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Deficiency Records for Dover Nursing and Rehabilitation Center
A list of the most recent deficiencies for Dover Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Dover Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2024-03-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-13 | 2024-02-01 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-12-13 | 2024-02-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-13 | 2024-02-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-13 | 2024-02-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-12-13 | 2024-02-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-13 | 2024-02-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-12-13 | 2024-02-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-13 | 2024-02-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-12-13 | 2024-02-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-13 | 2024-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-13 | 2024-02-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-13 | 2024-02-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-13 | 2024-02-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-12-13 | 2024-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-13 | 2024-02-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-13 | 2024-02-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-13 | 2024-02-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-13 | 2024-02-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-13 | 2024-02-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-13 | 2024-02-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-13 | 2024-02-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-13 | 2024-02-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-05 | 2024-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-05 | 2024-01-18 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-09-09 | 2022-10-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-09 | 2022-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-09 | 2022-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-10-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-08 | 2020-11-17 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-10-08 | 2020-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-08 | 2020-11-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-10-08 | 2020-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-08 | 2020-11-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-10-08 | 2020-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-08 | 2020-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-08 | 2020-11-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-10-08 | 2020-11-17 | N |
| Post nurse staffing information every day. | Health | 2020-10-08 | 2020-11-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-10-08 | 2020-11-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-10-08 | 2020-11-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-10-08 | 2020-11-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-10-08 | 2020-11-17 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2020-10-08 | 2020-11-17 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-10-08 | 2020-11-17 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-10-08 | 2020-11-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-10-08 | 2020-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-08 | 2020-11-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-09-29 | 2020-11-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-09-29 | 2020-11-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-09-29 | 2020-11-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-29 | 2020-11-16 | N |
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