Ocean Grove Post Acute

Inspectors wroteBased on record review and interview it was determined that for one (R182) out of sixteen residents reviewed for abuse the facility failed to ensure the resident was free from involuntary seclusion.

Inspectors wroteBased on record review and interview, it was determined that for four (R1, R32, R184 and R188) out of twenty-six residents reviewed for abuse and neglect, the facility failed to identify and report the allegations of abuse, neglect or suspicion of a crime to the State Agency within appropriate timeframe.

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to ensure protection of resident rights to promote dignity and respect when residents were not notified of mealtimes. Additionally, for one (R155) out of seventy-four residents sampled the facility failed to promote care in a manner that maintained or enhanced dignity and respect.

Inspectors wroteBased on interview and record review it was determined that for one (R184) out of seventeen residents reviewed for abuse the facility failed to ensure that the rights of resident representative were exercised.

Inspectors wroteBased on record review and interview it was determined that for one (R17) out of two residents reviewed for behavioral/emotional condition the facility failed to ensure adequate monitoring of antipsychotic medication use.

Inspectors wroteBased on record review and interview it was determined that for three (R158, R180 and R182) out of fifty-seven (57) residents reviewed the facility failed to ensure accuracy of the MDS assessment.

Inspectors wroteBased on observations, interviews, record review and review of other facility records, it was determined that for two (R137 and R128) out of fifty-seven (57) residents reviewed for care plans, the facility failed to revise care plans for identified changes in care.

Inspectors wroteBased on observation, interview, and record review, it was determined that for three residents (R13, R76, and R137) out of eight residents reviewed for ADL's, the facility failed to provide care and services reviewed for dependent residents.

Inspectors wroteBased on record review and interview it was determined that for two (R3 and R182) out of eight residents reviewed for infection control the facility to follow physicians' orders related to antibiotics.

Inspectors wroteBased on interview and record review it was determined that for one (R180) out of seventy-four residents reviewed the facility failed to ensure resident records were complete and accurately documented.

Inspectors wroteBased on record review and interview, it was determined for one (R1) out of three residents in the investigative sample the facility failed revise the care plan.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents.

Inspectors wroteBased on interview and record review, it was determined that for three (R16, R101 and R102) out of thirty-two residents in the investigative sample, the facility failed to revise and update the care plan for R16 and R101 to reflect resident's current needs. Additionally, the facility failed to have all the required interdisciplinary members present at R102's care plan meetings.

Inspectors wroteBased on record review, policy review and interview it was determined that the facility failed to implement an effective infection prevention program to prevent the spread of infection.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment for staff.

Inspectors wroteBased on observation and interview, it was determined that for one out of four resident units the facility failed to provide a clean and homelike environment.

Inspectors wroteBased on interview and record review, it was determined that for one (R102) out of thirty-two residents in the investigative sample, the facility failed to complete a comprehensive assessment after R102 had a significant change in status.

Inspectors wroteBased on interview and record review, it was determined that for one (R13) out of three residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR Level II evaluation was completed in response to a new mental health diagnosis.

Inspectors wrote2. Review of R102's clinical record revealed: 3/1/24 - R102 was admitted to the facility. 3/4/24 - A baseline care plan was initiated for R102. 12/13/24 - A signed hospice contract documented that R102 was admitted for hospice services. 2/27/25 - An annual MDS was completed for R102 and documented R102 was receiving hospice services. 6/30/25 - A review of R102's care plan lacked evidence that a care plan for hospice was developed and implemented. 7/1/25 11:45 AM - During an interview, E10 (RN UM) confirmed that R102 did not have a care plan developed for Hospice.

Inspectors wroteBased on record review and interview it was determined that for one (R163) out of two residents reviewed for wound care, the facility failed to ensure that wound care was performed in accordance with the physician's ordered frequency.

Inspectors wroteBased on interview and record review it was determined that for two (R120 and R157) out of two residents reviewed for bowel and bladder, the facility failed to provide services to maintain or restore bladder continence.

Inspectors wrote2. R91's clinical record revealed: 12/1/23 - R91 was admitted to facility with diagnoses including, but not limited to, stroke, traumatic spinal cord dysfunction, and progressive neurological dysfunction. 6/23/25 - An order documented, One time a day continuous tube feeding .Product: Osmolite 1.5 at 55 ml/hour via PEG tube .up at 12 p.m., down when total volume of 1100 ml's has been infused. 6/23/25 2:18 PM - An Observation of tube feeding, Osmolite 1.5, hung and infusing at 55 ml/hr with no date, time, rate or initials labeled on tube feed bottle. 6/23/25 2:23 PM - During an interview, E18 (LPN) confirmed that the tube feed did not have the proper labeling of tube feeding bottles such as date, time, rate or initials.

Inspectors wrote2. Review of R3's clinical record revealed: 7/12/25 - who admitted to the facility with diagnosis including, but not limited to, COPD, chronic anemia, and acute and chronic respiratory failue with hypoxia 7/20/24 8:26 PM - A physician's order documented change humidifier bottle weekly and prn. 7/21/25 - The facility treatment adminstration record documented that R3's humifier bottle was changed on 6/21/25. 6/23/25 10:51 AM - An observation of R3 's humidifier bottle dated 6/15/25. 6/24/25 9:30 AM - An observation of R3' s humidifier bottle dated 6/15/25. 6/25/25 11:30 AM - During an observation and subsequent interview, E27 (RN) confirmed the date on the humidifier bottle was 6/15/25. E27confirmed that the humidifier oxygen bottle should have been changed.

Inspectors wroteBased on interview, observation and record review it was determined that for three (R16, R101 and R120) out of three resident's reviewed for restraints, the facility failed to obtain consents from the resident/POA/resident representative before utilizing bed rails.

Inspectors wroteBased on record review and interview it was determined that for one (R27) out of six residents reviewed for medication review the facility failed to provide medications and/or biologicals, as ordered by the prescribe, to meet the needs of the resident.

Inspectors wroteBased on observation, interview and record review it was determined that for one (R164) out of three residents reviewed for nutrition the facility failed to ensure the resident received food that accommodated intolerance's.

Inspectors wroteBased on record review and interview, it was determined that for three (R127, R164 and R319) out of thirty-two (32) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure that essential kitchen equipment is maintained in safe operating condition.

Inspectors wrote3. 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. 7/15/24 9:45 AM - A review of R146's care plans revealed the facility lacked evidence of a cognitive impairment care plan with interventions. 7/15/24 1:35 PM - During an interview, E3 (QA/IP) confirmed the lack of care plan interventions with regard to R146's cognitive impairment. 4. Review of R109's clinical record revealed: 6/14/24 - R109 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation (Afib), deep vein thrombosis (DVT) and factor V Leiden heterozygous mutation, an inherited disorder that causes abnormal blood clots in legs or lungs. [...]

Inspectors wroteBased on record review and interview, it was determined that for six (R25, R37, R47, R66, R68, and R75) out of thirty-three sampled residents for care plan investigations, the facility failed to ensure that the required interdisciplinary team (IDT) memebers participated in the care plan meetings and for R66's care plan inaccurately includes dentures.

Inspectors wroteBased on record review and interview, it was determined that for six (R25, R37, R47, R66, R68, and R75) out of thirty-three residents in the investigative sample the facility failed to ensure that the required interdisciplinary team (IDT) memebers participated in the care plan meetings and additionally, R66's care plan inaccurately included dentures.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents.

Inspectors wroteBased on observations, interviews and record review, it was determined that for three (3) (R36, R47 and R461) out of thirty-three (33) reviewed in the investigative sample, the facility failed to ensure a urinary catheter bag was kept off the floor and to ensure staff utilized enhanced barrier precautions (EBP).

Inspectors wroteBased on observations, interviews and record review, it was determined that for one (R36) out of three residents reviewed for dignity, the facility failed to promote dignity by not using a privacy bag for a urinary collection bag.

Inspectors wroteBased on interview and record review it was determined that for one (R143) out of thirty-three residents reviewed in the investigative sample, the facility failed to ensure care preferences were being honored.

Inspectors wroteBased on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, the facility failed to have written policies and procedures regarding the visitation rights of residents with cognitive impairments that do not have a legal decision maker.

Inspectors wroteBased on record review and interview, it was determined that for one (R146) out of three residents reviewed for beneficiary notice, the facility failed to provide notification of service changes to R146's authorized representative.

Inspectors wroteBased on observation and interview, it was determined that for one out of five resident units, the facility failed to provide a clean and homelike environment.

Inspectors wroteBased on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, the facility failed to protect R146 from misappropriation of resident property/funds.

Inspectors wroteBased on record review and interview, it was determined that for one (R130) out of ten residents reviewed for hospitalization, the facility failed to notify R130's family representative and the Ombudsman of R130's transfers to the hospital on 3/15/24 and 3/24/24.

Inspectors wroteBased on record review and interview, it was determined that for one (R130) out of ten residents reviewed for hospitalization, the facility failed to notify the family representative of the bed-hold policy.

Inspectors wroteBased on record review and interview, it was determined that for three (R66 and R146) out of thirty-three residents reviewed in the investigative sample, the facility failed to ensure an accurate assessment.

Inspectors wrote2. Review of R37's clinical record revealed: 11/4/18 - R37 was admitted to the facility. 11/5/18 - A level l PASARR was completed and revealed . this patient appears to have: Indicators of mental illness, mental retardation/related conditions, but meets physician's exemption criterion . 12/20/18 - A level 1.5 PASARR was completed and revealed The individual does have a documented serious mental illness (SMI) or a mental illness other than SMI but further review of level of impairment, recent treatment history, or other circumstances demonstrates a full level II is not required . 5/12/23 - Unspecified mood (affective) disorder and unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance and anxiety were added to R37's list of diagnoses. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R128) out of seven residents reviewed for ADLs, the facility failed to provide mobility from bed to chair.

Inspectors wroteBased on record review and interview, it was determined that for one (R146) out of ten resident reviewed for hospitalization, the facility failed to ensure that R146's warfarin dosing was managed in accordance with the professional standards of practice.

Inspectors wroteBased on observation, interview and record review it was determined that for two (R123 and R143) out of three residents reviewed for bowel and bladder, the facility failed to respond to or provide services to restore bladder continence.

Inspectors wroteBased on observation, record review and interview, it was determined that for two (R47 and R121) out of two residents reviewed for respiratory care, the facility failed to provide respiratory care consistent with professional standards of practice.

Inspectors wroteBased on interview and record review, it was determined that for one (R47) out of two residents reviewed for respiratory care, the facility failed to ensure that the Physician's orders included trach size, type, and accurate emergency orders.

Inspectors wroteBased on interview and review of the clinical record, it was determined that for one (R47) out of two residents reviewed for respiratory care, the facility failed to have nursing staff with the appropriate competencies and skill sets to provide nursing and related services to a resident with a tracheostomy.

Inspectors wroteBased on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, it was determined that the facility failed to provide medically related social services to R146, who was cognitively impaired and did not have a legal decision maker.

Inspectors wroteBased on record review and interview, it was determined that for one (R128) out of thirty-three (33) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment for staff.

Inspectors wroteBased on review of facility documentation, review of cited deficiencies from the facility's annual survey of 7/14/23 and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies.

Inspectors wroteBased on observations, interviews and record review, it was determined that for one (R15) out of four residents reviewed for accident hazards, the facility failed to ensure the resident's environment was free of accident hazards. On 6/3/24, while being transported in the facility van, R15 fell from the wheelchair due to improper restraining. R15 was taken to the hospital for treatment of a cut to the forehead. The unsafe facility transport caused R15 harm.

Inspectors wroteBased on record review, interview and review of other facility documentation, it was determined that in accordance with accepted professional standards and practices, the facility failed to maintain the Controlled Drug Count Record report accurately and completely for the month of May 2024. The facility did not accurately reconcile the transfer of controlled drugs from one shift to another.

Inspectors wroteBased on record review, interview and review of other facility documents, it was determined that for one (R4) out of the nine sampled residents, the facility failed to identify and immediately report allegations of physical and/or emotional abuse.

Inspectors wroteBased on interview, record review and review of other facility documents, it was determined that for one (R1) out of four residents reviewed for discharge, the facility failed to ensure that R1's transfer and discharge requirement was met when he was discharged on 10/31/23 despite requesting a discharge appeal.

Inspectors wroteBased on interview, record review and review of other facility documents, it was determined that for two (R1 and R2) out of four residents reviewed for discharge, the facility failed to ensure that the notice requirements before discharge were met. For R1, the facility failed to notify the resident and update the notice as soon as practicable when information became available that the 30 day discharge notice dated 10/2/23 was rescinded by the facility on 10/27/23. In addition, the facility failed to communicate to the receiving community case manager necessary information to ensure a safe and effective transition of care. For R2, the facility failed to ensure that a written discharge notice was provided at least 30 days before his discharge on [DATE].

Inspectors wroteBased on interview, record review and review of other facility documents, it was determined that for one (R1) out of four residents reviewed for discharge, the facility failed to develop and implement a discharge plan to include identified specific needs and goals for a safe discharge to the community when R1 was issued a 30 day discharge notice on 10/2/23. In addition, the facility lacked communication with the community transition case manager.

Inspectors wroteBased on observation and interview, it was determined that for one out of five resident units, the facility failed to provide a clean and homelike environment.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that a qualified person in charge was present during all hours of Kitchen operation.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to prevent the occurrence of mold in high moisture areas, ensure safe storage of food and provide the sanitizing solution required for disinfecting food preparation surfaces.

Inspectors wroteBased on observation and interview, it was determined that in one out of five units, the facility failed to ensure that a handrail in a resident corridor was firmly affixed to the wall.

Inspectors wroteBased on interview and record review, it was determined that for one (R32) out of eight residents reviewed for abuse, facility staff failed to immediately report an allegation of abuse to the Administrator and the State Agency within two hours.

Inspectors wroteBased on interview, record review, and review of other facility documentation as indicated, it was determined that for one (R32) out of eight residents reviewed for abuse, the facility failed to have evidence of a thorough investigation of an allegation of abuse.

Inspectors wroteBased on interview and record review, it was determined that for one (R16) out of two residents reviewed for PASARR, the facility failed ensure that a referral for a PASARR screening was completed following new diagnosis of psychotic disorder which was not listed on the previous PASARR.

Inspectors wroteBased on record review and interview, it was determined that for one (R118) of two sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) Level I, the facility failed to have a currently dated PASRR Screening.

Inspectors wroteBased on record review and interview it was determined that for two (R7 and R32) out of twenty six residentssampled, the facility failed to develop and implement a comprehensive person-centered care plan.

Inspectors wroteBased on record review and interview, it was determined that for one (R32) out of twenty six sampled residents for care plans, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings.

Inspectors wrote2. Review of R195's clinical record revealed: 5/30/18 - R195 was admitted to the facility with diagnoses including: a stroke affecting the left dominant side, difficulty swallowing and need for assistance with personal care. 5/31/18 - R195's Baseline Care Plan under Assistance with ADL's stated, Nursing staff to provide care as needed related to deficits to ensure ADL care is being met. 12/14/20 - R195's quarterly MDS (Minimum Data Set) assessment documented R195 as an extensive, two plus person assist for transfers and toilet use, limited one person assistance (assist) for eating and extensive, one person assist for bed mobility, dressing, and personal hygiene. 12/16/20 2:12 PM - A Grievance email from F2 (R195's stepdaughter) to E15 (NHA) stated, Good afternoon E15 (former NHA), My mother (F3) just had a facetime with her husband (R195) who is my stepfather . She called me very upset. [...]

Inspectors wroteBased on observations, interview and record review, it was determined that for one (R67) out of one sampled resident reviewed for respiratory care, the facility lacked evidence that R67's nebulizer reservoir and tubing were labled with a date of use and were stored in a sanitary manner.

Inspectors wroteBased on record review and interview, it was determined that for one (R16) out of two residents reviewed for PASARR, the facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days.

Inspectors wroteBased on interview and record review, it was determined that for two (R32 and R118) out of four sampled residents for dental services, the facility failed to assist the resident in obtaining routine dental services.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps in the MRR process.