Dover Center For Health & Rehabilitation

Based on observation, interview, and record review, it was determined that the facility failed to determine if self-administration of medications was clinically appropriate for 1 of 4 residents reviewed for choices in a final sample of 20 residents. (Resident identifier is #68.) Findings include: Observation on 4/30/25 at approximately 8:35 a.m. of Resident #68's bedside table revealed a bottle of Refresh tears and Fluticasone nasal spray. Interview on 4/30/25 at approximately 8:35 a.m. with Resident #68 revealed that the medication has been on his/her bedside table since he/she was admitted about a month ago. Further interview revealed that he/she self-administers the medications 1-2 times a day. Observation on 4/30/25 at approximately 11:15 a.m. of Resident #68's bedside table revealed a bottle of Refresh tears and Fluticasone nasal spray. Review on 5/1/25 of Resident #68's medical record revealed that there was no assessment completed to determine if self-administration of medications is clinically appropriate for Resident #68. There was no physician orders for Refresh tears or…

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 interview and record review, it was determined that the facility failed to develop and implement a comphrensive care plan for 1 of of 3 residents reviewed for accidents in a final sample of 20 residents (Resident Identifier is #6). Findings include: Review on 5/1/25 of Resident #6's progress notes revealed the following notes: On 3/19/25 at 11:34 a.m., Resident noted to have scissors in [pronoun omitted ] room. Resident states [pronoun omitted] got them from [pronoun] niece. [Name omitted] and ADON [Assistant Director of Nursing] attempted to retrieve scissors from resident but [pronoun omitted] refused multiple times. On 3/19/25 at 12:14 a.m., Scissors and stapler obtained from Resident's room and kept in UM [unit manager] office for safety . On 4/12/25 at 10:58 a.m., This writer was notified by MNA [Medication Nursing Assistant] that resident took [pronoun omitted] scissors and an ensure from med cart when [pronoun omitted] stepped away. Scissors were found hiding inside resident's pillowcase. When staff removed scissors from resident's room, [pronoun omitted] began to…

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 observation, interview, and record review, it was determined that the facility failed to follow professional standards for medication storage and administration for 1 of 3 medication carts observed. (Resident identifier is #69.) Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 608 . Right Medication . Because the nurse who administers the medication is responsible for any errors related to it, nurses administer only the medications they prepare. You cannot delegate preperation of medication to another person and then administer the medication to a patient . Observation on 4/30/25 at approximately 7:30 a.m. of the medication cart TCU #4 with Staff B (Registered Nurse) revealed an unlabeled medication cup with pills in the top drawer. Further observation revealed that the medication cup was tipped on it's side and 3 unidentifiable pills were on the side of the medication cup on the bottom of the medication cart drawer.…

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, and record review, it was determined that the facility failed to maintain an environment free of accident hazards by not securing scissors when not in use for 1 of 3 residents reviewed for accidents in a final sample of 20 residents (Resident Identifier is #6). Findings include: Observation on 4/30/25 at 9:30 a.m. on the Transitional Care Unit (TCU) revealed that Resident #6 was ambulating with a rolling walker around the TCU unit going in and out of other resident's rooms. Review on 5/1/25 of Resident #6's progress notes revealed the following notes: On 3/19/25 at 11:34 a.m., Resident noted to have scissors in [pronoun omitted ] room. Resident states [pronoun omitted] got them from [pronoun] niece. [Name omitted] and ADON [Assistant Director of Nursing] attempted to retrieve scissors from resident but [pronoun omitted] refused multiple times. On 3/19/25 at 12:14 a.m., Scissors and stapler obtained from Resident's room and kept in UM [unit manager] office for safety . On 4/12/25 at 10:58 a.m., This writer was notified by MNA [Medication Nursing…

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 interview and record review, it was determined that the facility failed to ensure that the provider reviewed irregularities identified by the pharmacist during the monthly Pharmacy Medication Regimen Review (MRR) timely for 3 of 5 residents reviewed for unnecessary medications (Resident Identifiers are #1, #51, and #55). Findings include: Resident #1 Review on 5/2/25 of Resident # 1's Pharmacy MRR, dated 3/4/25, revealed the following recommendation: Resident has an order for Gabapentin 200 mg (milligrams), twice daily for, 'post herpetic neuralgia'. This order was initiated 9-16-2024. Please review if this scheduled medication for pain remains necessary for the resident. Further review of the MRR revealed that the physician did not address the recommendation until 5/1/25. Resident #51 Review on 5/2/25 of Resident #51's Pharmacy MRR, dated 3/4/2025, revealed the following recommendation: Resident is receiving Lipitor 40 mg. Please consider lipid panel with next resident lab draw and at least annually thereafter. Further review revealed that the physician did not address 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure that a resident receiving antipsychotic medication had an adequate indication for use for 1 of 5 residents reviewed for unnecessary medications in a final sample of 20 residents (Resident identifier is #1). Findings include: Review on 5/2/25 of Resident #1's physician orders revealed the following order: Seroquel (Antipsychotic Medication) Oral Tablet 25 mg (milligrams) Give 25 mg by mouth one time a day for confusion, agitation with a start date of 9/16/24. Review on 5/2/25 of Resident #1's medical record revealed that he/she was admitted to the facility on [DATE]. Review on 5/2/25 of Resident #1's diagnosis list revealed a diagnosis of Vascular Dementia, mild, with anxiety. Review on 5/2/25 of Resident #1's medical record for monitoring behavior symptoms revealed that Resident #1 did not exhibit any behaviors from 4/3/25 thru 5/2/25. Review on 5/2/25 of Resident #1's Psychiatric Evaluation and Consultation note, dated…

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 interview and record review, it was determined that the facility failed to ensure residents remained free from significant medication errors for 1 of 3 residents reviewed for accidents and hazards in a final sample of 20 residents. (Resident identifiers is #9.) Findings include: Review on 5/1/25 of Resident #9's medical record revealed a nursing note, written by Staff L (Registered Nurse), dated 4/23/25, at 7:51 p.m.: Med error reported to on call physician and DPOA (Durable Power of Attorney). Resident given 30 units of Lantus, 75 mg (milligrams) of Lyrica. 5 mg of oxy. Interview on 5/2/25 at approximately 1:00 p.m. with Staff E (Director of Nursing) confirmed that Resident #9 had received Resident #18's evening medications. Review on 5/2/25 of Resident #9's medical provider note dated 4/23/25 at 4:23 p.m. revealed that .Patient was given Lantus 30 units, Lyrica 75 mg, Oxycodone 5 mg with his usual nightly 4 ounces of scotch. Patient is a diabetic who takes 10 units of long acting typically . Review on 5/2/25 of Resident #9's active physician orders revealed the following:…

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, and record review, it was determined that the facility failed to label and store medications in accordance with professional standards for 2 of 3 medication carts observed. Findings include: Observation on 4/30/25 at approximately 7:20 a.m. of the medication cart Glenwood Cart 2 and 4 with Staff A (Registered Nurse) revealed: Resident #59's Incruse Inhaler, opened without a date of opening; Resident #32's Fluticasone Propionate and Salemetrol inhaler opened with a labeled date of expiration of 4/24; Resident #29's Incruse inhaler opened, without a date of opening; Resident #5's Anoro inhaler opened, without a date of opening. Interview on 4/30/25 at approximately 7:20 a.m. with Staff A confirmed the above findings. Observation on 4/30/25 at approximately 7:30 a.m. of the medication cart TCU #4 with Staff B (Registered Nurse) revealed an unlabeled medication cup with pills in it in the top drawer for Resident #69. Resident #9's Lispro insulin opened labeled with a date of expiration of 4/28/25. Interview on 4/30/25 at approximately 7:30 a.m. with…

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 interview and record review, it was determined that the facility failed to report an allegation of neglect to the State Survey Agency (SSA) for 1 out of 3 grievances reviewed for alleged neglect (Resident Identifier #4). Findings include: Review on 4/10/24 of the facility grievance form filed on 3/14/24 by Resident #4 revealed the following allegation: The resident reports [pronoun omitted] waited 30 minutes for [pronoun omitted] call light to be answered and ultimately self-ambulated to the bathroom and fell. [pronoun omitted] reports the nurse on overnight was not helpful and said it was the resident's fault that [pronoun omitted] fell. Interview on 4/10/24 at approximately 12:00 p.m. with Staff A (Administrator) revealed that the above allegation was not reported to the SSA. Review on 4/10/24 of the facility's policy titled Clinical Services, Abuse Policy and Procedure, Procedure for Abuse Investigation revised on 1/23 revealed: .Procedure Guidelines .5. The facility will notify Department of Public Health and Local Law Enforcement immediately but no later than two (2)…

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 interview and record review, it was determined that the facility failed to follow physician orders for 1 of 2 newly admitted residents reviewed for medications in a final sample of 20 residents (Resident Identifier is #346). Findings include: Review on 4/9/24 of professional nursing standard: Fundamentals of Nursing, [NAME], [NAME] A., and [NAME]. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009 revealed: Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician ' s orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Interview on 4/9/24 at approximately 10:45 a.m. with Resident #346 revealed that he/she was admitted to the facility in April 2024 in the afternoon and the facility did not administer his/her medications that evening. Review on 4/10/24 of Resident #346's April 2024…

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 observation, interview, and record review, it was determined that the facility failed to ensure that residents' environment remained as free as possible of accident hazards to prevent injury in regards to the application of seizure pads on the bed for 1 of 3 residents reviewed for accidents in a final sample of 20 residents (Resident Identifier #67). Findings include: Observation on 4/9/24 at approximately 11:15 a.m. of Resident #67 lying in bed with seizure pads attached to the outside of the quarter rails, with no padding between the bed rails and the resident's body. Observation on 4/9/24 at approximately 2:10 p.m. of Resident #67 lying in bed with seizure pads attached to the outside of the quarter rails, with no padding between the bed rails and the resident's body. Review on 4/9/24 of Resident #67's medical record showed diagnosis of epilepsy present on admission. Further review revealed the following physician's order for seizure pads: Seizure pads, every shift, order date 1/31/24. Interview on…

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 record review, observation, and interview, it was determined that the facility failed to maintain infection prevention related to catheter care for 1 of 3 residents reviewed for catheters (Resident Identifier #153). Findings include: Review on 4/9/24 of Resident #153's medical record revealed they had a Foley catheter since admission in April 2024. Further review of Resident #153's catheter care plan dated April 2024 revealed: .Keep urinary collection bag off the floor . Observation on 4/9/24 at approximately 12:30 p.m. revealed Resident #153 in a wheelchair with their Foley catheter drainage bag and catheter tubing resting on the floor. Interview on 4/9/24 at approximately 12:30 p.m. with Resident #153 revealed they did not place their Foley catheter drainage bag and catheter tubing on the floor. Observation on 4/10/24 at approximately 12:15 p.m. revealed Resident #153 in their wheelchair self-propelling with the bottom of their Foley catheter drainage bag dragging on the floor. Interview on 4/10/24 at approximately 12:35 p.m. with Staff B (Unit Manager) confirmed 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.