/18/2024

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

FF0867

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop

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.

FF0880

Provide and implement an infection prevention and control program.

The catheter collection bag did not have a privacy bag cover. An interview with E15 stated she brought R36 back from the large therapy room located off 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 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 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. 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. 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.

085037 07/18/2024

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

FF0921

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff

and the public.

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.

085037 07/18/2024

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

FF602

Minimal harm or sisters. [R146] does not feel like she can live on her own. It was reported to the social services department Few affected

Review of R146's clinical record revealed:

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

4/1/24 3:09 PM - R146 signed the facility's Admission Agreement, which included an authorization form to release financial data.

The clauses that identified 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 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 [R146] move in with one of her sisters .[R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit .

4/5/24 - 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 R146's EMR Update delivered to family and CM (case management) in phone call.

The facility failed to identify that 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 R146 to address the need for a responsible party with R146's two known sisters.

4/12/24 - R146 was given a Notice of Medicare Non-Coverage (NOMNC) that advised that 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 .

085037

Form Approved OMB

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

FF676

Potential for Many Based on review of facility documentation, review of cited deficiencies from the facility's annual survey of affected

Review of R128's clinical record revealed:

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

4/23/24 - R128's physicians orders documented 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 R128 was dependent for transfer from bed to chair or chair to bed. 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 R128 laying in bed.

7/12/24 9:33 AM -

During an interview 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 R128 was not out of bed on 7/11/24 and they did not offer to get 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 R128 got out of bed.

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

The facility documented that 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.

085037

Form Approved OMB

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

FF745

Minimal harm or Few affected

Review of R146's clinical record revealed:

3/30/24 - 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 R146's EMR.[R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit .

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

5/29/24 - E46 (Psychologist) documented in 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 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 R146 out of the facility in the Leave of Absence log. R146 was signed back into the facility at 11:35 AM.

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

According to the Release of Responsibility for Leave of Absence log, 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 R146's face sheet revealed that R146 listed as responsible party and F2 (R146's sister) listed as emergency contact #1 and F3 (R146's other sister) listed as emergency contact #2.

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

085037

Form Approved OMB

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

FF842

TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47621 Few hospitalization , the facility failed to ensure that R146's warfarin dosing was managed in accordance with the affected

Review of R128's clinical record revealed:

8/11/23 - 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 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 R128 had an impairment on one side for the upper extremities and no impairments for the lower extremities. 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. R128's BIMs score was 13 out of 15 which indicated intact cognition.

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

Observations of 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 R128 stated he did not get out of bed at any time on 7/11/24.

7/12/24 2:29 PM -

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 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.

085037

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MILLSBORO, DE, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OCEAN GROVE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.