Dove Healthcare - Fennimore

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care and the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This had the potential to affect all 42 residents residing in the facility. The facility enrolled residents in a service provided by a third party without the consent of each resident or their representative.

Inspectors wroteBased on interview and record review, the facility did not ensure that all resident records were kept confidential except when release is for treatment, payment, or health care operations. This has the potential to affect all 42 residents residing in the facility. The facility entered a business agreement with a third party company that had access and used resident information to provide treatment and health care operations that residents were unaware were occurring, did not consent to and were being billed for.

Inspectors wroteBased on document review, interview and policy review, the facility failed to protect the resident's rights for one of two residents (R1) reviewed for abuse to be free from verbal abuse. Facility failed to protect R1 from verbal abuse.

Inspectors wroteBased on document review, interview and policy review, the facility failed to thoroughly investigate an allegation of verbal abuse for one of two residents (R1) reviewed for abuse. The failure to thoroughly investigate an allegation of abuse had the potential to negatively impact residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents (R7) reviewed for falls out of a total sample of 12. R7 had a history of falls including one that resulted in a T11 spinal fracture and another that resulted in a laceration with 2 staples and a subdural hematoma. The facility did not complete a thorough root cause analysis on the falls or ensure that care planned interventions were in place for R7. As evidenced by:Facility policy, titled Fall Prevention Program, with last revision date of 8/2024, includes, in part: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: . 5. [...]

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the ability to affect all 34 residents. Food items were not dated or were expired. Food items were improperly storedA scoop was found in dry ingredients. Evidenced by:On 9/8/24 at 9:51 AM, Surveyor observed, along with DM I (Dietary manager), the following inside the main kitchen's walk-in refrigerator:*An opened pack of sliced cheese with no open date or use by date.*An opened pack of 3 tortillas with no open date or use by date.*2 baked potatoes in a Ziplock bag with 8/25 written on bag.*5 loaves of bread with no use by or expiration dates.*An apple on the floor At 10:15 AM, Surveyor observed an open bag of milk crystals with no date in the dry storage area. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 34 residents. Garbage was observed surrounding the garbage dumpster. Evidenced by:On 9/8/2025 at 9:51 AM, Surveyor and DM I (Dietary Manager) observed the following outside the facility in the garbage dumpster area:*Used napkins*Approximately 10 used latex gloves*Various unknown food items crushed into the ground*Condiment packetsIt should be noted that these items were surrounding the dumpster area and also along the small hillside on the backside of the garbage dumpsters. On 9/8/25 at 9:53 AM, DM I indicated to Surveyor that there was too much garbage on the ground, and it was dirty and needed to be cleaned up. DM I was unable to identify the food items that were crushed on the ground.

Inspectors wroteBased on interview and record review, the Facility did not ensure allegations of abuse, suspected neglect, and/or injury of unknown origin were reported to the State Agency during the required timeframe for 1 of 12 residents (R26) reviewed. On 8/31/25, R26 reported to the facility staff that another resident came into his room and was yelling at R26 and poured urine on R26's shoes. The facility did not report this to the state agency. This is evidenced by:The facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program, last revised on 10/23, states: Each resident of [Facility Name] has the right to be free from abuse, neglect. Residents will not be subjected to abuse by anyone, including but not limited to,.any other individuals. [...]

Inspectors wroteBased on interview and record review the Facility did not have evidence all alleged violations of mistreatment were thoroughly investigated for an allegation of abuse involving 2 residents (R26 and R15)On 8/31/25, R26 reported to the facility staff that another resident came into his room and was yelling at R26 and poured urine on R26's shoes. The facility did not thoroughly investigate this allegation. This is evidenced by:The facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program, last revised on 10/23, states: Alleged violation is a situation or occurrence that is observed or reported by staff, resident.but not yet been investigated. 5. Investigation: All of the following are promptly investigated per facility policies and practices. All resident accidents and incidents including: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 (R3) of 4 sampled residents. R3 has diagnoses including cerebral infarction (stroke), type 2 diabetes with retinopathy and neuropathy (diabetes causing damage to the nerves and retina), morbid obesity, cognitive communication deficit, generalized muscle weakness, and dementia. R3 developed a diabetic ulcer of his right great toe in the facility that became infected. R3 had a change of condition, became febrile with emesis and the facility failed to notify the physician immediately with this change of condition. R3 was later admitted to the hospital with a wound infection requiring Intravenous (IV) antibiotics. This is evidenced by:The facility does not have a diabetic foot check policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident environments remained free of potential accidents/hazards for 1 of 1 residents (R2) reviewed for electric wheelchairs. R2 utilizes a power wheelchair for mobility, which was noted to be charging in his room. As evidenced by: Facility policy, titled Motorized Assistive Device Policy and Procedure, dated May 2024, states, in part: Policy Statement: it is the policy of the facility to promote the safety of all residents, staff members and contractors, and visitors as well as the integrity of the facility grounds by defining allowable use and limitations for resident's personal motorized assistive devices Procedure: . If a resident chooses to utilize a motorized assistive device, resident will agree to do the following: . 1 . e. Availability of safe storage and electrical charging location. f. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure basic life support measures including cardiopulmonary resuscitation (CPR) were in place immediately, when needed, for a resident requiring emergency care for 1 of 2 residents (R35) reviewed during closed record review. R35 was a full code (wanted CPR). On [DATE], R35 stated she had chest pain rating at a 9/10 or 10/10. RN E (Registered Nurse) gave Tums and Tylenol which were not effective for R35's chest pain. R35's blood pressure was below R35's baseline. R35 continued to complain of chest pain. After 1 hour and 43 minutes from R35's initial complaint of chest pain, the facility called 911 for emergency medical services (EMS). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 31 residents. The facility did not know what PPM (Parts Per Million) to use for their low temperature, sanitizing dishwasher and had no record that the three compartment sink sanitizing agent was being monitored. Food items with no dating or past the use by dates

Inspectors wroteBased on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 31 residents (R) in the facility. The facility's policies have not been updated annually. The facility did not track infection control rates by infection type. The facility did not have a staff infection control line list prior to June 2024. The facility did not maintain an accurate staff infection control line list. The facility allowed staff to return to work before the recommended time frame for illness. The facility did not maintain an accurate resident line list. The facility did not place residents into isolation precautions timely. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator and appropriate agencies for 2 of 16 sampled residents (R31 and R35). R31 was noted to have bruising to his left hip measuring 11 cm by 7.5 cm of unknown source. The nurse did not report this injury of unknown source to the State Agency. R35 reported to a nurse that two CNAs requested that R35 have sex with them. This allegation of abuse was not reported to the State Agency or Law Enforcement. Evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are thoroughly investigated for 2 of 16 sampled residents (R31 and R35). R31 was noted to have bruising to his left hip measuring 11 cm by 7.5 cm of unknown source. The injury of unknown source was not investigated at the time it was noted. R35 reported to a nurse that two CNAs requested that R35 have sex with them. This allegation of abuse was not investigated. Evidenced by: The facility policy titled Resident Abuse, Neglect, Misappropriate of Property, and Exploitation Prevention Program with last review date of October 2023, states, in part: .The facility will do all that is within its control to protect its residents from abuse, neglect, misappropriation of resident property, and exploitation. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents reviewed for unnecessary medications (R22). R22 was taking a psychotropic medication, and a Gradual Dose Reduction (GDR) was not attempted due to family preference.

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 16 sampled residents (R6) and 1 of 1 supplemental residents (R32) reviewed for antibiotic stewardship. R6 was on an antibiotic for urinary tract infection without an appropriate indication. R32 was on an antibiotic for urinary tract infection without an appropriate indication. This is evidenced by: The facility policy titled Antimicrobial Stewardship Procedure with a last review date of March 2024, states in part: .Purpose: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 Certified Nursing Assistants (CNAs; CNA L and CNA M) of 5 CNA's employed by the facility received 12 hours per year of in-service training. This practice had the potential to affect multiple residents in the facility. CNA L was hired on 6/21/22 and did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA M was hired on 3/3/22 and did not have 12 hours of in-service training during the most recent anniversary of hire year. Evidenced by: On 8/1/24, Surveyor reviewed documents that indicated the following: - CNA L received 10.8 of the required 12 hours of in-service training. - CNA M received 7.45 of the required 12 hours of in-service training. [...]

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to inform the resident representative of a change in condition for one resident (R) (R5) of four residents reviewed for change in condition. The facility failed to inform R5's representative of increased respiratory symptoms including being positive for the respiratory syncytial virus (RSV) for two days prior to having to be transferred to the hospital. This failure placed the resident representative at risk of not being aware of the care and services provided by the facility.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure three residents (R) (R2, R3, and R4) were provided care in a manner to prevent mistreatment and neglect by Certified Nurse Aide (CNA) 5.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure two Residents (R) (R5 & R6) reviewed in a total sample of 18, were free of any significant medication errors.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to consistently document bathing/showers and repositioning for one Resident (R) (R1) of three residents reviewed in a total sample of 18, who were dependent or required extensive assistance from staff to complete their activities of daily living (ADLs). This failure placed the resident at risk for a diminished quality of life and unmet care needs.

Inspectors wroteBased on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, not later than 24 hours if the events that cause the suspicion do not result in serious bodily harm for 2 of 2 sampled residents (R2 and R3.) According to §483.12(c)(1) of the State Operations Manual; [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 2 of 2 incidents reviewed (R2 and R3). R2 alleged that the agency CNA (Certified Nursing Assistant) would not assist her with toileting and left her to finish having a bowel movement before assisting her. R3's granddaughter alleged that the agency CNA had put bedpan under R3 incorrectly causing R3 to soil the bed. The agency CNA then placed a soaker pad under R3 and left her without changing her bedding.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R3) reviewed who used mechanical lifts. Surveyor observed a CNA (Certified Nursing Assistant) transfer R3 using a sit to stand lift with assist of one staff. R3's care plan indicates R3 is to be transferred using a sit to stand with two-assist. Evidenced by: The facility Safe Resident Handling/Transfers policy, dated 7/5/23, includes, in part, the following: Compliance Guidelines: 3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies. 4. Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts. 13. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident maintains acceptable parameters of nutritional status including dietary supplementation for 1 of 3 residents reviewed for nutrition concerns (R5). R5 had orders for Juven for nutritional supplementation and wound healing. The facility did not receive the nutritional supplement and did not notify a physician when Juven was not received and not available to administer as ordered.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure that food served to residents was palatable. This failure had the potential to affect 52 of 52 residents who received meals from the kitchen.

Inspectors wroteBased on interviews, record reviews, facility document review, and facility policy review, it was determined the facility failed to report a resident-to-resident incident of verbal and physical abuse to the state agency for 1 (Resident 38) of 5 residents reviewed for behavioral symptoms. Resident 38 was observed by staff yelling at Resident 34 and had their hands on Resident 34 while Resident 34 was lying in the bed and this incident was not reported to the state agency.

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed for 1 (Resident 12) of 3 residents reviewed for PASARR screening.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure activity of daily living (ADL) care to maintain good grooming was provided for 2 (Resident 12 and Resident 19) of 2 residents reviewed for ADL care. The facility failed to ensure Resident 12, and Resident 19 received nail care to ensure their fingernails were trimmed.