Dugan Memorial Home

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were provided with a dignified dining experience when one (1) of three (3) residents at the table did not receive their meal at the same time.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure informed consent was obtained prior to the initiation of a psychotropic medication for one (1) of five (5) residents reviewed for unnecessary medications.

Inspectors wroteBased on resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure a cognitively intact resident was provided the opportunity to participate in and make informed decisions regarding her advance directive, including end-of-life preferences for one (1) of 24 advance directives reviewed. (Resident #1) Findings Include:Review of the facility policy titled Advance Directives Policy and Acknowledgment, updated 9/3/25, revealed, Resident has the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives. Record review of the facility's Advance Directives/Medical Treatment Decisions form, dated 2/17/22, revealed Resident #1 was designated as Do Not Resuscitate (DNR); [...]

Inspectors wroteBased on staff interview, observation of video camera footage, record review, and facility policy review, the facility failed to ensure a resident's right to be free from sexual abuse by another resident for one (1) of four (4) residents sampled. (Resident #1) Specifically, the facility failed to prevent Resident #2, a cognitively intact resident with mental health diagnoses, from engaging in non-consensual sexual contact with Resident #1, a severely cognitively impaired resident, in a supervised common area of the facility. This failure resulted in actual harm to Resident #1, as she experienced inappropriate sexual contact without the ability to consent, resist, or report the incident.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure the medical provider was notified of a resident refusing multiple doses of prescribed antibiotics for one (1) of six (6) residents reviewed for medication use.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to implement a care plan for one (1) of 18 sampled residents' care plans. Resident #21 Findings Include: Record review of facility's policy titled, Comprehensive Care Plans dated 10/22, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of Resident #21's care plan revealed a focus area dated 9/15/24 of Elder has pneumonia. Interventions listed included administer medications as ordered, Cefdinir for ten days for pneumonia, and to keep informed of changes and update MD as needed. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to initiate contact isolation precautions for a resident with Methicillin-resistant Staphylococcus Aureus (MRSA) and failed to prevent the possibility of the spread of infection by not utilizing proper hand hygiene for one (1) of four (4) resident care observations. Resident #19. Findings Include: Review of the facility policy Clean Dressing Change dated 10/2022 revealed, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. [...]

Inspectors wroteBased on resident and staff interview, record review and facility policy review, the facility failed to prevent verbal abuse to a resident from a staff member for one (1) of three (3) residents reviewed for abuse. Resident #1 Findings Include: Review of the facility policy titled, Abuse, Neglect and Exploitation-2019 with a review date of 2019 revealed, Policy .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This review revealed under, IV. Identification of Abuse, Neglect and Exploitation .B. 5. Verbal abuse of a resident overheard. [...]

Inspectors wroteBased on observations, staff interview and facility policy review, the facility failed to store food items in a manner that maintains the safety of the food as evidenced by uncovered, unlabeled and undated food in the refrigerator and freezer for one (1) of two (2) kitchen tours.

Inspectors wroteBased on record review, staff interview and facility policy review the facility failed to develop a person-centered care plan for a resident with a contracture for one (1) of 14 resident care plans reviewed. Resident #16 Findings Include: Review of the facility policy titled, Comprehensive Care Plans with an implementation date of 10/2022 and no revision date revealed, Policy .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. An observation on 07/11/23 at 9:55 AM, of Resident #16 revealed the resident had a right-hand contracture with a carrot roll placed in the right hand. [...]

Inspectors wroteBased on observations, staff interviews and facility policy review, the facility failed to provide personal hygiene to a resident requiring assistance as evidenced by long nails with a brown substance underneath for one (1) of 14 residents sampled.