Dove Healthcare - Regional Vent Center

Inspectors wroteBased on record review and interview, the facility did not notify the Ombudsman of residents who were transferred from the facility to a hospital for 5 of 5 residents (R) (R4, R7, R20, R31, R33). The facility was unable to locate a policy pertaining to ombudsman notification for transfers. Example 1 (R7) On 02/27/2026, R7 had a change in condition and was transferred to the hospital. On 04/15/2026 at 10:03 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated he was unable to find documentation that the Ombudsman was notified of resident transfers and/or discharges. NHA A stated the staff member responsible for Ombudsman notification left in September of 2025 and NHA A was unable to locate the notifications to the Ombudsman requested. [...]

Inspectors wroteBased on observation and interviews, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. This had the potential to affect all 13 of the 29 residents that eat orally.-Cook did not check the temperature of the fried eggs prior to serving.-Personal food was stored in the resident's refrigerator-Food was dished up in bowls with no label or date on dish or tray.-Cereal was not covered prior to leaving kitchen and going to resident's room.-Rectangular baking pans were on bottom shelf not enclosed, not covered, or inverted. -An open bag of macaroni was on kitchen shelf without an open on or use by date.

Inspectors wroteBased on interview and record review, the facility did not immediately consult with the resident's physician when there is need to alter treatment for 2 of 5 residents (R4 and R13) reviewed for MD notification. -R4 began to have difficulty with nebulizer treatments with increased dyspnea and shortness of breath which were then held by nursing staff and not administered as physician orders specify. Staff did not notify the provider with condition change and holding of the nebulizer treatments for 2 days.-R13 had a change of condition with low oxygen saturations, and the MD was not notified of the change in respiratory status and low oxygen saturations. The next day R13 was transferred to the emergency room and was diagnosed with pneumonia.

Inspectors wroteBased on record review and interview the facility did not provide the accurate Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) thus did not provide the accurate potential financial liability to residents whose Medicare coverage ended for 1 of 1 resident reviewed (R7). R7 was receiving Medicare A benefits. R7's Medicare coverage ended on 12/12/25. R7 was not provided with a SNFABN form thus not provided with accurate financial liability. Evidenced by: Surveyor reviewed R7's beneficiary notices for Medicare Part A services ending. Surveyor could not find that a SNFABN Form was given to R7 to inform R7 of the financial liability. On 04/14/26 at 1:13 pm, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for beneficiary notices for R7 when R7's Medicare benefits were ending. [...]

Inspectors wroteBased on interview and record review, the facility did not develop a comprehensive person-centered care plan for the diagnosis of fluid overload and new anticoagulation medication administration post hospitalization for 1 of 16 residents (R) R4 reviewed for care plans. This is evidenced by: R4 was admitted to facility on 01/30/26, with diagnoses including, in part, acute chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, type 2 diabetes mellitus with diabetic nephropathy, fusion of spine, post-polio syndrome, insomnia, hyperkalemia, scoliosis, anxiety disorder, gastrostomy status, tracheostomy, and dependence on respirator ventilator status. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not review/revise the resident's person-centered comprehensive care plan for 1 resident (R13) of 16 residents reviewed for care plans in a sample of 16 residents. The facility's interdisciplinary team (IDT) did not update/revise R13's care plan after each quarterly or comprehensive review assessments to reflect R13's refusals of using the ventilator at night and noncompliance to fluid restrictions, resulting in a possible decline in R13's physical health and hospitalization.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure 3 of 3 residents (R) reviewed, (R1, R2, and R3) who required oxygen with ventilator (Vent) and respiratory care were provided such services consistent with professional standards of practice, the resident's comprehensive person-centered care plan, and physician orders on the ventilator unit. R1 is ventilator dependent and requires oxygen continuously via the ventilator to maintain oxygen levels above 90% saturation. On [DATE], when R1 was put to bed, staff did not connect R1 to the stationary liquid oxygen tank, but left R1 connected to a portable oxygen tank that runs out of oxygen within 3-4 hours. Respiratory Therapist (RT) skipped ventilator spot checks for R1 at 2:00 AM on [DATE]. R1 was found at 6:00 AM on [DATE] with low saturations, no pulse, and died. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness by having a separate hand washing sink separate from those used for food preparation for 11 residents (R) (R4, R5, R8, R9, R12, R24, R17, R18, R19, R20, R27).

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (R). (R3, R4, R5) Staff did not complete appropriate glove change and hand hygiene when providing personal cares for R3. Catheter bags were placed directly on the floor. This is evidenced by: The facility's policy titled Hand Hygiene with the last review date of 06/24, read in part, .2. g. Decontaminate hands if moving from a contaminated-body site to a clean-body site during resident care. h. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. i. Decontaminate hands after removing gloves .7. e. [...]