Hennis Care Centre of Dover

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide a dignified dining experience for Resident #20 who received a blood glucose check at the dining room table with other residents present. This affected one resident (Resident #20) out of five residents (#20, #38, #49, #54, and #326) observed for dining on the Gardens unit.

Inspectors wroteBased on record review, staff interview, and Resident Assessment Instrument (RAI) Manual review, the facility failed to accurately complete the Minimum Data Set (MDS) Nutritional Status section for a resident receiving additional fluid intake via a percutaneous endoscopic gastrostomy (PEG) tube. This affected one resident (Resident #13) out of five residents reviewed for nutrition. The facility census was 75. Findings Include: Review of the medical record for Resident #13 revealed admission date on 11/19/24 and re-admission date on 02/07/25 with diagnoses including, but not limited to, paranoid schizophrenia, type two diabetes, major depression, personality disorder, high blood pressure, and osteomyelitis of vertebra. [...]

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure infection control practices were followed when medications were being administered. This affected one (Resident #29) out of five residents observed for medication administration. The facility also failed to ensure enhanced barrier precautions were implemented for Resident #13 and Resident #276. This affected two (Resident #13 and #276) out of three residents reviewed for infection control. The facility census was 75.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a permanent operational and functional Heating, Ventilation and Air Conditioning (HVAC) system and failed to ensure necessary repairs to the existing system were addressed/completed timely to prevent potential interruption of heating/cooling services. This had the potential to affect all 79 residents who resided in the facility.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure residents representatives were informed of changes in condition including new skin impairments. This affected two residents (#11 and #78) of three residents reviewed.

Inspectors wroteBased on record review, review of the facility standing orders, and interview, the facility failed to provide appropriate treatment of a skin laceration. This affected one resident (#78) of three residents reviewed. The census was 83.

Inspectors wroteBased on record review, Physician Communication Book review, and interview, the facility failed to ensure physician services responded to facility requests for resident care 24 hours a day. This affected one resident (#78) of three residents reviewed with the potential to affect all 83 residents in the facility.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure infection control practices were maintained during a wound dressing change. This affected one resident (#78) of two residents observed for wound care. The census was 83.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to ensure food was stored under sanitary conditions. This had the potential to 67 residents receiving food from the facility's kitchens. One resident (#3) did not receive nutrition from the kitchen. The facility census was 68.

Inspectors wroteBased on review of Quality Assessment and Assurance (QAA) meeting sign in sheets and interview, the facility failed to ensure the Medical Director or his designee attended quarterly meetings. This had the potential to affect all 68 residents in the facility.

Inspectors wroteBased on observation, review of the medical record, staff interviews and facility policy review the facility failed to ensure Resident #18, #29, #38, #57, and #287's call lights were maintained within their reach. This affected five of six residents reviewed for call light access. The facility census was 70.

Inspectors wroteBased on record review and interview, the facility failed to ensure minimum data set (MDS) assessments were completed and submitted within required timeframes. This affected 10 (Resident's #1, #4, #9, #39, #42, #49, #61, #66, #68, and #69 ) of 10 residents reviewed. The facility census was 68.

Inspectors wroteBased on observation, record review, interview, and review of manufacturer guidelines the facility failed to ensure their bowel protocol was implemented, measures were in place for peripheral edema and ear irrigation treatment was provided as ordered. This affected two (Residents #5 and #188) of two residents reviewed for edema, one (Resident #13) of one resident reviewed for communication, and one (Resident #25) of five residents reviewed for unnecessary medication. The facility census was 68.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to provide food in a form to meet the nutritional needs of residents. This had the potential to affect eight residents (#23, #31, #32, #38, #42, #57, #61, and #286) receiving a pureed diet. The facility census was 68.

Inspectors wroteBased on record review and interview the facility failed to provide evidence in the medical record to support the receiving provider received the appropriate resident care information for continuity of care. This affected one Resident (#62) of one resident reviewed for hospitalization. The facility census was 68.

Inspectors wroteBased on record review, interview, and review of the Minimum Data Set (MDS) manual the facility failed to ensure an annual comprehensive MDS assessment was completed timely. This affected one (Resident #39) of four residents reviewed for timely completion of assessment.

Inspectors wroteBased on record review, interview and review of the Minimum Data Set (MDS) manual, the facility failed to ensure a quarterly MDS was completed timely. This affected two (Resident #9 and #68) of four residents reviewed for timely completion of assessment.

Inspectors wroteBased on record review and interview the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessments were accurate. This affected two residents (#5 and #25) of seven residents reviewed for accuracy of assessments. The facility census was 68.

Inspectors wroteBased on review of the medical record and staff interview the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was obtained after a new diagnosis of a mental disorder for Resident #31. This affected one resident (Resident #31) of one resident reviewed for PASARR.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to develop comprehensive plans of care in the areas of activities of daily living (ADL) and activities. This affected two (Residents #20 and #51) of 21 residents reviewed. The facility census was 68.

Inspectors wroteBased on observation, review of the medical record, staff interview and facility policy review the facility failed to ensure Resident #24 was shaved and the toenails of Resident #51 were trimmed per their preferences. This affected two residents ( Resident #24 and #51) of four reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to provide activities to meet the residents' needs, and did not provide a scheduled activity calendar or activities on the weekends. This affected two residents (#20 and #187) of two residents reviewed for activities. The facility census was 68.

Inspectors wroteBased on review of the medical record, observation, staff interviews and facility policy review, the facility failed to ensure Resident #31 was turned and repositioned every two hours, failed to have a treatment order in place for four days for a new open area, and failed to have weekly measurements and assessments documented in the resident's medical record. This affected one resident ( Resident #31) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure falls risk interventions were consistently implemented. This affected one out of two residents reviewed for accidents (Resident #16). The facility census was 68.

Inspectors wroteBased on observations, interviews, and record review the facility failed to obtain an order for oxygen administration for Resident #9. This affected one of two residents (Resident #9) reviewed for oxygen administration. The facility identified 35 residents on oxygen therapy, Residents #3, #5, #6, #7, #9, #12, #13, #16, #18, #19, #21, #27, #31, #33, #34, #35, #36, #37, #38, #39, #46, #47, #48, #49, #53, #57, #59, #60, #66, #67, #71, #73, #184, #187, and #284.

Inspectors wroteBased on record review an interview, the facility failed to assess a fistula for dialysis access. This affected one (Resident #13) of one resident reviewed for dialysis. The facility identified three (Residents #13, #51 and #70) residents in the facility receiving hemodialysis.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to their use. This affected two residents (#14 and #20) of five residents reviewed for accidents. The facility census was 68.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure Resident #26 did not receive excessive doses of antibiotics. This affected one (Resident #26) of two residents reviewed for antibiotic use. The facility identified six additional residents receiving antibiotics at the time of the survey (Residents #12, #22, #31, #70, #133 and #284). Facility census was 68.

Inspectors wroteBased on observation and staff interview the facility failed to ensure ophthalmic (eye drops) medication was dated as to when opened and discarded after eight weeks. This affected one of 10 residents receiving eye drops, Resident #11.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure appropriate infection control measures were implemented during dressing changes and pericare. This affected one (Resident #31) of two residents reviewed for pressure ulcers and one (Resident #57) resident observed for incontinence care. The facility census was 68.

Inspectors wroteBased on record review, interview and facility policy review the facility failed to ensure sufficient information was obtained prior to initiation of antibiotics. This affected two Residents (#70 and #286) of four residents reviewed for infections. The facility census was 68.

Inspectors wroteBased on record review, interview, and policy review the facility failed to provide notification to the ombudsman regarding transfers and discharges from the facility. This affected one Resident (#62) of one resident reviewed for hospitalization. The total number of residents affected over a three-month review was 64 (Residents #2, #7, #8, #10, #15, #20, #37, #40, #41, #44, #45, #49, #50, #56, #62, #64, #68, #70, #73, #74, #75, #77, #78, #79, #133, #190, #191, #192, #193, #194, #195, #196, #197, #198, #199, #200, #201, #202, #203, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, #223, #224, #225, #226, #227, and #228. The facility census was 68.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent contamination. This had the potential to affect 114 of 114 residents receiving nutritional services from the kitchen. The facility identified seven residents (#32, #56, #68, #90, #93, #102 and #117) not receiving nutritional services from the facility kitchen. The facility census was 121.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure Hospice care was accurately reflected, care planned and coordinated for Resident #427 and failed to ensure an effective bowel regimen and/or bowel monitoring was completed for Resident #64, Resident #90 and Resident #110. This affected one resident (#427) of one resident reviewed for Hospice services and three residents (#64, #90 and #110) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure Resident #64 was provided the right to participate in the development and implementation of her person-centered plan of care. This affected one resident (#64) of two residents reviewed for care conferences.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure Advanced Directives were consistent between facility documentation and accurately reflected on Resident #64, #107 and #110's medical chart. This affected three residents (#64, #107 and #110) of five residents reviewed for advanced directives.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #15 and Resident #117, remaining in the facility received the required liability notices once Medicare Part A services ended. This affected two residents (#15 and #117) of three residents reviewed for liability notices.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to ensure Resident #53 and Resident #108's wheelchairs were maintained in a clean and sanitary manner. This affected two residents (#53 and #108) of two residents reviewed for equipment.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure Resident #53, #107 and #108, who required staff assistance for activities of daily living (ADL) received timely and necessary care to maintain proper grooming/hygiene related to fingernail care. This affected three residents (#53, #107 and #108) of three residents reviewed for ADL care.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure pressure ulcer treatments and/or pressure revealing interventions were implemented as ordered/care planned. This affected two residents (#115 and #427) of five residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, record review, staff interview and policy review, the facility failed to ensure residents were re-weighed timely when weight loss of greater than five pounds was identified and failed to document residents' meal intakes. This affected two (#37 and #49) five residents reviewed for nutrition.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure weights, fluid restriction monitoring and access site assessments were completed for Resident #59 related to hemodialysis. This affected one resident (#59) of one resident reviewed for hemodialysis.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure proper infection control practices were maintained following perineal care for Resident #56 to prevent the spread of infection. This affected one resident (#56) of one resident observed for catheter care.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure Resident #16, who received antibiotics for urinary tract infections was comprehensively assessed to determine appropriate indication for antibiotic use via the antibiotic stewardship program. This affected one resident (#16) of seven residents reviewed for antibiotic use.

Inspectors wroteBased on review of the daily nursing postings, interview and policy review the facility failed to ensure the daily nursing posting was accurate and included all required information. This had the potential to affect all 121 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure quarterly Minimum Data Set (MDS) 3.0 assessment were submitted timely as required. This affected ten residents (#2, #3, #5, #6, #7, #8, #10, #12, #20, and #23) of ten residents reviewed for MDS assessments.