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Deficiency Records for Excel Care at Dover
A list of the most recent deficiencies for Excel Care at Dover. 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 Excel Care at Dover. 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 at least two remote exits on each floor or fire section of the building. | Fire Safety | 2024-05-31 | 2024-08-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-31 | 2024-08-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-31 | 2024-07-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-31 | 2024-07-15 | 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 | 2024-05-31 | 2024-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-31 | 2024-07-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-31 | 2024-07-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-31 | 2024-07-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-05-31 | 2024-07-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-05-31 | 2024-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-31 | 2024-07-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-05-31 | 2024-07-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-05-31 | 2024-07-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-31 | 2024-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-31 | 2024-07-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-31 | 2024-07-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-31 | 2024-07-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-31 | 2024-07-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-31 | 2024-07-15 | Y |
| Use approved construction type or materials. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-31 | 2024-07-15 | 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 | 2024-05-31 | 2024-07-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-31 | 2024-07-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-31 | 2024-06-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-05-31 | 2024-06-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-21 | 2024-04-30 | Y |
| 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 | 2024-03-21 | 2024-04-30 | Y |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2022-05-02 | 2022-07-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-02 | 2022-07-26 | N |
| Use approved construction type or materials. | Fire Safety | 2022-05-02 | 2022-07-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-02 | 2022-07-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-02 | 2022-07-08 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-05-02 | 2022-07-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-02 | 2022-07-08 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-05-02 | 2022-07-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-02 | 2022-07-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-02 | 2022-07-08 | 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 | 2022-05-02 | 2022-07-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-02 | 2022-07-01 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-05-02 | 2022-07-01 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-05-02 | 2022-07-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-02 | 2022-06-27 | 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 | 2022-05-02 | 2022-06-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-02 | 2022-06-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-02 | 2022-06-13 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2021-04-22 | 2021-10-04 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-04-22 | 2021-05-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-22 | 2021-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-22 | 2021-05-20 | N |
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