Dover Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, record review, and review of the Resident Assessment Instrument (RAI), the facility failed to ensure an assessment accurately reflected the resident's status for 1 of 18 sampled residents, Resident (R) 52. Review of the admission Minimum Data Set (MDS) assessment, dated 08/18/2025, and review of the quarterly MDS assessment, dated 02/14/2026, revealed the facility failed to identify R52 had an indwelling catheter.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 18 sampled residents, Resident (R) 70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who needed respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 18 sampled residents, Resident (R) 2.

Inspectors wroteBased on interview and review of the facility's documents, the facility failed to ensure nurse aides received a performance review at least once every 12 months for 1 of 4 employee files reviewed, State Registered Nurse Aide (SRNA) 6.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to store food safely in two of two nourishment refrigerators as determined by observations on 12/09/2024, the nourishment refrigerators on the A Unit and the B Unit.

Inspectors wroteBased on observation, interview, review of the package insert for latanoprost ophthalmic solution, and review of the facility's policy, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents and were stored properly for one of four medication carts, the B Wing Upper medication cart. 1. Observation on [DATE] of the B Wing Upper medication cart revealed it was unlocked and unattended. The staff member who was working with the cart was not in the area. 2. Observation on [DATE] of the B Wing Upper medication cart revealed it contained an unopened box of latanoprost ophthalmic solution 0.005% (used to treat glaucoma) belonging to Resident (R) 3, which was labeled refrigerate. There was also an opened box of latanoprost 0.005% belonging to R3, and neither the box nor bottle were dated.

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to protect 9 of 15 sampled residents from abuse and neglect. Specifically, the facility failed to protect Residents #79, #5, #63, #18, and #48 from staff-to-resident verbal and/or physical abuse and Resident #21 from staff neglect. In addition, the facility and failed to protect Residents #63, #34, #49, and #231 from resident-to-resident physical and/or verbal abuse.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to post the contact information needed for residents to file concerns with the State Survey Agency (SSA). This deficient practice had the potential to affect eighty-one (81) residents.

Inspectors wroteBased on observations, interviews, and facility document and policy review, it was determined the facility failed to act promptly on grievances from individual residents and from the Resident Council related to call light response times, receiving scheduled showers, and food concerns involving nine (9) of thirty (30) sampled residents (Residents #2, #13, #14, #35, #42, #50, #51, #54, and #58) with the potential to affect eighty-one (81) residents.

Inspectors wroteBased on observations, interviews, and facility document and policy review, it was determined the facility failed to label and date food items in the reach-in and walk-in coolers; failed to ensure stored cookware was free of food particles and debris; failed to ensure staff maintained the appropriate parts per million (ppm) of available sanitizer for dishes; and failed to ensure staff utilized proper hand hygiene practices and the appropriate use of gloves to prevent food contamination. This deficient practice had the potential to affect 81 residents.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to report allegations of abuse to the State Survey Agency (SSA) within the mandated timeframes for seven (7) of fifteen (15) residents sampled for allegations of abuse (Residents #184, #79, #5, #63, #48, #34 and #49).

Inspectors wroteBased on observations, record reviews, interviews, review of facility policies, and review of the Centers for Disease Control and Prevention (CDC) article titled Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, the facility failed to ensure staff performed proper hand hygiene practices and disinfected contaminated scissors during wound care for one (1) of four (4) sampled residents reviewed for pressure ulcers (Resident #21). In addition, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) when interacting with one (1) of four (4) sampled residents reviewed for transmission-based precautions (Resident #76). [...]

Inspectors wroteBased on observations, interviews, record review, and facility document and policy review, the facility failed to promote the dignity for two (2) of thirty (30) sampled residents (Resident #2 and Resident #48).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of six (6) residents, observed during medication administration, was prohibited from maintaining their albuterol sulfate inhaler in their possession for self-administration, despite a physician's order indicating the resident was not capable of medication self-administration and without evidence of an assessment to determine if the resident was clinically appropriate for medication self-administration (Resident #23).

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the resident's responsible party when there was a change of condition for one (1) of one (1) sampled residents reviewed for behavioral health when the resident reported suicidal thoughts (Resident #80).

Inspectors wroteBased on interview and record review, it was determined the facility failed to provide an Advance Beneficiary Notice (ABN) for two (2) of three (3) sampled residents reviewed for Beneficiary Notices (Residents #18 and #31).

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure allegations of abuse were investigated to ensure residents were protected from further abuse for three (3) (Residents #184, #34, and #49) of fifteen (15) residents sampled for allegations of abuse.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and provide a copy of the written notice to the long-term care ombudsman for one (1) (Resident #16) of one (1) sampled resident reviewed for hospitalization.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to provide written information regarding the facility's bed-hold policy to a resident and/or their representative when the resident transferred to the hospital for one (1) of one (1) sampled resident reviewed for hospitalization (Resident #16).

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0, it was determined the facility failed to complete an admission assessment timely for one (1) of twenty-three (23) sampled residents reviewed for Minimum Data Set (MDS) assessments (Resident #234).

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within the required timeframe for one (1) of one (1) sampled residents reviewed for hospice and end of life care (Resident #13).

Inspectors wroteBased on interviews, record review and facility policy review, it was determined the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASRR) was conducted for two (2) of three (3) sampled residents reviewed for PASRR (Resident #55 and Resident #54). Specifically, the facility failed to refer Resident #55 and Resident #54 for a Level II PASRR when the resident was newly diagnosed with a mental illness.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to develop and implement comprehensive care plans to address specific areas for four (4) (Residents #180, #48, #17, and #231) of thirty (30) sampled residents.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of fifteen (15) sampled residents reviewed for abuse (Resident #63).

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to provide showers as scheduled and failed to provide incontinence care for three (3) of seven (7) sampled residents (Resident #48, Resident #2, and Resident #17) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to follow Physician's Orders to obtain laboratory values for two (2) of five (5) sampled residents (Resident #4 and Resident #51) reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to secure an indwelling urinary catheter to prevent trauma or accidental removal for one (1) of three (3) sampled residents (Resident #48) reviewed for urinary catheters.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to provide sufficient psychosocial monitoring for one (1) (Resident #180) of one (1) sampled resident reviewed for behavioral health. Specifically, the facility failed to properly document every fifteen (15)-minute monitoring of the resident after a suicide watch was initiated when the resident verbalized the desire for suicide.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure the medication error rate was not 5% or greater. There were two (2) errors out of twenty-eight (28) opportunities observed for two (2) of six (6) residents (Resident #56 and Resident #23) observed during medication administration, which resulted in a medication error rate of 7.14%.