Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ocean Grove Post Acute during CMS and state inspections, most recent first.
A resident who was documented as cognitively intact and without a dementia diagnosis was transferred from an LTC unit to a locked dementia unit. After the move, the resident repeatedly expressed distress and stated she did not belong there, while psych and nursing notes documented anxiety, tearfulness, mood lability, social isolation, and emotional outbursts related to the unit transfer.
Failure to Timely Report Allegations of Abuse, Neglect, and Suspected Crime: The facility did not timely report multiple allegations to the State Agency, including a cognitively impaired resident’s insurance disenrollment signed without POA involvement and not recognized as possible forgery, two residents’ blood sugar checks that staff believed may have been inaccurate and possibly made up, and an allegation that a staff member pushed a resident after a fall. The DON confirmed the facility did not identify these events as abuse, neglect, or suspected crime within the required timeframe.
A facility failed to notify residents of current mealtimes, with residents on one unit reporting meals were late or inconsistent and observations showing no posted meal schedule in multiple areas. The facility also failed to maintain dignity for a resident with moderate cognitive impairment when a CNA provided ADL care with the door and curtain open while the resident was unclothed.
A resident with dementia and severe cognitive impairment had an insurance disenrollment form completed and signed by the resident instead of the resident’s DPOA/representative, even though the facility had previously recognized the spouse as the decision-maker. The family later reported the insurance was changed without their knowledge or permission, and the BOM confirmed the form was completed without involvement of the responsible party.
A resident with anxiety, schizophrenia, and depression had repeated AIMS assessments showing side effects from antipsychotic use, but psychiatric evaluations did not document the AIMS scores and continued the medication. An RN note described auditory hallucinations, paranoia, lethargy, confusion, tremors, constipation, rash, and a poor AIMS score, but there was no evidence the psych NP or PCP were informed of the increased side effects; the psych NP later confirmed the facility did not relay this information.
Inaccurate MDS Assessments: Three residents had inaccurate MDS coding. One resident’s quarterly MDS omitted a BIMS score despite a later social work assessment documenting intact cognition, another resident’s MDS failed to code documented threatening behavior, and a third resident’s MDS recorded a BIMS score of 00 even though the resident refused to answer the BIMS questions. The RNAC confirmed the errors during interview.
Two residents had care plans that were not updated when their needs changed. One resident had documented refusal of shaving/personal grooming services and visible facial hair, but the care plan did not reflect the refusal. Another resident was changed to a mechanically soft diet due to difficulty chewing, and meal observations and MDS documentation reflected the diet change, but the care plan still listed a regular diet instead of the updated diet order.
Failure to provide ADL care and assistance: A resident with dementia who was dependent on staff for bathing and hygiene was repeatedly observed with an untrimmed beard, and an RN confirmed he had not been shaved. A hospice resident who was dependent for eating was not served breakfast or lunch because CNAs believed hospice status meant meals should be withheld, despite no order to hold food. Another resident who required substantial to maximum assistance with personal hygiene was observed with facial hair growth and later stated he wanted to be shaved.
Failure to follow antibiotic orders for two residents. One resident was seen for cellulitis of the foot and returned with an oral antibiotic from urgent care, but the medication was held and not started until days later after a verbal order was not entered. Another resident had a telehealth visit for a purulent arm pustule, and although Augmentin was ordered after a wound culture, the order was not properly transcribed and the medication administration record reflected an incorrect one-time dose instead of the ordered course.
A resident’s record was incomplete because progress notes documented repeated verbal aggression, yelling, threatening comments, cursing, and false accusations, but the behavior monitoring sheets for two months contained no behavior documentation. The DON confirmed the point-of-care task sheets did not reflect the resident’s behavior episodes.
A resident’s care plan was not properly revised after a change in code status. The resident was initially care planned as full code and accepting CPR, but a later physician order changed the status to DNR with RN to pronounce, and a subsequent care plan documented do not resuscitate, do not hospitalize, and do not intubate. Despite this, both the original full code care plan and the updated DNR care plan remained active, and the outdated full code plan was never discontinued. An LPN reported that the Social Worker was responsible for updating code status in the care plan and confirmed that the care plan had not been updated appropriately; these findings were reviewed with the NHA and DON.
Surveyors found that a resident unit was not maintained in a clean and homelike condition, with multiple rooms exhibiting brown stains near an air conditioning unit, ceiling, and closet, as well as a leaking shower head, slippery substances on shower tiles, and missing tiles and baseboards. Maintenance staff confirmed these areas were in disrepair.
A resident with multiple wounds did not consistently receive daily wound care as ordered by the physician. Documentation showed missed treatments on several days, with no evidence of resident refusal or absence. Interviews with the resident and staff confirmed that wound care was not always performed due to staffing issues, and the unit manager was unaware of the missed treatments.
A resident with diabetes did not receive prescribed injections of Ozempic and Bydureon as ordered, due to pharmacy dispensing errors, medication order changes, and product unavailability. Documentation and interviews confirmed that the medications were not administered on multiple occasions, and facility staff acknowledged the lack of timely delivery and communication regarding the resident's medication needs.
A resident with severe cognitive impairment and GERD was served meals containing foods such as tomato products and onions, which were specifically listed as intolerances in their care plan. Staff and dietary personnel were unaware of these restrictions, and meal tickets did not reflect the need to avoid these foods, resulting in the resident receiving inappropriate meals.
Three residents experienced deficiencies in clinical documentation, including unsigned medication administration records for pain medication and an incorrect nutritional assessment for tube feeding. Although medications were administered and orders were followed, the records did not accurately reflect the care provided due to documentation errors by nursing staff.
The facility failed to create comprehensive care plans for four residents, including those with incontinence, cognitive impairment, and the need for anti-coagulation therapy. Despite assessments indicating these needs, care plans were not developed, as confirmed by staff interviews.
The facility failed to ensure required IDT members participated in care plan meetings for several residents, with missing input from physicians, nurses, and nutrition staff. One resident's care plan inaccurately included dentures, and another's did not reflect current tracheostomy needs. Additionally, a resident's care plan did not accurately reflect interventions for dementia-related resistance to care.
The facility failed to ensure required IDT members participated in care plan meetings for six residents, and inaccurately included dentures in one care plan. Additionally, LPNs, instead of RNs, completed admission assessments and baseline care plans, contrary to Delaware State regulations. This was confirmed through record reviews and staff interviews.
The facility failed to properly store, prepare, and serve food, risking foodborne illness. An undated Nutritional Shake was found in a nourishment refrigerator, and the walk-in refrigerator had rusted shelves, a wet floor, and ice buildup. Additionally, the sanitizing solution in a prep area bucket was insufficient for proper sanitization.
The facility failed to implement proper infection control measures for three residents. One resident with a tracheostomy did not have necessary supplies for enhanced barrier precautions, and an LPN did not use a gown or face shield during care. Another resident with a PICC line and staph infection was not cared for with required precautions, as an LPN only wore gloves during medication administration. A third resident's catheter bag was repeatedly observed on the floor, violating infection control protocols.
A facility failed to notify a resident's authorized representative about the termination of Medicare coverage. The resident, with severe cognitive impairment, was given a Notice of Medicare Non-Coverage, but the resident's sister, listed as an emergency contact, was not informed or offered an opportunity to appeal. The facility lacked evidence of attempts to notify the emergency contacts.
The facility did not maintain a clean and homelike environment in the Ocean Gardens unit. A broken handrail with jagged edges in the 300 hallway was not covered, and the baseboards in the 400 hallway were dirty and dusty, with a dark substance spilled on the wall. These issues persisted over several days, despite the Maintenance Director's awareness.
A resident with severe cognitive impairment was not protected from misappropriation of funds when the facility's staff assisted them in writing checks despite their inability to understand financial transactions. The facility failed to report the incident of missing funds to the State agency, and the checks were returned for insufficient funds.
A resident with severe cognitive impairment was financially exploited when their checkbook, secured in the facility safe, was used to write checks that later bounced due to missing funds. Despite discovering the issue, the NHA did not report it to Adult Protective Services until prompted by a surveyor, indicating a failure to follow timely reporting protocols.
The facility failed to address incontinence issues for two residents, who experienced frequent episodes of bladder incontinence without a structured plan to restore continence. Despite assessments indicating the ability to use adaptive equipment, the facility did not implement a toileting program or utilize such equipment, as confirmed by staff interviews.
The facility failed to maintain a safe and sanitary environment in the clean laundry room, where pipes were dripping water onto the floor and into a trash can. The pipes had black staining, some appearing fuzzy, and wet towels were found on the floor. A laundry staff member confirmed the issue had persisted for several months.
A facility failed to maintain a resident's dignity by not using a privacy bag for a urinary collection bag, as required by policy. The resident, with an indwelling catheter for neurogenic bladder, was observed multiple times with the catheter bag visible and uncovered. An employee confirmed the deficiency and covered the bag after it was pointed out. The issue was reviewed with facility leadership.
A resident's bathing preferences were not honored, as the facility scheduled showers based on room assignment rather than individual choice. Despite the resident's preference for morning showers, the schedule was set for specific days and times without their input. Staff interviews confirmed the scheduling practice, and the issue was reviewed with facility leadership.
A resident with severe cognitive impairment was allowed to leave the facility multiple times with unrelated persons without family consent, due to the facility's lack of policies for residents without a legal decision maker. Staff interviews confirmed the absence of procedures or restrictions for such residents, leading to this deficiency.
A facility failed to notify a resident's family representative and the Ombudsman of two hospital transfers. The resident, with severe cognitive impairment, was incorrectly listed as the responsible party for notifications. The facility's records showed the resident's son as the emergency contact, but he was not informed of the transfers. Additionally, the transfers were not included in the Ombudsman Admission/Discharge Notice. These findings were reviewed with facility staff.
A facility failed to notify a resident's family representative of the bed-hold policy during two hospitalizations. The resident, with severe cognitive impairment, was incorrectly listed as the responsible party for receiving the notices, despite their son being the emergency contact.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their care plans. One resident was incorrectly documented as edentulous despite having broken teeth, while another resident's MDS inaccurately noted the absence of a wander guard, despite its confirmed presence. These inaccuracies were confirmed through staff interviews.
The facility failed to complete necessary PASARR screenings for three residents, leading to a deficiency. One resident, admitted with mental health diagnoses, did not receive a Level II PASARR despite new diagnoses of dementia and violent behavior. Another resident, initially exempt from Level II, developed mood disorder and dementia but was not reassessed until much later. A third resident, with new diagnoses of dementia and psychotic disturbance, also lacked a Level II PASARR. The absence of a psych nurse practitioner contributed to these oversights.
A resident with cerebral infarction and hemiplegia was not assisted to get out of bed as per physician's orders, despite being cognitively intact. Observations showed the resident remained in bed, and staff interviews confirmed no refusals were documented. A CNA admitted they did not ask the resident if he wanted to get up, leading to a deficiency finding.
A resident with atrial fibrillation and other conditions was not managed effectively for warfarin dosing, resulting in consistently subtherapeutic INR levels. Despite dosage adjustments, the facility failed to achieve the therapeutic INR range, leading to the resident's hospitalization for further anticoagulation treatment. Interviews confirmed the prolonged failure to reach the INR goal, and the issue was discussed with facility leadership.
The facility failed to provide appropriate respiratory care for two residents. One resident with a tracheostomy had discrepancies in trach size documentation and lacked proper emergency equipment. Another resident with acute respiratory failure had unlabeled oxygen tubing, contrary to physician's orders. These issues indicate lapses in maintaining accurate records and equipment management.
A facility failed to ensure a resident's physician's orders included necessary details for tracheostomy care. The orders lacked information on the current trach size and brand, and emergency instructions were inaccurate. This was confirmed by an LPN and a nurse practitioner, and discussed with facility leadership during the exit conference.
The facility failed to ensure nursing staff had the necessary competencies to care for a resident with a tracheostomy. A resident with a traumatic brain injury and tracheostomy status required specific care, but interviews revealed staff were unsure of emergency procedures. The facility lacked evidence of verifying competencies for agency nurses and staff in emergency tracheostomy procedures.
A facility failed to provide necessary social services to a cognitively impaired resident who lacked a legal decision maker. The resident, with a severe cognitive deficit, signed an Admission Agreement without understanding it. The facility did not identify a responsible party or initiate a timely capacity determination. The resident was signed out by unauthorized persons, and the facility failed to inform the family about Medicare coverage changes or report potential financial exploitation.
A facility failed to maintain accurate documentation for a resident who was required to be out of bed for at least two hours daily. Despite observations and the resident's statement confirming they remained in bed, the treatment administration record inaccurately indicated compliance with the order. Interviews with staff revealed a lack of documentation for refusals, highlighting a failure to adhere to professional standards.
The facility's QAPI program failed to address previously cited deficiencies in the MRR policy, which lacked specified time frames for pharmacist responses and facility actions. Despite a Plan of Correction, the policy remained unchanged, as confirmed by the NHA. These issues were discussed with key staff during the exit conference.
A resident with hemiplegia fell from a wheelchair during transport in a facility van due to improper restraining, resulting in a head injury. The van driver did not use the shoulder belt as per facility guidelines, leading to the resident's fall and subsequent hospital treatment.
The facility failed to maintain accurate Controlled Drug Count Records for May 2024, with missing evidence of narcotic counts and discrepancies in records, such as scribbled-out entries and incomplete categories. These issues were confirmed by the NHA and DON, indicating a failure to reconcile controlled drugs between shifts.
Involuntary Seclusion Related to Transfer to Dementia Unit
Penalty
Summary
The facility failed to ensure one resident was free from involuntary seclusion when R182 was transferred from a long-term care unit to the locked dementia unit despite being documented as cognitively intact. R182 was admitted with diagnoses including anxiety and depression, and an admission MDS documented a BIMS score of 15 with no behaviors and no diagnosis of dementia. Social services documented that both the resident and the resident’s daughter were informed of the room change and were agreeable, but subsequent records show the resident was moved to the dementia unit and continued to express distress about the transfer. After the move, psychiatric and psychological notes repeatedly documented that R182 was upset about being placed on the dementia unit, stating she did not belong there and believed she still had all her mental faculties. Staff documented anxiety, tearfulness, mood lability, social isolation, intermittent emotional outbursts, and perseveration related to the unit transfer, while also noting the resident was alert and oriented and had no psychosis. The quarterly MDS later documented verbal behaviors during the assessment period, but did not document dementia, physical behaviors, or elopement risk.
Failure to Timely Report Allegations of Abuse, Neglect, and Suspected Crime
Penalty
Summary
The facility failed to identify and report allegations of abuse, neglect, or suspicion of a crime to the State Agency within the required timeframe for four residents. For one resident with dementia and cognitive communication deficit, the record showed the resident was admitted with Medicare Advantage coverage and had severe cognitive impairment and upper extremity range-of-motion impairments. A disenrollment form changing the resident’s insurance was completed and signed by the resident, but the resident’s POA was not consulted. The BOM stated she entered the date next to the resident’s signature and confirmed the resident’s mental status was not reviewed before obtaining the signature. The NHA confirmed the facility knew the POA did not sign the consent and that the BOM assisted the cognitively impaired resident with signing the insurance disenrollment form, but the facility did not recognize this as suspicion of forgery and did not report it to the State Agency. For two residents, physician orders required blood sugar checks, and the MAR documented blood sugar results obtained on the same day. The DON later documented that two LPNs expressed concerns that the blood sugar results were inaccurate and possibly made up. During interview, the DON stated there were suspicions about the blood sugars and confirmed the facility did not recognize the allegation as neglect and did not report it to the State Agency. For another resident, an incident was documented alleging that a staff member pushed the resident when attempting to get up from the floor after a fall. Although a facility incident was submitted to the State Agency the next day, the DON stated staff failed to recognize the event as an allegation of abuse and the report was not submitted within the appropriate timeframe.
Meal Times Not Posted and Resident Care Provided Without Privacy
Penalty
Summary
The facility failed to ensure residents were notified of mealtimes and failed to promote care in a manner that maintained dignity and respect for one resident. During the survey, residents on Unit One reported that meals were never on time, lunch was never on time, and meals were served at inconsistent times. The facility provided a meal schedule showing lunch on Unit One at 12:00 PM to 12:08 PM and in the Main Dining Room at 12:00 PM, but observed lunch cart delivery times on Unit One were later than the posted schedule. Observations on Unit One, Unit Two, Unit Three, Unit Four, and the Main Dining Room also lacked evidence of posted mealtimes notifying residents of current mealtimes. An acting RCP stated that a change in mealtimes had been communicated at the Food Committee Meeting but was not posted, and the Dietary Director later provided a revised meal schedule showing lunch on Unit One at 12:45 PM to 12:50 PM while the Main Dining Room remained open at noon. The NHA confirmed the revised meal schedule had not been posted for residents. For R155, the clinical record showed admission to the facility on 11/15/23 and a quarterly MDS dated 5/7/26 documenting a BIMS score of 12, indicating moderate cognitive impairment, along with a need for supervision or touching supervision for ADLs and lower body dressing. During direct observation, a CNA was providing ADL care to R155 in the corner of the room with the door and curtain open. R155 was not clothed while the CNA washed, dried, and assisted the resident into a clean brief. When interviewed shortly afterward, the CNA confirmed that R155 received ADL care with the door and curtain open and stated that the door and curtain should have been closed to maintain dignity.
Resident Representative Not Involved in Insurance Change
Penalty
Summary
The facility failed to ensure that the resident representative’s rights were exercised for one resident with dementia and cognitive communication deficit. The resident was admitted on 1/26/26, and the admission agreement was signed by the resident’s durable power of attorney, who had served in that role since June 2010. A progress note on the day of admission documented that code status was confirmed with the spouse/representative, and the admission MDS later documented severe cognitive impairment. Despite this, on 2/26/26 a disenrollment form changing the resident’s insurance coverage was completed by the BOM and signed by the resident rather than the resident’s representative. A social services note later documented that the family expressed concern about the insurance being converted and upset about the change. During interviews, the representative stated the change was made without knowledge or permission and that the facility did not discuss it beforehand, and the BOM confirmed the disenrollment form was completed without involvement of the responsible party.
Inadequate monitoring and communication of antipsychotic side effects
Penalty
Summary
The facility failed to ensure adequate monitoring of antipsychotic medication use for one resident with anxiety, schizophrenia, and depression. Review of the resident’s record showed multiple AIM assessments documenting side effects from antipsychotic medications, including scores of 4.0, 3.0, and later 27.0, while psychiatric evaluations completed on 11/19/25 and 1/9/26 did not document the AIM scores and both recommended continued use of the antipsychotic medication. The resident’s annual MDS also documented hallucinations, delusions, and receipt of antipsychotic medications. A progress note written by an RN documented that the resident had auditory hallucinations, paranoia, lethargy, isolation, confusion, constipation, rash, tremors, and was recently started on Clozapine; the note also stated the resident scored poorly on AIMS. The note did not show that the psych NP or the resident’s primary care provider were informed of the AIMS assessments. During interview, the RN confirmed completing the AIMS assessment but could not confirm notification of the increased side effects, while the DON stated the facility did notify the provider. The psych NP later confirmed the facility did not relay that the resident was having an increase in side effects related to antipsychotic medication use.
Inaccurate MDS Assessments
Penalty
Summary
Ensure each resident received an accurate MDS assessment. For R158, a quarterly MDS completed on 6/8/26 documented that cognitive status was not assessed and contained no BIMS score, while a social services assessment completed on 6/17/26 documented a BIMS score of 15, indicating the resident was cognitively intact. During interview, the RNAC confirmed the quarterly MDS was inaccurate because the BIMS score was omitted and stated the social worker did not complete it on time. For R180, a progress note dated 8/20/25 documented that staff reported the resident was witnessed cursing at and threatening a female resident, but the 8/24/25 quarterly MDS assessed the resident as having no behaviors. The RNAC confirmed the MDS was incorrect and that threatening should have been coded in the behavior section. For R182, a quarterly MDS dated 4/7/26 documented a BIMS score of 00, while a social work assessment dated 4/8/26 documented that the resident refused to answer assessment questions for BIMS. The RNAC confirmed the quarterly MDS was incorrect and that a score of 99 should have been documented for refusal.
Care plans not revised for changed grooming and diet needs
Penalty
Summary
The facility failed to revise care plans for two residents when their care needs changed. For one resident, the clinical record showed an annual MDS assessment indicating dependence for personal hygiene, and observations on multiple days revealed visible facial hair growth on the upper lip, chin, cheeks, and sideburns. The resident’s care plans were reviewed and did not include the resident’s refusal of personal grooming services for facial hair. A CNA stated that the resident refused personal grooming services for facial hair, and an RN confirmed during care plan review that the refusal to be shaved was not documented in the care plan. For another resident, the record showed that a quarterly MDS documented the resident was not on a mechanically altered diet, while a dietitian progress note documented difficulty chewing certain foods and a change to a mechanical soft diet with thin liquids and no-added-salt. Later observations of meal trays and meal tickets showed the resident receiving mechanically soft food, and a subsequent quarterly MDS documented the resident was on a mechanically altered diet. The dietitian confirmed that the resident had been downgraded to a mechanically soft diet due to difficulty chewing, but the care plan had not been updated from a regular diet to a mechanically soft diet.
Failure to Provide ADL Care and Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for dependent residents. For one resident with dementia who was documented as severely cognitively impaired and dependent on staff for bathing and hygiene, the record showed shower days were scheduled, but the resident was repeatedly observed over several days with visible facial hair growth and an untrimmed beard. An RN confirmed the resident had not been shaved, and CNAs stated that shaving male residents was part of complete bathing care. The DON also confirmed the resident had not been shaved. The facility also failed to provide meals and assistance with eating for a resident on hospice who was documented as dependent on staff for eating and whose care plan included providing and serving the ordered diet. During dining observations, the resident’s tray remained in the holding cabinet while other residents were served breakfast and lunch. CNAs stated the resident would not be served because he was on hospice and comfort measures, and the meal ticket had been torn in half. An RN confirmed there was no order to hold food, and the unit manager stated staff should have offered both meals and attempted to feed the resident. A third resident who required substantial to maximum assistance with showers, bathing, and personal hygiene was observed on multiple days with visible facial hair growth, stated he wanted to be shaved, and was later shaved by a CNA after staff reported he usually refused shaving.
Failure to Follow Antibiotic Orders
Penalty
Summary
The facility failed to follow physician orders related to antibiotics for two residents. For one resident, the clinical record showed that after a walk-in clinic visit for cellulitis of the right foot due to injury, an oral antibiotic was prescribed and called in to a local pharmacy. The resident returned to the facility with the medication bottle, but a nurse documented that, per MD instructions, the antibiotic was to be held until the resident was evaluated in the morning. The next day, an NP gave a verbal order to start the antibiotic, but the order was not entered, and the antibiotic was not administered until three days after the original prescription and two days after the verbal order. Interviews confirmed the resident’s daughter had taken her to a walk-in clinic because the foot was infected and that the prescription was brought to the facility but not given right away. For the second resident, a telehealth provider documented a purulent pustule on the right upper arm with swelling, redness, and warmth, and ordered warm compresses, a wound culture, labs, and Augmentin after the culture was obtained. Medication records showed Augmentin was removed from the emergency medication system and a physician order was later documented, but the order was scheduled as a one-time administration and then documented as administered, rather than being transcribed and carried out as ordered for a 10-day course. Staff interviews confirmed the expectation that verbal orders be entered into the EMR promptly, and the CNO confirmed the antibiotic was to start after the culture was obtained and was ordered twice daily for 10 days.
Incomplete Behavior Monitoring Documentation
Penalty
Summary
The facility failed to ensure resident records were complete and accurately documented for one resident, R180, out of 74 residents reviewed. Review of R180’s clinical record showed progress notes documenting verbally agitated behavior, yelling, staff concerns that the resident’s anger and tone made them feel threatened, staff reporting verbally harassing and threatening comments, cursing at and threatening a female resident, and false accusations against staff. However, review of R180’s behavior monitoring sheets for July 2025 and August 2025 lacked documentation of any behaviors, despite the progress notes describing repeated episodes of verbal aggression and threatening behavior. During interview, the DON confirmed that R180’s behavior monitoring was incomplete because the point-of-care task sheets did not reflect the resident’s episodes of behaviors.
Failure to Discontinue Outdated Full Code Care Plan After Change to DNR Status
Penalty
Summary
The facility failed to properly revise and update a resident’s care plan to reflect a change in code status. The resident was initially admitted with a care plan documenting full code status and acceptance of CPR. On a later date, a physician’s order changed the resident’s status to DNR with authorization for an RN to pronounce. Subsequently, a new care plan entry documented that the resident had made end-of-life decisions including do not resuscitate, do not hospitalize, and do not intubate. However, review of the care plan showed that both the original full code care plan and the later DNR-focused care plan remained active at the same time, and the earlier full code care plan had not been discontinued. During an interview, an LPN stated that the Social Worker was expected to update care plans regarding code status and confirmed that the care plan had not been updated appropriately for this resident. The deficiency was discussed with the NHA and DON during the exit conference.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that one out of four resident units failed to maintain a clean and homelike environment. In the Ocean Gardens unit, multiple rooms were found with significant issues: two large brown areas, approximately six inches in length, were noted by the air conditioning unit in one room, which maintenance staff confirmed had recently been replaced due to leaking. Another room had approximately six circular brown areas in a linear pattern on the ceiling and a large brown area, about twelve inches long, in the closet. Additionally, a third room had a leaking shower head, and the shower tiles were covered with a pink and gray slippery substance; several tiles and baseboard lining were missing from the bathroom wall and floor. Maintenance staff confirmed these areas were in disrepair during interviews.
Failure to Provide Wound Care per Physician Orders
Penalty
Summary
A deficiency occurred when wound care for a resident with multiple wounds related to diabetes and poor circulation was not performed according to the physician's ordered frequency. The facility's policy required wound treatments to be provided as ordered and documented in the electronic health record. However, review of the resident's treatment administration record (TAR) showed that daily wound care treatments were not documented as completed on several specific dates. There was also no documentation in the progress notes to indicate that the resident was absent or refused care on those dates. Interviews with the resident and staff confirmed that wound care was not consistently provided as ordered. The resident reported that dressings were not changed every day due to staffing issues. The wound care nurse acknowledged that treatments were sometimes missed and confirmed the gaps in the TAR. The unit manager also confirmed the findings and stated unawareness of the missed treatments. These actions and inactions led to the failure to provide wound care in accordance with physician orders.
Failure to Provide Ordered Diabetes Medications Due to Pharmacy and Order Issues
Penalty
Summary
A deficiency occurred when the facility failed to provide medications as ordered for a resident with diabetes. Upon admission, the resident had a physician's order for Ozempic injections, which was later changed to Bydureon and then to Exenatide due to medication availability issues. The facility's policy required timely receipt of medications from the pharmacy, but documentation showed that Ozempic was not administered on two scheduled dates, and Bydureon was not administered as ordered. The resident's Medication Administration Record (MAR) confirmed these missed doses. Interviews with facility staff and the consulting pharmacist revealed that the pharmacy did not dispense the ordered medications due to order changes and product discontinuation. The pharmacist acknowledged a missed opportunity to dispense the second order and confirmed that Bydureon was unavailable due to manufacturer discontinuation. The resident reported not receiving their prescribed medication, and facility leadership confirmed the lack of evidence for medication delivery from the pharmacy.
Failure to Accommodate Dietary Intolerances for Resident with GERD
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of gastroesophageal reflux disease (GERD) and a feeding tube was not provided with food that accommodated their dietary intolerances as outlined in their care plan. The care plan specifically directed avoidance of foods and beverages that could irritate the esophageal lining, such as tomato products, onions, garlic, and other acidic or spicy foods, and encouraged a bland diet. Despite these documented needs, the resident was observed being fed meals containing tomato sauce, garlic bread, tomato juice, and steak with onions and peppers. The lunch tickets accompanying the meals did not indicate the need to avoid these foods, and the dietary department was unaware of the resident's dietary intolerances related to GERD. Staff interviews confirmed that only texture restrictions were known and followed, and the dietary department had not been informed of the resident's GERD-related dietary needs. The assigned RN reviewed the care plan and acknowledged that the meals provided did not avoid the resident's documented dietary intolerances. These findings were confirmed during the survey exit conference with facility leadership.
Failure to Maintain Accurate Clinical Documentation for Medication and Nutrition Orders
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation for three residents. For two residents who were prescribed morphine sulfate ER for pain management, the medication administration records contained blank, unsigned entries for scheduled doses. However, a review of the controlled drug administration record and the backup pharmacy dispensary log confirmed that the medication was administered as ordered, but the responsible nurse did not document the administration in the electronic medication administration record at the time of administration. For another resident with a feeding tube, there was a discrepancy between the physician's order and the nutritional assessment. The physician's order specified that the resident should receive liquid nutrition through the feeding tube if more than 50% of a meal was consumed, but the nutritional assessment incorrectly documented that tube feeding should occur when less than 50% of a meal was consumed. This inconsistency was due to a documentation error in the nutritional assessment, which did not align with the physician's order or the hospital discharge records.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for four residents in the investigative sample. For one resident, who was admitted in February 2024 and initially assessed as continent, the facility did not create an incontinence care plan despite a later assessment indicating frequent incontinence. Another resident, admitted in April 2024, was occasionally incontinent, yet also lacked an incontinence care plan. Interviews with facility staff confirmed the absence of these care plans. Additionally, a resident with severe cognitive impairment, as indicated by a BIMS score of three, did not have a care plan addressing cognitive impairment. Another resident, admitted with atrial fibrillation, deep vein thrombosis, and a genetic mutation predisposing them to blood clots, lacked a care plan for necessary anti-coagulation therapy. These deficiencies were confirmed through interviews with facility staff and discussed during an exit conference with key personnel.
Deficiencies in Care Plan Meetings and Documentation
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in care plan meetings for six residents. For one resident, the quarterly care plan meeting lacked input from the physician, registered nurse, nurse aide, and food/nutrition services staff, and there was no evidence of a quarterly care plan meeting in December 2023. Another resident's care plan meetings were undated and lacked evidence of participation from the necessary IDT members, with no documentation for previous meetings. Additionally, a resident's care plan inaccurately included dentures, and the facility failed to hold quarterly care plan meetings as required. Further deficiencies were noted in the care plans of other residents. One resident's care plan did not reflect the current needs related to their tracheostomy, including the tracheostomy size and emergency needs if it dislodges. Another resident's care plan did not accurately reflect interventions for their resistance to care due to dementia, as confirmed by a staff member. These findings were reviewed with the facility's administration and nursing staff during the exit conference.
Failure to Ensure Proper IDT Participation and RN-Led Assessments
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in care plan meetings for six residents out of thirty-three in the investigative sample. Additionally, one resident's care plan inaccurately included dentures. This deficiency was identified through record reviews and interviews, revealing that the necessary IDT members were not involved in the care planning process, which is a critical component of ensuring comprehensive and individualized care for residents. Furthermore, the facility did not comply with the Delaware State regulation for the Board of Nursing Scope of Practice, which mandates that a Registered Nurse (RN) must complete admission assessments and baseline care plans. Instead, Licensed Practical Nurses (LPNs) were responsible for these tasks for several residents, including completing various assessments and generating baseline care plans. This practice was confirmed through interviews with staff members, who indicated that LPNs were performing duties that should have been completed by RNs, as per state regulations.
Food Storage and Sanitization Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents foodborne illness to the residents. During an observation, a carton of Nutritional Shake was found undated in the nourishment refrigerator at the nurse's station, despite instructions indicating it should be discarded after four days once opened. Additionally, the food storage shelves in the walk-in refrigerator were covered in rust, the floor was wet, and there was ice buildup in the walk-in freezer. Furthermore, the sanitizing solution in a bucket from the prep area was found to have an insufficient chemical concentration for proper sanitization, as observed during a kitchen tour with the Dining Services Director and Assistant Dining Services Director.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures for three residents, leading to deficiencies in care. For one resident with a tracheostomy, the facility did not provide the necessary supplies for enhanced barrier precautions, and a Licensed Practical Nurse (LPN) failed to use a gown or face shield during tracheostomy care. This resident's care plan required enhanced barrier precautions due to the presence of a tracheostomy, but these precautions were not followed during an observed care session. Another resident with a peripherally inserted central catheter (PICC) line and a staph infection did not receive care with the required enhanced barrier precautions. During medication administration, an LPN was observed wearing only gloves, without the necessary gown. Additionally, a third resident with an indwelling catheter had their catheter collection bag repeatedly observed lying on the floor or dragging along the floor, which is against the facility's policy. Despite attempts to correct the issue, the catheter bag was not consistently kept off the floor, indicating a failure to adhere to infection control protocols.
Failure to Notify Resident's Representative of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide proper notification of service changes to a resident's authorized representative. The resident, identified as R146, was admitted to the facility with a severe cognitive impairment, as indicated by a BIMS score of three. On April 12, 2024, the resident was given a Notice of Medicare Non-Coverage (NOMNC), indicating that Medicare coverage would end on April 17, 2024. The document was signed by facility staff with a note stating the resident was unable to sign due to the BIMS score. However, the resident's sister, listed as the emergency contact, reported not being informed about the end of Medicare coverage or given the opportunity to appeal. The facility could not provide evidence of any attempt to notify the emergency contacts listed in the resident's records.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its resident units, specifically the Ocean Gardens unit. Observations on multiple occasions revealed a broken handrail with jagged edges in the 300 hallway, which was not covered, posing a potential safety hazard. Additionally, the baseboards in the 400 hallway were found to be dirty and dusty, with a dark substance spilled on the wall, creating a stain. These observations were consistent over several days, indicating a lack of timely maintenance and cleaning in these areas. Interviews with the Maintenance Director confirmed awareness of these issues, but they remained unaddressed over the observed period.
Failure to Protect Resident from Misappropriation of Funds
Penalty
Summary
The facility failed to protect a resident, identified as R146, from the misappropriation of their property and funds. R146, who was admitted to the facility with a severe cognitive impairment as indicated by a BIMS score of three, was involved in a financial transaction that they were not capable of understanding. Despite the resident's cognitive limitations, the facility's Business Office Manager and Nursing Home Administrator assisted R146 in writing checks for room and board and a deposit for an assisted living facility. This action was taken without proper consideration of R146's cognitive capacity, as documented by a psychologist and later confirmed by a physician's affidavit for guardianship, which stated that R146 lacked the capacity to make healthcare decisions. The facility also failed to report the incident of missing funds to the State agency, as required. The Business Office Manager and the Nursing Home Administrator were the only individuals with access to the safe where R146's checkbook was stored. Despite being aware of the resident's cognitive impairment, they facilitated the financial transaction, which resulted in a check being returned for insufficient funds. The facility did not provide evidence that the allegation of missing resident funds was reported to Adult Protective Services, highlighting a failure in safeguarding the resident's property and adhering to reporting protocols.
Failure to Report Financial Exploitation of Resident
Penalty
Summary
The facility failed to immediately recognize and report an allegation of financial exploitation involving a resident with severe cognitive impairment. The resident, who was admitted to the facility with a BIMS score indicating severe cognitive impairment, had their financial documents, including a checkbook, secured in the facility safe. Despite a family member's request that the resident not sign anything without family present, the facility's NHA and Business Office Manager assisted the resident in writing checks for room and board and a deposit for an assisted living facility. It was only after these checks bounced that the facility became aware of a potential issue with the resident's finances. The Business Office Manager and NHA discovered the financial discrepancy when the checks bounced, indicating that the funds were missing. Despite this discovery, the NHA did not report the issue to Adult Protective Services as required. It was not until prompted by a surveyor's inquiry that the Director of Nursing reported the situation to the local police. This delay in reporting the suspected financial exploitation represents a failure to adhere to protocols for timely reporting of abuse, neglect, or theft.
Failure to Address Incontinence in Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents, R123 and R143, in terms of responding to and providing services to restore bladder continence. R123 was initially assessed as continent of bowel and bladder upon admission, but subsequent assessments and task flow sheets revealed a significant decline in continence, with frequent episodes of incontinence recorded over several months. Despite this decline, there was no evidence that the facility implemented a toileting program or utilized adaptive equipment such as a urinal or commode, which R123 was assessed to be able to use safely. Interviews with staff confirmed the lack of a structured plan to address R123's incontinence. Similarly, R143 was admitted as occasionally incontinent of bowel and bladder, but task flow sheets indicated frequent incontinence episodes. Although a voiding diary was completed, there was no evidence of a plan to restore continence. Interviews with staff revealed that R143 was independent in managing incontinence, but the facility still lacked a formal response to the resident's decreased continence. The facility's failure to address these issues was confirmed during interviews with various staff members, including the Nursing Home Administrator and Director of Nursing.
Unsafe and Unsanitary Conditions in Laundry Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for staff in the clean laundry room. Several pipes in the ceiling were observed dripping water onto the floor and into a trash can placed under the leaking area. The pipes had numerous areas of black staining, some of which appeared fuzzy, indicating potential mold growth. Three wet and stained towels were found on the floor under the leaks. During an interview, a laundry staff member confirmed the ongoing issue, stating that the water had been dripping and pooling on the floor for several months. These findings were reviewed with the nursing home administrator, director of nursing, quality assurance/infection preventionist, corporate registered nurse, and assistant director of nursing at the exit conference.
Failure to Use Privacy Bag for Urinary Collection
Penalty
Summary
The facility failed to uphold the dignity of a resident by not using a privacy bag for a urinary collection bag, as required by their policy. The resident, who was admitted to the facility with an indwelling catheter for neurogenic bladder, was observed on multiple occasions with the catheter collection bag visible from the hallway and not covered by a privacy bag. These observations occurred on different days, including when the resident was lying in bed and when being transported in a wheelchair. An employee confirmed the absence of a privacy cover and subsequently covered the bag after the deficiency was pointed out. The findings were reviewed with the nursing home administrator, director of nursing, quality assurance/infection preventionist, corporate registered nurse, and assistant director of nursing during the exit conference.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the care preferences of a resident, identified as R143, regarding their bathing schedule. Upon admission, R143 was not assessed for shower or bathing preferences, despite an admission recreation assessment indicating that choosing between different types of baths was very important to them. A physician's order specified shower days and times, but R143 expressed dissatisfaction, stating a preference for morning showers, which was not accommodated. Interviews with facility staff, including the Activities Assistant Director and Licensed Practical Nurses, revealed that the shower schedule was determined based on room assignment rather than individual resident preferences. These findings were discussed with facility leadership during the exit conference.
Lack of Policy for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to have written policies and procedures regarding the visitation rights of residents with cognitive impairments who do not have a legal decision maker. This deficiency was identified in the case of a resident with severe cognitive impairment, who was admitted with diagnoses including altered mental status. The resident scored 3/15 on the BIMS assessment, indicating severe cognitive deficit, and was documented by a psychologist as having impaired judgment and insight, rendering her incapable of making her own healthcare decisions. Despite this, the resident was allowed to leave the facility on multiple occasions with unrelated persons without the consent of her family, who were listed as emergency contacts. Interviews with facility staff, including the Nursing Home Administrator, Social Work Director, and Nurse Practitioner, revealed that there were no existing policies or procedures for residents deemed not to have capacity and without a legal guardian or power of attorney. The staff acknowledged the absence of special orders or restrictions for such residents, and there was no precedent for contacting family members or appointing a guardian ad litem. This lack of policy and oversight led to the resident leaving the facility without appropriate consent, highlighting a significant gap in the facility's management of residents with severe cognitive impairments.
Failure to Notify Family and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the family representative and the Ombudsman of a resident's transfers to the hospital on two occasions. The resident, who was admitted to the facility's locked dementia unit, had a diagnosis of dementia with agitation and a BIMS score indicating severe cognitive impairment. Despite this, the facility listed the resident as the responsible party for notification purposes. On March 15, 2024, the resident was transferred to the hospital due to gastrointestinal bleeding and returned to the facility on an unspecified date. Again, on March 25, 2024, the resident was transferred for a syncopal episode and returned on an unspecified date. The facility's records showed that the resident's son was listed as the emergency contact, yet he was not notified of the hospital transfers. Additionally, the facility failed to include the resident's transfers in the Ombudsman Admission/Discharge Notice for March 2024. This oversight was confirmed during a review of the resident's electronic medical records and transfer notices, which revealed that the resident was incorrectly listed as the responsible party. The findings were discussed with the facility's administration and nursing staff during an exit conference.
Failure to Notify Resident Representative of Bed-Hold Policy
Penalty
Summary
The facility failed to notify the appropriate resident representative of the bed-hold policy for a resident with severe cognitive impairment. The resident, who was admitted to the facility's locked dementia unit with a diagnosis of dementia with agitation, had a BIMS score of five, indicating severe cognitive impairment. During two separate hospitalizations for medical issues, the facility listed the resident as the responsible party for receiving the bed-hold policy notices, despite the resident's son being listed as the emergency contact. This oversight resulted in the family representative not being informed of the facility's bed-hold policy during the resident's hospitalizations.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. For one resident, the clinical record inaccurately documented the resident as edentulous, despite the presence of broken teeth. Interviews with staff and the resident confirmed the resident had teeth in disrepair and did not use dentures, contradicting the MDS assessment. Another resident's admission MDS assessment indicated severe cognitive impairment, and a wander guard was ordered. However, the quarterly MDS inaccurately documented the absence of a wander guard, despite staff confirming its presence. These discrepancies were confirmed during interviews with facility staff, highlighting a failure in maintaining accurate resident assessments.
Failure to Complete PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure that a referral for a PASARR screening was completed for three residents, leading to a deficiency. Resident R14 had a Level I PASARR completed in May 2021, but after being admitted with diagnoses including major depressive disorder and delusional disorder, and later diagnosed with dementia and violent behavior, a Level II PASARR was not completed. This was confirmed by the Social Work Director during an interview. Resident R37 was admitted in November 2018 and had a Level I PASARR indicating mental illness, but a Level II was not deemed necessary at the time. However, with new diagnoses of mood disorder and dementia in May 2023, a Level II PASARR was still not completed until July 2024, as confirmed by the Nursing Home Administrator. Resident R98 had a Level I PASARR completed at the hospital in December 2020, indicating no need for a Level II. After being admitted with cerebral infarction and altered mental status, new diagnoses of dementia with psychotic disturbance and violent behavior were added in 2023. Despite multiple psychiatry visits, a Level II PASARR was not submitted, which was confirmed by the Social Work Director. The facility's lack of a psych nurse practitioner with a definitive schedule contributed to the oversight, resulting in missed screenings for some residents.
Failure to Assist Resident with Mobility
Penalty
Summary
The facility failed to ensure that a resident, identified as R128, was provided with mobility assistance from bed to chair as per the physician's order. R128 was admitted with diagnoses including cerebral infarction and hemiplegia affecting the nondominant left side. The resident's clinical record indicated a physician's order for R128 to be out of bed for a minimum of two hours every day, with nursing staff required to document and notify the family of any refusals during the day shift. Despite this order, observations on multiple occasions revealed that R128 remained in bed and did not receive the necessary assistance to get out of bed. Interviews with the resident and staff confirmed that R128 did not get out of bed on a specific day, and there was no documentation of any refusal by the resident to do so. A CNA admitted that they did not ask R128 if he wanted to get up, and an LPN stated that refusals should be documented in the electronic notes. However, there was no facility documentation of any refusals by R128 on the day in question. This lack of action and documentation led to the deficiency being identified during the survey.
Failure to Manage Warfarin Dosing
Penalty
Summary
The facility failed to manage a resident's warfarin dosing in accordance with professional standards of practice, leading to subtherapeutic INR levels. The resident, who was admitted with conditions including atrial fibrillation, deep vein thrombosis, and factor V Leiden mutation, was prescribed warfarin with a therapeutic goal INR range of 2.0 to 3.0. Despite adjustments to the warfarin dosage, the resident's INR levels consistently remained below the therapeutic range, indicating inadequate anticoagulation management. Throughout the resident's stay, multiple INR tests showed results below the desired therapeutic range, with no evidence of appropriate interventions to address these subtherapeutic levels. The facility's medical staff made incremental increases to the warfarin dosage, but these adjustments did not align with professional guidelines for achieving therapeutic INR levels. The resident was hospitalized due to shortness of breath and was treated with Lovenox, a heparin injection, to reach the desired anticoagulation goal, highlighting the facility's failure to manage the resident's anticoagulation therapy effectively. Interviews with facility staff, including a nurse practitioner and a medical doctor, confirmed the ongoing issue with achieving the resident's INR goal. Despite recognizing that the timeframe to reach the therapeutic goal was excessively long, the facility did not provide evidence of successful anticoagulation management by the time of the survey team's exit. This deficiency in managing the resident's warfarin therapy was discussed with facility leadership during the exit conference.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R47 and R121, as per professional standards. R47, who was admitted with a traumatic brain injury and tracheostomy status, had a physician's order for an emergency trach supply list to be kept at the bedside. However, there was a lack of evidence in the electronic medical record (EMR) regarding the current tracheostomy size and brand. Interviews with staff revealed uncertainty about R47's trach size, and it was confirmed that the facility did not have the proper equipment to accommodate the required trach size. Observations showed discrepancies between the trach sizes available at the bedside and the physician's order, indicating a failure to maintain accurate and accessible records for emergency tracheostomy care. For R121, who was admitted with acute respiratory failure with hypoxia, there was a physician's order for continuous oxygen via nasal cannula, with specific instructions for changing and labeling the oxygen tubing. During an observation, it was noted that the oxygen tubing was not labeled with the date and initials, as required. This was confirmed by an LPN, indicating a failure to adhere to the prescribed protocol for oxygen equipment management. These deficiencies highlight lapses in maintaining accurate records and ensuring the availability of appropriate respiratory care equipment and procedures.
Deficiency in Tracheostomy Order Management
Penalty
Summary
The facility failed to ensure that a resident's physician's orders included the necessary details for respiratory care, specifically regarding tracheostomy management. The resident, who was admitted to the facility in 2016, had a physician's order from 2022 for an emergency tracheostomy supply list, which included items such as a trach of the same size, a smaller trach, an Ambu bag, and other necessary supplies. However, a review conducted in 2024 revealed that the physician's orders lacked information on the current tracheostomy size and brand. An interview with an LPN Unit Manager confirmed that the electronic medical record did not indicate the resident's trach size and type. Further, a nurse practitioner confirmed that the emergency order instructions were not accurate for the resident's plan of care. These findings were discussed with the nursing home administrator, director of nursing, quality assurance/infection preventionist, corporate RN, and assistant director of nursing during the exit conference.
Inadequate Tracheostomy Care Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skills to provide care for a resident with a tracheostomy. The resident, admitted with a traumatic brain injury and tracheostomy status, required tracheostomy care as indicated in an annual MDS. Interviews with nursing staff revealed a lack of knowledge and preparedness in handling tracheostomy emergencies. One RN was unsure of the trach size, and an agency LPN admitted to not knowing the emergency procedures, stating they would call a supervisor for help. Additionally, the facility lacked evidence of verifying competencies for all agency nurses and staff regarding emergency tracheostomy procedures, as noted in the review of competency checklists by the Staff Educator RN.
Failure to Provide Medically Related Social Services to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R146, who was cognitively impaired and lacked a legal decision maker. Upon admission, R146 signed the facility's Admission Agreement despite having a severe cognitive deficit, as indicated by a BIMS score of 3. The facility did not identify a responsible party for R146, nor did they initiate a referral for a capacity determination in a timely manner. This oversight led to R146 being unable to make informed decisions about her care and financial matters. Throughout her stay, R146 was involved in several incidents where she was signed out of the facility by unrelated persons without proper authorization. The facility did not verify the authorization of these individuals, which further compromised R146's safety and well-being. Additionally, the facility failed to inform R146's family about significant changes in her Medicare coverage and did not offer them the opportunity to appeal the decision. The facility's lack of a policy or procedure for residents deemed not to have capacity contributed to the ongoing issues. Despite being aware of R146's cognitive impairment, the facility did not take appropriate steps to ensure her protection and support. This included failing to report potential financial exploitation to Adult Protective Services and not updating R146's face sheet to reflect her lack of capacity and need for a legal guardian.
Inaccurate Documentation of Resident's Out-of-Bed Status
Penalty
Summary
The facility failed to ensure accurate documentation in the clinical record for one resident, identified as R128, out of a sample of thirty-three residents. R128 was admitted to the facility on August 11, 2023, and had a physician's order dated April 23, 2024, requiring the resident to be out of bed for a minimum of two hours every day, with nursing staff documenting and notifying the family of any refusals during the day shift. Despite this order, observations on July 10 and July 11, 2024, noted that R128 remained in bed, and during an interview on July 12, 2024, R128 confirmed not being out of bed on July 11, 2024. The treatment administration record inaccurately indicated that the task was completed, as confirmed by LPN E8, who stated that the checkmark meant the resident was out of bed. Further interviews revealed that CNA E25 confirmed R128 was not out of bed on July 11, 2024, and they did not offer assistance to get the resident out of bed. LPN E26 mentioned the requirement to document refusals in the electronic notes, yet there was no documentation of any refusals by R128 on that day. The facility inaccurately documented that R128 was out of bed, despite evidence to the contrary, indicating a failure to maintain accurate clinical records in accordance with professional standards.
Failure to Update Medication Regimen Review Policy
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to address previously cited deficiencies related to the Medication Regimen Review (MRR) policy. A review of the facility's undated MRR policy revealed a lack of specified time frames for pharmacist responses, both urgent and non-urgent medication recommendations, and facility responses to these recommendations. This deficiency was previously cited during the facility's annual survey on 7/14/23. An interview with the Nursing Home Administrator (NHA) confirmed that the MRR policy provided was current, yet it had not been updated as per the Plan of Correction dated 9/6/23, which indicated that the facility would revise and update the policy. These findings were discussed with the NHA, Director of Nursing (DON), Quality Assurance/Infection Preventionist (QA/IP), Corporate Registered Nurse (RN), and Assistant Director of Nursing (ADON) during the exit conference.
Failure to Properly Restrain Resident During Transport
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R15, during transportation in a facility van, leading to an accident. R15, who has a history of hemiplegia and hemiparesis affecting the left side, was being transported in a wheelchair when he fell due to improper restraining. The facility's Driver/Operator Instruction Guide specifies the use of both lap and shoulder belts for securing passengers, but the van driver, E13, did not recall being trained on the use of the shoulder belt and only secured the lap belt. During the transport, R15 fell out of the wheelchair when the van took a sharp turn, resulting in a laceration to his forehead and requiring hospital treatment. Interviews and observations revealed that the lap belt was not properly secured, as confirmed by the EMT who found R15 without any belt upon arrival. The driver, E13, admitted to not using the shoulder belt, which she believed was ineffective. The incident was reviewed with facility leadership, including the Nursing Home Administrator and Director of Nursing, highlighting the failure to adhere to safety protocols for resident transportation, which directly led to the resident's injury.
Inaccurate Controlled Drug Count Records
Penalty
Summary
The facility failed to maintain accurate and complete Controlled Drug Count Records for the month of May 2024, as required by accepted professional standards and practices. The deficiencies were identified through a review of records and interviews with facility staff. Specific instances of non-compliance included missing evidence of narcotic counts being completed during various shifts, such as the 3:00 PM - 11:00 PM shift on May 2, 2024, and the 11:00 PM - 7:00 AM shift on May 3, 2024. Additionally, there were discrepancies in the records, such as scribbled-out entries and numbers that were difficult to decipher, indicating a lack of proper reconciliation of controlled drugs between shifts. Further issues were noted on multiple dates, including incomplete categories for narcotic counts, such as 'Completed/Disposed', 'Received from Pharmacy', and '# Items in Drawer'. For example, on May 8, 2024, and May 9, 2024, these categories were not completed for the 11:00 PM - 7:00 AM shift. On May 11, 2024, there was a discrepancy in the number of items in the drawer, and on May 13, 2024, an entry was overwritten, making it difficult to decipher. These findings were confirmed in interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), who acknowledged the failure to accurately reconcile the transfer of controlled drugs from one shift to another.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 150 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Millsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cadia Rehabilitation Renaissance | 6.1 mi | ★★★★★ | 0 | 0 |
| Delaware Bay Rehabilitation And Healthcare Center | 9.1 mi | ★★★★★ | 0 | 0 |
| The Moorings At Lewes | 14.2 mi | ★★★★★ | 0 | 0 |
| Excelcare At Lewes Llc | 14.9 mi | ★★★★★ | 26 | 0 |
| Willowbrooke Court Skilled Center At Manor House | 17.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.