Dugan Memorial Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were provided with a dignified dining experience when one (1) of three (3) residents at the table did not receive their meal at the same time. Resident #11 Findings include: Record review of facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes dated March 2025, revealed, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. During an observation of lunch in the dining room on 3/16/26 from 12:10 PM through 12:15 PM, it was noted that the two residents sitting at the table with Resident #11 both had their meal and were eating their lunch. Resident #11 was observed without food. She continued to sit and watch the other two residents at her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure informed consent was obtained prior to the initiation of a psychotropic medication for one (1) of five (5) residents reviewed for unnecessary medications. Resident #9 Findings include:Record review of facility policy titled, Use of Psychotropic Medications, with an implemented date of 10/2025, revealed, .9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medications .11. The facility will document that the resident or resident representative was informed in advance (e.g., written consent form, narrative note, etc.)Record review of Resident #9's Order Summary Report revealed an order dated 7/28/25 for Trazadone Hydrochloride (HCL) oral tablet 50 milligrams (mg) to be given by mouth at bedtime for sleep.Record review revealed no signed informed consent for Trazadone was present in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure a cognitively intact resident was provided the opportunity to participate in and make informed decisions regarding her advance directive, including end-of-life preferences for one (1) of 24 advance directives reviewed. (Resident #1) Findings Include:Review of the facility policy titled Advance Directives Policy and Acknowledgment, updated 9/3/25, revealed, Resident has the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.Record review of the facility's Advance Directives/Medical Treatment Decisions form, dated 2/17/22, revealed Resident #1 was designated as Do Not Resuscitate (DNR); however, the form was not signed by Resident #1 and was instead signed by her sister.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, record review, and facility policy review, the facility failed to ensure the medical provider was notified of a resident refusing multiple doses of prescribed antibiotics for one (1) of six (6) residents reviewed for medication use. Resident #21 Findings include: Record review of facility policy titled Medication Administration dated 1/24, revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .18. Report and document any adverse side effects or refusals . During an interview on 9/25/24 at 3:50 PM, Registered Nurse (RN) #2 revealed Resident #21 had recently been in the hospital and diagnosed with pneumonia and was on antibiotics. She revealed the resident would often refuse her medications and that if a resident refused medications, the nurse was to notify the provider and the resident's representative. On 9/25/24 at 4:10 PM, an interview with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and facility policy review, the facility failed to implement a care plan for one (1) of 18 sampled residents' care plans. Resident #21 Findings Include: Record review of facility's policy titled, Comprehensive Care Plans dated 10/22, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of Resident #21's care plan revealed a focus area dated 9/15/24 of Elder has pneumonia. Interventions listed included administer medications as ordered, Cefdinir for ten days for pneumonia, and to keep informed of changes and update MD as needed. An interview with the Director of Nursing (DON) on 9/25/24 at 4:10 PM, revealed Resident #21 refused several doses of the antibiotic medication ordered for the treatment of pneumonia and the provider was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and facility policy review the facility failed to initiate contact isolation precautions for a resident with Methicillin-resistant Staphylococcus Aureus (MRSA) and failed to prevent the possibility of the spread of infection by not utilizing proper hand hygiene for one (1) of four (4) resident care observations. Resident #19. Findings Include: Review of the facility policy Clean Dressing Change dated 10/2022 revealed, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Review of the undated facility policy Transmission-Based Precautions revealed, It is our policy to take appropriate precautions to prevent transmission of infectious agents Contact Precautions - Intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . On 09/24/24 at 1:00 PM, on entrance into the facility, a brief interview with Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, record review and facility policy review, the facility failed to prevent verbal abuse to a resident from a staff member for one (1) of three (3) residents reviewed for abuse. Resident #1 Findings Include: Review of the facility policy titled, Abuse, Neglect and Exploitation-2019 with a review date of 2019 revealed, Policy .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This review revealed under, IV. Identification of Abuse, Neglect and Exploitation .B. 5. Verbal abuse of a resident overheard. An interview on 6/11/24 at 8:05 AM, with the Administrator revealed she was notified on 5/26/24 by the Director of Nurses (DON) that Certified Nurse Assistant (CNA) #1 had been witnessed by CNA #2 and CNA #3 talking ugly to Resident #1 and was sent home that day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview and facility policy review, the facility failed to store food items in a manner that maintains the safety of the food as evidenced by uncovered, unlabeled and undated food in the refrigerator and freezer for one (1) of two (2) kitchen tours. Findings include: Record review of the facility policy titled Storage of Food and Supplies with a revision date of 12/7/2020 revealed, Description: all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Also revealed under, Method/How To/Procedure: . Cover, label and date unused portions and open packages. An observation of the chest freezer with the Dietary Supervisor on 7/11/23 at 9:15 AM, revealed a large round clear container with a dark yellow substance inside and no covering. There was no label observed to identify the substance or the date it was opened. An interview with the Dietary Supervisor revealed the item was frozen mango ice cream that was left over…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review the facility failed to develop a person-centered care plan for a resident with a contracture for one (1) of 14 resident care plans reviewed. Resident #16 Findings Include: Review of the facility policy titled, Comprehensive Care Plans with an implementation date of 10/2022 and no revision date revealed, Policy .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. An observation on 07/11/23 at 9:55 AM, of Resident #16 revealed the resident had a right-hand contracture with a carrot roll placed in the right hand. Record review of Resident #16's care plans revealed there was no care plan regarding the right-hand contracture or placement of the carrot roll as to how…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and facility policy review, the facility failed to provide personal hygiene to a resident requiring assistance as evidenced by long nails with a brown substance underneath for one (1) of 14 residents sampled. Resident #5 Findings include: Review of the facility policy titled Nail Care with no revision date revealed, Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during Activity of Daily Living (ADL) care on an ongoing basis. 4. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes . An observation on 7/12/23 at 8:15 AM, revealed a contracture to Resident # 5's right hand with all fingers bent inwardly toward the palm of the hand. A hand roll was observed intact and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.