Dover Center For Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, New Hampshire.
- Location
- 307 Plaza Drive, Dover, New Hampshire 03820
- CMS Provider Number
- 305018
- Inspections on file
- 13
- Latest survey
- May 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Dover Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident was found self-administering Refresh tears and Fluticasone nasal spray without a clinical assessment or provider order, contrary to facility policy requiring evaluation and authorization for self-administration. Staff confirmed that the necessary assessment and orders were not completed.
A resident with a history of taking and concealing dangerous items, as well as threatening staff and other residents, did not have a care plan addressing these behaviors. Staff were aware of the resident's actions, and unsecured items like scissors were observed on the medication cart, but no interventions or goals were documented in the care plan to address the safety risks.
A medication cart was found with an unlabeled cup containing multiple pills, including a controlled substance, that had been pre-poured by a night shift LPN and left for a day shift RN to administer to a resident. The medications were not prepared and administered by the same nurse, and the controlled substance was not double locked, violating both professional standards and facility policy.
A resident with a history of wandering, taking items, and making threats was able to access and hide scissors on multiple occasions, including obtaining them from a medication cart left unattended by an RN. Staff confirmed that scissors were not always secured, resulting in an environment with accident hazards and insufficient supervision.
Pharmacist recommendations from monthly MRRs regarding medication necessity and monitoring for three residents were not reviewed or addressed by providers in a timely manner, as required by facility policy. Delays included recommendations for reviewing pain medication, ordering a lipid panel, and assessing the ongoing need for a GI medication, with some recommendations not addressed at all.
A resident was prescribed Seroquel for confusion and agitation despite no documented behavioral symptoms or significant psychiatric diagnosis. The medical record did not provide adequate justification for the ongoing use of the antipsychotic, contrary to facility policy requiring a specific indication for psychoactive medications.
A resident was given another resident's evening medications, including Lantus, Lyrica, and oxycodone, despite not having orders for all of these drugs and being prescribed a lower dose of insulin. The error occurred when staff failed to properly identify the resident before administering medications, as required by facility policy.
Surveyors found that medications, including inhalers and insulin, were not properly labeled with opening or expiration dates, and a medication cup containing a controlled substance was left unsecured in a medication cart. Nursing staff confirmed these lapses, which were not in accordance with facility policy or manufacturer instructions.
A resident reported waiting 30 minutes for their call light to be answered, self-ambulated to the bathroom, and fell. The nurse on duty was unhelpful and blamed the resident for the fall. The facility failed to report this allegation of neglect to the SSA as required by their policy.
A newly admitted resident did not receive their prescribed medications on the evening of their admission, despite the medications being available in the facility's automated dispensing machine. The facility's policy on handling unavailable medications was not followed, leading to this deficiency.
The facility failed to ensure a resident's environment was free from accident hazards by improperly applying seizure pads on the bed. Observations showed the pads were attached to the outside of the quarter rails, contrary to the physician's order and professional nursing standards. The resident had a diagnosis of epilepsy.
The facility failed to maintain infection prevention for a resident with a Foley catheter. Observations revealed the catheter drainage bag and tubing were on the floor, contrary to the care plan and CDC guidelines. Interviews confirmed these findings.
The facility failed to ensure complete and accurate resident records for three residents, with missing documentation of blood sugar values and insulin administration on multiple occasions. Staff confirmed these findings, which were not in compliance with the facility's Diabetes Management Protocol.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed to have a bottle of Refresh tears and Fluticasone nasal spray on their bedside table, which the resident reported self-administering 1-2 times daily since admission about a month prior. Despite these observations, there was no documentation in the resident's medical record of an assessment to determine if self-administration of these medications was clinically appropriate. Additionally, there were no physician orders for either medication. Further review of facility policy revealed that residents requesting to self-administer medications must undergo a self-administration evaluation by a licensed nurse to assess safety and understanding, and a healthcare provider's order is required. The policy also specifies that residents should be instructed on safe storage of medications, including the use of a locked box. Staff confirmed that these procedures were not followed for this resident.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Unsafe Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's behaviors that posed safety risks to themselves and others. Documentation showed that the resident repeatedly obtained and concealed potentially dangerous items such as scissors and a stapler, sometimes refusing to relinquish them when approached by staff. The resident also exhibited behaviors such as taking items from the medication cart, hiding them in their room, and threatening staff when attempts were made to retrieve these items. Additionally, the resident was observed attempting to access staff offices and locked cabinets, and had a documented history of being physically threatening to both residents and staff. Despite these incidents, a review of the resident's care plan revealed no documented focus, goals, or interventions addressing the resident's unsafe behaviors or the risk of physical threats. Staff interviews confirmed awareness of the resident's actions and history, yet no specific care plan strategies were in place to mitigate these risks. Observations further revealed that potentially dangerous items, such as scissors, were left unsecured on the medication cart, accessible to residents. The Director of Nursing confirmed the absence of appropriate care plan interventions for the resident's behaviors.
Failure to Follow Professional Standards for Medication Preparation and Administration
Penalty
Summary
A deficiency was identified when a medication cart was observed to contain an unlabeled medication cup with pills, including three unidentifiable pills, in the top drawer. The cup was tipped on its side, and the pills were not secured. Staff interviews confirmed that the medication cup was intended for a specific resident, and that the medications had been prepared by the night nurse but were administered by a different nurse on the day shift. The day shift nurse did not prepare the medications themselves, contrary to professional standards and facility policy, which require that nurses only administer medications they have prepared. Further review revealed that the medications included controlled substances such as Oxycodone, which was not double locked as required. The facility's policy explicitly prohibits pre-pouring medications and mandates that administration and documentation occur at the time of the medication pass. The night nurse admitted to preparing the medications in advance and leaving them in the cart for the day nurse to administer, resulting in a failure to follow both professional standards and facility policy for medication storage and administration.
Unsecured Scissors and Inadequate Supervision Lead to Accident Hazard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by not securing scissors when not in use, specifically for one resident with a history of wandering, taking items from others, and exhibiting physically threatening behavior. Observations showed that this resident was able to access and hide scissors in their room, and staff documented multiple incidents where the resident obtained scissors from various sources, including a medication cart and a family member. Staff also reported that the resident had threatened to stab a staff member, leading to changes in staff assignments. Additionally, during observation, scissors were found left unattended on a medication cart while a nurse was administering medication in another room. Staff confirmed that the scissors were not secured. The combination of unsecured sharp objects and a resident with a known history of wandering, taking items, and making threats contributed to the facility's failure to provide adequate supervision and prevent accident hazards.
Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that providers reviewed and addressed irregularities identified by the pharmacist during the monthly Medication Regimen Review (MRR) in a timely manner for three out of five residents reviewed for unnecessary medications. For one resident, the pharmacist recommended reviewing the continued necessity of Gabapentin for post-herpetic neuralgia, but the physician did not address this recommendation until nearly two months later. Another resident was receiving Lipitor, and the pharmacist suggested a lipid panel be considered with the next lab draw and at least annually, but this recommendation was also not addressed by the physician until almost two months after it was made. For a third resident, the pharmacist recommended considering tapering or discontinuing Protonix, or documenting the medical necessity and risk versus benefit of continued therapy. There was no documentation that the provider reviewed or addressed this recommendation, and the resident continued to receive Protonix for acid reflux. The facility's policy requires that pharmacist recommendations be communicated and acted upon in a timely fashion, with a response prior to the next MRR, but this was not followed in these cases. Interviews with the Director of Nursing confirmed that the recommendations were not reviewed or addressed as required.
Failure to Ensure Antipsychotic Medication Was Clinically Indicated
Penalty
Summary
A resident was prescribed Seroquel, an antipsychotic medication, at a dose of 25 mg daily for confusion and agitation. The resident's medical record indicated a diagnosis of mild vascular dementia with anxiety, but there was no significant past psychiatric history documented. Review of behavioral monitoring records showed that the resident did not exhibit any behavioral symptoms over a one-month period. Additionally, psychiatric evaluations noted the absence of significant psychiatric diagnoses and described the dementia as unspecified without behavioral disturbance and of low severity. Despite the ongoing prescription of Seroquel, there was no documented evidence of a specific condition or targeted behavior that warranted the use of this psychoactive medication, as required by the facility's policy. The family had refused a gradual dose reduction, but the clinical record lacked justification for the continued use of the antipsychotic. This failure to ensure an adequate indication for the antipsychotic medication resulted in the resident's drug regimen not being free from unnecessary drugs.
Resident Given Another Resident's Medications Due to Identification Failure
Penalty
Summary
A significant medication error occurred when a resident was administered another resident's evening medications, including 30 units of Lantus, 75 mg of Lyrica, and 5 mg of oxycodone, despite not having physician orders for Lyrica or oxycodone and only being prescribed 10 units of Lantus for diabetes. The error was documented in the nursing notes and confirmed by the Director of Nursing. The resident's medical record indicated that the medications were given along with the resident's usual nightly 4 ounces of scotch. Review of the facility's Medication Pass Policy revealed that staff are required to identify each resident prior to medication administration, but this protocol was not followed, resulting in the medication error.
Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not labeled and stored according to professional standards on two of three medication carts. Specifically, several residents' inhalers were found opened without a date of opening, and one inhaler was labeled with an expiration date that had already passed. Additionally, an insulin pen was labeled with an expiration date, but it was unclear if it was within the manufacturer's recommended usage period after opening. These findings were confirmed through interviews with nursing staff, who acknowledged the lack of proper labeling and dating on the medications. Further observations revealed that a medication cup containing pills, including a controlled substance (Oxycodone), was left unlabeled in the top drawer of a medication cart and was not double-locked as required for controlled substances. Interviews with both the day and night shift nurses confirmed that the night nurse had pre-poured the morning medications and left them unsecured for administration by the day nurse. Review of the facility's policies and manufacturers' instructions confirmed that these practices were not in compliance with established procedures for medication labeling, dating, and secure storage.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency (SSA) for one resident. The resident filed a grievance stating that they waited 30 minutes for their call light to be answered, ultimately self-ambulated to the bathroom, and fell. The resident also reported that the nurse on duty during the overnight shift was not helpful and blamed the resident for the fall. An interview with the facility's administrator confirmed that this allegation was not reported to the SSA. The facility's policy requires immediate notification to the Department of Public Health and Local Law Enforcement within two hours of an allegation involving abuse, which was not followed in this case.
Failure to Administer Prescribed Medications to Newly Admitted Resident
Penalty
Summary
The facility failed to follow physician orders for a newly admitted resident, identified as Resident #346. Upon admission in April 2024, the resident did not receive their prescribed medications that evening. The medications included Atorvastatin Calcium, Finasteride, Oxcarbazepine, Tamsulosin HCL, and Apixaban. A review of the Medication Administration Record (MAR) indicated that these medications were documented as not available, despite the fact that Atorvastatin Calcium, Oxcarbazepine, Tamsulosin, and Apixaban were available in the Omnicell automated dispensing machine. This discrepancy was confirmed by Staff C, the Unit Manager, who acknowledged that the medications were indeed available for administration at the time of the resident's admission. The facility's policy on unavailable medication, revised in May 2023, outlines procedures for promptly notifying the pharmacy and appropriate practitioners to obtain a new medication supply or order if a medication is unavailable. The policy also requires the Nursing Supervisor or Charge Nurse to check all possible storage areas for the medication, including the emergency box and the automated dispensing machine. If the medication is still not available, the policy mandates notifying the physician or nurse practitioner to obtain an alternate medication order or to hold the medication until delivery. These procedures were not followed in the case of Resident #346, leading to the failure to administer the prescribed medications.
Failure to Properly Apply Seizure Pads
Penalty
Summary
The facility failed to ensure that Resident #67's environment was free from accident hazards, specifically in the application of seizure pads on the bed. Observations on two separate occasions revealed that the seizure pads were attached to the outside of the quarter rails, with no padding between the bed rails and the resident's body. Resident #67 had a diagnosis of epilepsy and a physician's order for seizure pads to be applied every shift. An interview with the Unit Manager confirmed that the seizure pads should have been attached to the inside of the quarter rails towards the resident, as per professional nursing standards.
Failure to Maintain Infection Prevention for Catheter Care
Penalty
Summary
The facility failed to maintain infection prevention related to catheter care for a resident with a Foley catheter. The resident had a Foley catheter since admission in April 2024, and their care plan specified that the urinary collection bag should be kept off the floor. However, observations on two separate occasions revealed that the resident's Foley catheter drainage bag and tubing were resting on the floor and dragging on the floor while the resident was self-propelling in their wheelchair. Interviews with the resident and the Unit Manager confirmed these findings. Review of the CDC guidelines for Catheter-Associated Urinary Tract Infections (CAUTI) emphasized that the collecting bag should be kept below the level of the bladder and not rest on the floor.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for three residents. For Resident #34, the April 2024 Medication Administration Record (MAR) showed an order for HumaLOG Solution (Insulin Lispro) to be administered based on a sliding scale. However, on 4/7/24 at 6:30 a.m., there was no documentation of blood sugar being taken or insulin being administered. Additionally, there were no nursing notes explaining why the insulin was not given. Staff C confirmed these findings during an interview on 4/10/24. For Resident #24, the April 2024 MAR revealed orders for Insulin Glargine and Insulin Lispro to be administered at specific times. However, there was no documentation of blood sugar values or insulin administration on multiple occasions, including 4/4/24 at bedtime, 4/4/24 at 8:00 p.m., 4/7/24 at 6:30 a.m., and 4/8/24 at 6:30 a.m. Similarly, for Resident #67, the MAR showed an order for Basaglar KwikPen (Insulin Glargine) to be administered daily at 6:00 a.m., but there was no documentation of blood sugar values or insulin administration on 4/7/24 and 4/8/24. Staff C confirmed these findings as well. The facility's policy on Diabetes Management Protocol, revised in March 2023, requires documentation of finger stick results, insulin doses administered, and the site of administration, which was not followed in these cases.
Latest citations in New Hampshire
Unsanitary conditions were observed in the main kitchen, including debris, wet towels and washcloths on the floor, cloudy liquid under the rinse sink, missing laminate flooring in front of the rinse sink, and buildup of grease and debris under and around the dishwasher, sinks, oven, hood vent, and center island. Bread was stored on shelves with debris underneath, and soda and beer were stored on the floor. The ED confirmed the observations, and the cited FDA Food Code required smooth, easily cleanable, nonabsorbent surfaces.
The facility failed to include personal humidifiers in its Water Management Plan. The Legionella Water Management Program and staff education materials identified humidifiers as a possible source for Legionella exposure, but observations on multiple units found humidifiers in resident rooms and the Water Management Program did not list them or include controls to prevent growth of Legionella and other opportunistic waterborne pathogens. The IP confirmed humidifiers were in use but not included in the plan.
The facility failed to report abuse allegations to the state survey agency. One incident involved two residents with severe cognitive impairment, where an LPN observed one resident exposed while another attempted sexual contact. Another incident involved an LNA witnessing a resident aggressively shake and push another resident’s wheelchair while yelling. Staff confirmed both incidents were not reported to the SSA or law enforcement.
Failure to investigate and report abuse allegations: Staff observed one resident attempting sexual contact with another resident, both with severe cognitive impairment, and another resident aggressively shaking a peer’s wheelchair while yelling. The DON confirmed that neither incident had been investigated, despite staff notification to leadership.
Failure to provide appropriate care to maintain mobility was identified for a resident dependent on an AFO before getting OOB. The resident reported the foot rolled out of the AFO and it caused pain, while the record showed an OT consult order for repair of a broken strap with no evidence the consult was completed or that anyone contacted the AFO provider. The AFO was observed on the bed with the ankle strap missing.
Expired eye drops were found on 2 medication carts, including Timolol for one resident and Latanoprost for another, with staff confirming one should have been discarded. In addition, a medication cart was observed unlocked and unattended, despite facility policy requiring carts to be locked when not in use.
Humidifier equipment was not maintained and cleaned as required for three residents. Staff did not have a reliable tracking system for resident-owned humidifiers, and the DON confirmed the facility was not following manufacturer-specific cleaning instructions. One resident’s humidifier was observed plugged in with an empty tank, another resident did not know how often the unit was cleaned, and staff reported using vinegar for all units instead of the required cleaning methods.
Failure to assess residents for self-administration of medications: two residents had medications left at bedside without the required assessment or provider order. One resident had eye drops on the bedside table and stated he/she self-administered them, while the other had multiple morning meds left at bedside in a medicine cup. Staff confirmed neither resident had documentation authorizing self-administration.
The facility failed to report alleged abuse incidents involving two residents to the SSA within the required timeframe. One resident was documented pushing another resident after grabbing the resident by the chest, and another incident involved physical contact between two residents with one resident sustaining a wrist bruise. The ADON stated these resident-to-resident incidents were not reported to the SSA.
A resident’s fall care plan was not updated after a fall. The fall summary identified a new intervention for staff to offer the resident the choice to keep the curtain open between the sides of the room except during cares, but the care plan was not revised to include it. The UM confirmed the finding, and the facility policy states the IDT fall meeting should develop new fall prevention interventions and update the resident care plan accordingly.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen with the Executive Director, multiple unsanitary conditions were identified, including a white substance buildup on the floor beside the dishwasher, a wet hand towel and a wet washcloth on the floor under the dishwasher, debris under the rinse sink, and a pink container filled with cloudy liquid sitting under the drain beneath the rinse sink. The laminate flooring in front of the rinse sink was missing in an area measuring approximately 4.5 inches by 5 inches, and there was also a large amount of debris under the sanitizing sink, dust between the wall and the left side of the oven, debris under the oven, and a buildup of debris and grease on the hood vent. Additional observations showed debris under the center island where bread was being stored, debris on the shelves under the island, and three cases of soda plus a six pack of beer stored on the floor on the corner shelf. The Executive Director confirmed all of these observations during the interview. Review of the FDA Food Code 2017 cited requirements that nonfood-contact surfaces exposed to splash or food debris be constructed of nonabsorbent materials and that floors, walls, wall coverings, and ceilings be smooth and easily cleanable.
Water Management Plan Did Not Include Humidifiers
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to identify personal humidifiers in its Water Management Plan. Review of the facility's Legionella Water Management Program showed that the program was intended to identify areas in the water system where Legionella bacteria can grow and spread and specifically listed humidifiers among the water system components that could encourage the growth and spread of Legionella or other waterborne bacteria. Staff education materials also identified humidifiers as a possible pathway for exposure to Legionella bacteria. However, observations on the Granite, Profile, and Maple Units found humidifiers in use in resident rooms, and review of the Water Management Program showed that it did not identify humidifiers in use in the facility or controls to prevent the growth of Legionella and other opportunistic waterborne pathogens. The Infection Preventionist confirmed that humidifiers were in use in the building but were not included in the Water Management Plan.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency for two incidents involving residents with severe cognitive impairment. In one event, a nursing note documented that a LPN entered a resident’s room and observed one resident lying back in a recliner with briefs pulled off and pajama pants pulled above the pelvis while another resident was kneeling in front of the recliner attempting to have sex with the resident. The LPN separated the residents, notified the DON and administrator, and placed the resident on 1:1 safety checks. The record showed both residents had BIMS scores indicating severe cognitive impairment, and staff confirmed the incident was not reported to the State Agency. In another event, a nursing note documented that an LNA witnessed one resident coming out of a room and grabbing the back of another resident’s wheelchair and shaking it aggressively. The LNA later confirmed witnessing the resident shake and push the wheelchair while yelling at the other resident. The administrator confirmed this incident was also not reported to the State Survey Agency or other law enforcement. The facility policy required immediate reporting of abuse allegations to the state licensing/certification agency and other officials according to state law.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that two allegations of abuse were investigated and reported to the State Agency. One incident involved Resident #82 and Resident #11, both of whom had severe cognitive impairment, with BIMS scores of 02 and 00 respectively. A nursing note documented that a LPN entered Resident #82’s room and observed Resident #11 lying back in a recliner with clothing pulled off and Resident #82 kneeling in front of the recliner attempting to have sex with Resident #11. The LPN separated the residents, notified the DON and Administrator, and placed Resident #82 on 1:1 checks, but the DON later confirmed that no investigation was initiated. A second incident involved Resident #29 and Resident #55. A nursing note stated that an LNA witnessed Resident #29 coming out of a peer’s room and grabbing the back of the peer’s wheelchair and shaking it aggressively. The LNA later confirmed that Resident #29 shook and pushed forward Resident #55’s wheelchair while yelling at them. The DON confirmed that this incident had not been investigated.
Failure to Address Broken AFO for Resident With Limited Mobility
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM, and/or mobility was not ensured for a resident with limited mobility. Resident #4’s care plan, initiated on 7/9/25, included an intervention stating the resident was dependent on application of an AFO prior to out of bed to the right lower leg. The medical record showed a physician order dated 3/2/26 for an OT consult to have the resident’s right AFO sent for repair because the strap was broken, but there was no indication that an OT consult had been completed or that anyone had been contacted about the AFO needing repair. During interview, the resident stated they had told their provider that their foot rolls out of the AFO and it causes pain when worn, and that no one had come to see them or talk with them about the AFO since they spoke to their provider a few weeks earlier. Observation of the resident’s room showed the AFO lying on the bed with the ankle strap missing.
Medication carts left unsecured and expired eye drops kept in use
Penalty
Summary
Medications and biologicals were not properly labeled and stored on multiple medication carts. On the Maple Unit short hall cart, a bottle of Timolol Maleate solution for Resident #55 was observed with handwritten opening and expiration dates showing it had been opened on 2/27 and expired on 3/27, while the manufacturer’s instructions provided by the facility stated the unit dose container should be used within one month after the foil package is opened. Staff A, a LMA, confirmed the finding during the observation. On the Meadow Unit long hall cart, a bottle of Latanoprost Solution 0.005% for Resident #23 was observed with handwritten dates showing it had been opened on 2/9/26 and expired on 3/23/26, and Staff B, an RN, confirmed the medication had been administered and should have been discarded. In addition, the Profile Unit medication cart was observed unlocked with no nursing staff present, and Staff D, an RN, confirmed the cart was unattended and unsecured. Facility policy stated medication carts are to be locked when not in use and opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Humidifiers Not Maintained or Cleaned per Policy and Manufacturer Instructions
Penalty
Summary
The facility failed to maintain safe and clean humidifier equipment for 3 of 3 residents reviewed for environment, identified as residents #41, #63, and #100. The facility’s admission procedures and Resident Information Guide stated that if a humidifier is brought in, nursing staff must be aware of it so it can be placed on the cleaning schedule. However, interview with staff revealed that the Unit Aide Book did not contain information about which residents had humidifiers or any tracking of cleaning dates, and the Director of Nursing confirmed this. The facility’s Humidifier Maintenance policy stated that nursing staff were to unplug the device daily and rinse/refill it with fresh tap water, while housekeeping was to clean humidifiers monthly with a 1:2 acetic acid and water solution. Resident #41 had a Pelonis humidifier plugged into the room, and the resident’s family stated they purchased it and staff were aware of it; later observation showed the humidifier plugged in with an empty water tank. Resident #63 had a Breezome humidifier in the room, and the resident did not know how often it was cleaned. Resident #100 had a Vick’s humidifier in the room, and the manufacturer’s instructions required weekly cleaning with vinegar for scale removal and a bleach solution for disinfecting. Staff stated that all humidifiers were cleaned with vinegar, and the DON confirmed the facility was not following the specific manufacturer instructions for cleaning individual humidifiers.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine that self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 35 residents. For one resident, a box of Ketotifen Fumarate Ophthalmic Solution 0.035% eye drops was observed on the bedside table with an open date of 1/26/26. The resident stated that he/she would self-administer the eye drops, and the MDS showed a BIMS score of 15/15, indicating cognitive intactness. However, the medical record contained no documentation of a self-administration assessment or an order allowing the resident to self-administer the eye drops, and staff confirmed that no such assessment or order existed. For another resident, a medicine cup containing multiple pills/capsules was observed on the bedside table while the resident was in bed with eyes closed and no staff present. Staff stated that the morning medications had been left at the bedside, and further stated that the resident did not have a physician's order or assessment to self-administer medication. The MAR showed multiple morning medications left at bedside, including furosemide, levetiracetam, metformin ER, metoprolol tartrate, multivitamin with minerals, omeprazole magnesium, potassium chloride ER, sertraline HCL, Synthroid, and apixaban. The medical record confirmed there was no physician's order or assessment for self-administration.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation, to the State Survey Agency for 2 of 2 residents reviewed for abuse. For Resident #3, nursing progress notes documented that an LNA reported the resident had pushed another resident after grabbing the other resident by the chest while shouting to "get out." The other resident was found on the floor against the wall in a slouched position and was able to get up with assistance from staff. The nursing supervisor was notified, a message was left for the guardian, and 15-minute safety checks were started. Social services notes later referenced the recent resident-to-resident altercation in which one resident pushed another resident who wandered into the room. For Resident #145, nursing progress notes documented a potential altercation between 2 residents after camera footage was reviewed and physical contact was observed between the residents. One resident was observed grabbing at the other resident, and the other resident sustained a bruise to the wrist. The primary nurse was instructed to complete an incident report, and notification was sent to administration. The facility policy titled Abuse And Neglect Policy stated that all allegations of abuse or neglect, including reportable resident-to-resident incidents, would be reported immediately, defined as within 2 hours, yet the Assistant Director of Nursing stated that the resident-to-resident incidents were not reported to the SSA.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a care plan for one resident reviewed for falls. Resident #178 had a fall on 12/24/25, and the fall summary report identified a new intervention to be added to the resident’s care plan: staff were to offer the resident the choice to keep the curtain open between the sides of the room except during cares per resident choice. However, review of the care plan titled "at risk for falls" showed that this intervention was not added after the fall. During interview on 3/25/26 at 8:30 a.m., Staff O, the Unit Manager, confirmed the findings. The facility policy titled, "Fall/Accident Management Program," revised 12/2024, states that the IDT fall meeting will occur weekly after a fall and include discussion of possible causes of the fall and development of new fall prevention interventions, and that the resident care plan will be updated accordingly.
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