Dexter Health Care

Inspectors wroteBased on record review and interviews, the facility failed to follow a physician's order to perform wound vac dressing changes every 48 hours for 1 of 2 residents reviewed for wound vac care (Resident #1 [R1]).

Inspectors wroteBased on a clinical record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 sampled resident with a surgical wound. (Resident #1 [R1]).

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure infection control practices were implemented to prevent the spread of infections, including Enhanced Barrier Precautions (EBP) for open wounds. For 1 of 1 resident reviewed with open wounds. (Resident 1 [R1])

Inspectors wroteBased on observations, Medication Administration Record (MAR) review, and interviews, the facility failed to ensure a Physician ordered medication was available for use for 1 of 14 residents observed during medication administration (Resident #12 [R12]).

Inspectors wroteBased on interviews and record reviews, the facility failed to protect a resident's right to a dignified existence for 1 of 1 resident reviewed for abuse (Resident #44 [R44]).

Inspectors wroteBased on record review and interview, the facility failed to revise a care plan for a resident requiring Enhanced Barrier Precautions for 1 of 1 resident reviewed for Tube Feeding (Resident #6 [R6]).

Inspectors wroteBased on clinical record review, observation, and interview, the facility failed to ensure a resident was free from a significant medication error when a medication to control blood pressure was prepared and ready to be administered to a resident that was in excess of the prescribed dose as ordered by a physician for 1 of 14 residents reviewed during a medication administration observation (Resident #23 [R23]).

Inspectors wroteBased on record review and interviews, the facility failed to ensure a contract was signed between the facility and Hospice Agency for 1 of 1 resident (Resident #4 [R4]) reviewed with services from St [NAME] Hospice.

Inspectors wroteBased on observations, facility policy review, and interviews, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed for 1 of 3 residents who were on EBP (Resident #6 [R6]).

Inspectors wroteBased on review of the facility's policy's, review of the Nursing Facility Reportable Incident Form, review of the facility investigative report, review of the clinical record, and staff interviews, the facility failed to ensure a resident's right to be free from mental abuse, physical restraint, and involuntary seclusion. Specifically, Registered Nurse #1 (RN1) engaged in multiple abusive behaviors, including yelling at the resident repeatedly in response to the resident banging on the door and requesting to go outside, resulting in the resident being transferred to an acute care hospital. For 1of 2 residents sampled (Resident #1[R1]) for abuse.

Inspectors wroteBased on review of the facility's Nursing Facility Reportable Incident Form and investigation, facility policy review, employee file review, and interviews, the facility failed to ensure a resident was free from involuntary seclusion for 1 of 1 facility reported incidents reviewed (8/16/25).

Inspectors wroteBased on review of the facility's investigation/written statements and interviews, the facility failed ensure that a resident was free from restraint when a Registered Nurse used body contact as a method of physical restraint to limit a resident's voluntary movement for 1 of 1 facility reported incidents reviewed (8/16/25).

Inspectors wroteBased on facility policy review, the Nursing Facility Reportable Incident Form and investigation review, timecard review, and interviews, the facility failed to protect residents after staff notification of concern of behavior by a Registered Nurse towards a Resident for 1 of 1 facility reported incident reviewed (8/16/25).

Inspectors wroteBased on Nursing Facility Reportable Incident Form review and interview, the facility failed to notify the State Agency (Division of Licensing and Certification [DLC]) timely for an allegation of abuse for 1 of 1 facility reported incidents reviewed (8/16/25).

Inspectors wroteBased on record review, facility investigation with written statements, and interviews, the facility failed to fully develop and implement a care plan for a resident who was agitated and trying to leave the facility for 1 of 1 facility reported incidents reviewed (8/16/25) when staff observed a Registered Nurse yelling at the resident instead of approaching/speaking in a calm manner and for the intervention to distract the resident from eloping, the resident preferences was BLANK.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information which included documentation of Resident Representative notification of hospital transfer, charge nurse documentation of resident behaviors as directed per Treatment Administration Record (TAR), and documentation to indicate that a resident returned from the hospital for 1 of 1 facility reported incidents reviewed (8/16/25). On 8/26/25, the surveyor reviewed Resident #1's (R1) clinical record after an incident that occurred on 8/16/25 which resulted in R1 being transferred to the hospital for evaluation of increased behaviors. [...]

Inspectors wroteBased on a complaint report, clinical record reviews, and interviews, the facility neglected to protect a resident from receiving another residents medications resulting in the resident being transported to an Acute Care Emergency Department and later admitted to the hospital for evaluation, monitoring and treatment of low blood pressure and syncope episodes. (Resident #31 [R31]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that physician orders for medications and treatments were followed for 6 of 25 sampled residents medications reviewed (Resident #11 [R11]), R14, R15, R27, R30, R144, ).

Inspectors wroteBased on the Center for Disease Control and Prevention, Enhanced Barrier Precaution policy, Wound Care policy, record reviews, observations, and interviews the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections during pressure ulcer dressing changes for 2 of 2 residents requiring pressure ulcer dressing changes (Resident #17 [R17], and Resident #11 [R11]). In addition, the facility failed to follow Enhanced Barrier Precautions (EBPs) pertaining to a Resident with an indwelling urinary catheter for 1 of 1 resident observed for urinary catheter care (R17).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's choice in the area of bathing was being followed for 1 of 1 sampled resident (Resident #3 [R3]).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building, resident equipment in good repair and in a sanitary condition for 2 of 2 environmental tours. On 10/30/24 at 1:35 p.m. through 1:55 p.m., and at 2:45 p.m., environmental tours were conducted with the Administrator.

Inspectors wroteBased on record review and interview, the facility failed to implement a care plan intervention for 1 of 1 residents reviewed for nutrition (Resident #27 [R27}).

Inspectors wroteBased on observation and interview, the facility failed to ensure that a physician order was followed for a pressure ulcer dressing change for 1 of 1 observation for Resident #11 [R11].

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 11 residents reviewed (Residents #6 [R6]).

Inspectors wroteBased on daily schedules review and interview, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 2 of 7 weekend shifts reviewed for RN coverage.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was a physician ordered renewal for an as needed (PRN) psychotropic medication before entering into the new electronic charting system (PCC)'s current physician orders and entered this order without a stop date, making it available for administration for 1 of 5 residents reviewed for unnecessary medications (Resident #9 [R9]).

Inspectors wroteBased on observations and interviews, the facility failed to label supplements with a thaw date and failed to remove expired food for 2 of 4 days of survey (10/28/24 and 10/29/24). In addition, the facility failed to ensure the kitchen was maintained in a clean manner for the exhaust fan located in the dishwashing room on the clean dish side for 3 of 4 days of survey (10/28/24 to 10/30/24).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a clinical record contained complete and accurate information for 3 of 7 residents reviewed (Resident #11 [R11], R27, and R9).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a Physician ordered lab was completed and/or completed timely for a urine test for 2 of 2 residents reviewed with urinary symptoms (Resident #3 (R3) and R44).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a resident requiring feeding assistance was done in a dignified manner for 1 of 2 residents observed requiring feeding assistance (Resident #18 [R18]).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that transportation assistance was available and provided for a scheduled eye appointment for 1 of 2 Residents reviewed for eye appointments (Resident #31 [R31]).

Inspectors wroteBased on record review and interview, the facility failed to ensure weekly pressure ulcer documentation was completed for 1 of 2 residents reviewed for pressure ulcers (Resident #6 [R6].

Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to monitor and document the effectiveness of PRN (as needed) pain medications for 1 of 1 sampled residents reviewed for pain control (Resident # [R} 3).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Medical Provider wrote an electronic prescription and provided it to the pharmacy timely for a narcotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident # [R] 3). This failure resulted in R3 having to wait 7 days in order to receive the medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 1 medication supply room (medication supply storage room behind nursing station), and 1 of 2 medication carts (medication cart A).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a physician order for an x-ray was completed timely for 1 of 1 resident (Resident #13 [R13]).

Inspectors wroteBased on observations, and interview the facility failed to ensure that proper hand sanitizing and proper food handling during lunch service was followed for 1 of 2 lunch service observations in the dining room (11/6/23).

Inspectors wroteBased on observation and interview, the facility failed to post in a place readily accessible to residents, family members, and legal representatives, the results of the most recent survey of the facility in 1 of 1 survey books.

Inspectors wroteBased on interviews, review of the facility incident report, and investigation, the facility failed to ensure the entrance door locked/alarmed when a resident that wore an ankle secure care transmitter and had been identified as an elopement risk was able to leave the building unnoticed for 1 of 1 facility reported incidents reviewed (10/2/23). A nearby neighbor who lived 0.2 miles away called the facility to let staff know that Resident #1 was at their residence.