Dover Care Center

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 1 of 3 (Cook A) staff members in the kitchen handled residents' food with no gloves on. The facility had a census of 47 with 47 of those residents receiving a tray from the kitchen.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 9 staff members Certified Nursing Assistant (CNA) B failed to handle and serve food under sanitary conditions for 2 of 20 (Resident #14 and #45) residents observed during dining, and when 1 of 2 Registered Nurses (RN) C failed to perform hand hygiene for 3 of 5 (Resident #17, #47, and #55) residents observed during medication administration.

Inspectors wroteBased on interviews, record review, facility documents, and facility policy review, the facility failed to report allegations of abuse to the state agency within the two hours for 2 (Residents #1 and #4) of 4 residents reviewed for allegations of abuse/neglect; and failed to report an allegation of neglect within 24 hours for 1 (Resident #2) of 3 residents reviewed for allegations of abuse/neglect.

Inspectors wroteBased on observations, interviews, record review, facility policy, and facility document review, the facility failed to ensure allegations of abuse were thoroughly investigated for 3 (Residents #4, #3, and #2) of 4 residents reviewed for abuse.

Inspectors wroteBased on interview, record review, facility policy, and facility document review, the facility failed to protect the resident's right to be free of physical abuse by a contracted staff member, Licensed Practical Nurse (LPN) #1. This failure affected 1 (Resident #1) of 4 sampled residents. On 08/18/2023, Certified Nursing Assistant (CNA) #2 observed LPN #1 take a sandwich from Resident #1's hand despite the resident's objection, hold the resident's hands, and forcefully pushed a spoonful of crushed medications into the resident's mouth through the resident's closed lips.

Inspectors wroteBased on interviews, record review, facility documents, and facility policy review, the facility failed to ensure 1 (Resident #1) of 4 abuse/neglect investigations was reported and addressed in the facility's Quality Assurance and Performance Improvement (QAPI) program. Specifically, the facility's abuse/neglect policy required all substantiated allegations of abuse be review by the facility's QAPI Committee; however, the facility failed to ensure a substantiated abuse allegation for Resident #1 was reported to the committee.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when an indwelling urinary catheter bag was not concealed in a privacy bag for 1 of 2 sampled resident (Resident #20) reviewed for an indwelling urinary catheter.

Inspectors wroteBased on medical record review, and interview, the facility failed to accurately assess residents for Antibiotic, Opioid, and Diuretic use and tracheostomy care when 3 of 5 sampled residents (Resident #8, #47 and #51) reviewed for accuracy of Minimum Data Set (MDS) assessments.

Inspectors wroteBased on medical record review and interview, the facility failed to develop a Baseline Care Plan within 48 hours of admission that included the initial goals and needs for 1 of 3 sampled residents (Resident #205) reviewed.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings which included the Interdisciplinary Team (IDT) for 2 of 13 sample resident (Resident #41 and #47) reviewed for care plan meetings.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to ensure the completion of a discharge summary that included a recapitulation of resident's stay, physicians orders, the disposition status of the resident at the time of discharge and a post discharge plan of care for 1 of 2 sample resident (Resident #57) reviewed for discharge.

Inspectors wroteBased on the facility guideline, medical record review, observation, and interview, the facility failed to ensure a resident's skin condition was accurately assessed, treatments were documented as provided and care plan was updated for 1 of 2 sampled residents (Resident #26) reviewed with pressure ulcers.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to accurately assess the nutritional status and to follow the Registered Dietician's (RD) recommendations to provide nutritional interventions for 1 of 3 sampled residents (Resident #16), failed to follow the facility's policy for monitoring weights for 1 of 3 sampled residents (Resident #16), and failed to properly label an enteral feeding for 1 of 1 sampled resident (Resident #205) reviewed for nutrition.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to provide the necessary respiratory care and services for tracheostomy care and there were no physicians orders for oxygen for 2 of 2 sampled residents (Resident #8 and #205) reviewed for oxygen therapy and tracheostomy care.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unattended and unsecured when 1 of 3 nurses (Registered Nurse (RN) #1) left medications unattended and unsecured on top of the medication cart, and when 2 of 6 medication storage areas (C Hall Medication Cart and the Treatment Cart) were left unlocked and unattended on the hallway.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) #1 and 2) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control practices to prevent the potential spread of infection in 1 of 1 laundry room.