Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
119% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 4
Dec 13, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage and food safety regulations at Dover Nursing & Rehabilitation Center.
Findings
The facility failed to ensure medication carts were secured and medications were stored properly, including an unlocked medication cart and undated/unrefrigerated medications. Additionally, the facility failed to store food safely in nourishment refrigerators, with undated and unlabeled food items and missing temperature documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Medication cart was unlocked and unattended, allowing potential unauthorized access. | Level of Harm - Minimal harm or potential for actual harm |
| Medications, including latanoprost ophthalmic solution, were not stored properly; unopened box labeled refrigerate but opened box and bottle were undated and unrefrigerated. | Level of Harm - Minimal harm or potential for actual harm |
| Food items in nourishment refrigerators were not labeled or dated, including opened containers of applesauce and pudding, grapes, Chinese food, and lemon glycerin swab sticks. | Level of Harm - Minimal harm or potential for actual harm |
| Temperature monitoring logs for nourishment refrigerators were incomplete, missing documentation for multiple days. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication carts: 4
Temperature log missing days: 3
Popsicles: 36
Shelf life of latanoprost after removal from refrigerator: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 2 | Registered Nurse | Assigned to B Wing Upper medication cart, unaware it was left unlocked |
| Licensed Practical Nurse 5 | Unit Manager of B Wing | Stated she always dated medications when opened and noted undated latanoprost was overlooked |
| Director of Nursing | Director of Nursing | Stated expectations for medication cart security and refrigeration of medications |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated expectation for medication carts to be locked when unattended |
| Administrator | Administrator | Discussed medication storage expectations and plans to address issues in QAPI meeting |
| Dietary Manager | Dietary Manager | Discussed food storage practices and responsibility for temperature monitoring |
| Licensed Practical Nurse 1 | A Unit Manager | Stated nurses on night shift responsible for recording nourishment refrigerator temperatures |
Inspection Report
Complaint Investigation
Deficiencies: 7
Dec 13, 2023
Visit Reason
The inspection was conducted based on multiple complaints and allegations of abuse, neglect, medication errors, and failure to provide adequate care to residents at Dover Nursing & Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including failure to prohibit self-administration of medication when clinically inappropriate, failure to protect residents from staff-to-resident and resident-to-resident abuse, failure to timely report and investigate allegations of abuse, failure to provide adequate activities of daily living care including incontinence care and showers, failure to follow physician orders for lab monitoring, and medication errors including crushing enteric-coated medications and missed medication doses.
Complaint Details
The complaint investigation included allegations of medication self-administration errors, staff-to-resident and resident-to-resident abuse, failure to timely report abuse, failure to investigate abuse allegations, inadequate provision of activities of daily living care including incontinence care and showers, failure to follow physician orders for lab monitoring, and medication errors including crushing enteric-coated medications and missed medication doses.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Actual harm: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure one resident was prohibited from self-administering medication despite physician's order and lack of assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to protect 9 of 15 sampled residents from staff-to-resident and resident-to-resident abuse. | Level of Harm - Actual harm |
| Facility failed to timely report allegations of abuse to the State Survey Agency for 7 of 15 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to investigate allegations of abuse to ensure residents were protected from further abuse for 3 of 15 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide showers as scheduled and failed to provide incontinence care for 3 of 7 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to follow physician orders to obtain laboratory values for 2 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure medication error rate was not 5% or greater, with 2 errors out of 28 opportunities (7.14%). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.14
Residents affected by abuse: 9
Residents with late abuse reporting: 7
Residents with inadequate abuse investigation: 3
Residents with inadequate ADL care: 3
Residents with missed lab monitoring: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #40 | State Registered Nurse Aide | Named in findings related to rough incontinence care and abuse allegations. |
| SRNA #46 | State Registered Nurse Aide | Named in findings related to verbal abuse and intimidation of residents and staff. |
| SRNA #35 | State Registered Nurse Aide | Named in findings related to rough handling of resident briefs and abuse allegations. |
| LPN #6 | Licensed Practical Nurse | Named in findings related to medication administration errors and failure to report abuse. |
| LPN #22 | Licensed Practical Nurse | Named in findings related to witnessing rough care but not reporting concerns. |
| LPN #39 | Licensed Practical Nurse | Named in findings related to failure to be aware of resident abuse incidents. |
| LPN #37 | Licensed Practical Nurse | Named in findings related to incontinence care and abuse reporting. |
| LPN #21 | Licensed Practical Nurse | Named in findings related to treatment nurse role and skin care. |
| RN #19 | Registered Nurse | Hospice nurse assigned to Resident #48, interviewed about incontinence care. |
| DA #45 | Dietary Aide | Named in findings related to witnessing verbal abuse by staff. |
| KMA #13 | Kentucky Medication Aide | Named in findings related to witnessing brief handling and reporting. |
| SRNA #34 | State Registered Nurse Aide | Named in findings related to witnessing abuse and delayed reporting. |
| Administrator | Facility Administrator | Named in multiple interviews regarding abuse allegations, reporting, and disciplinary actions. |
| DON | Director of Nursing | Named in multiple interviews regarding abuse allegations, reporting, investigations, and medication errors. |
| Pharmacist #33 | Consultant Pharmacist | Named in findings related to medication monitoring and lab follow-up. |
Inspection Report
Routine
Deficiencies: 15
Dec 13, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of Dover Nursing & Rehabilitation Center to assess compliance with healthcare facility regulations, including resident care, medication administration, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, inadequate medication self-administration assessments, failure to post State Survey Agency contact information, failure to notify responsible parties of resident suicidal ideations, failure to provide Advance Beneficiary Notices, failure to promptly and effectively address resident grievances, multiple incidents of staff-to-resident and resident-to-resident abuse, failure to timely report abuse allegations, incomplete and untimely assessments, failure to provide scheduled care such as showers and incontinence care, medication errors, improper infection control practices, and failure to secure urinary catheters.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to promote resident dignity related to incontinence care and call light response. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure medication self-administration assessments were conducted and residents prohibited from self-administration without proper evaluation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post contact information for State Survey Agency for resident grievances. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify resident's responsible party of suicidal ideations and failure to provide sufficient psychosocial monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide Advance Beneficiary Notice (ABN) for residents losing Medicare covered services. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to promptly and effectively address resident grievances related to call light response, showers, and food concerns. | Level of Harm - Minimal harm or potential for actual harm |
| Multiple incidents of staff-to-resident verbal and physical abuse, resident-to-resident abuse, and staff neglect with delayed reporting and investigation. | Level of Harm - Actual harm |
| Failure to notify resident, representative, and Ombudsman in writing of hospital transfer and bed-hold policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete admission and significant change in status Minimum Data Set (MDS) assessments timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and revise comprehensive care plans to address resident needs and behavioral symptoms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide scheduled showers and incontinence care as needed, resulting in residents being left soiled and unbathed. | Level of Harm - Minimal harm or potential for actual harm |
| Medication errors including crushing enteric-coated medication and omission of ordered medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to label and date food items, failure to ensure cookware cleanliness, failure to maintain sanitizer levels, and improper glove use in food preparation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to perform proper hand hygiene and use appropriate personal protective equipment (PPE) during blood glucose monitoring, insulin administration, wound care, and transmission-based precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to secure indwelling urinary catheter to prevent trauma or accidental removal. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.14
Residents affected by call light grievance: 9
Residents affected by food concerns: 6
Residents affected by shower grievances: 8
Residents affected by abuse and neglect: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #47 | State Registered Nurse Aide | Named in dignity and incontinence care findings |
| SRNA #40 | State Registered Nurse Aide | Named in abuse allegation for rough incontinence care |
| LPN #22 | Licensed Practical Nurse | Witnessed incontinence care incident and interviewed |
| SRNA #34 | State Registered Nurse Aide | Witnessed rough care by SRNA #40 and reported incident |
| DA #45 | Dietary Aide | Overheard verbal abuse by SRNA #46 |
| SRNA #46 | State Registered Nurse Aide | Named in verbal abuse and resident verbal altercation |
| HSKP #56 | Housekeeping Supervisor | Overheard verbal abuse incident involving SRNA #46 |
| LPN #6 | Licensed Practical Nurse | Observed resident abuse and reported incident |
| SRNA #35 | State Registered Nurse Aide | Named in rough care and brief yanking incident |
| SRNA #11 | State Registered Nurse Aide | Named in neglect allegation |
| SRNA #12 | State Registered Nurse Aide | Assisted SRNA #11 with resident care |
| LPN #29 | Licensed Practical Nurse | Observed dropping and not disinfecting scissors during wound care |
| LPN #7 | Licensed Practical Nurse | Interviewed about incontinence care and catheter securement |
| RN #19 | Registered Nurse | Hospice nurse for Resident #48, interviewed about catheter care |
| SRNA #36 | State Registered Nurse Aide | Interviewed about catheter securement |
| LPN #20 | Licensed Practical Nurse | Interviewed about catheter securement |
| SRNA #51 | State Registered Nurse Aide | Interviewed about shower care |
| KMA #24 | Kentucky Medication Aide | Observed crushing enteric-coated medication |
| RN #5 | Registered Nurse | Interviewed about medication administration |
| LPN #6 | Licensed Practical Nurse | Observed medication error and interviewed about medication administration |
| Pharmacist #33 | Consultant Pharmacist | Made recommendations on lab follow-up |
| DA #54 | Dietary Aide | Interviewed about food safety and sanitation |
| DM | Dietary Manager | Interviewed about food safety and sanitation |
| RDM | Regional Dietary Manager | Interviewed about food safety and sanitation |
| ADON | Assistant Director of Nursing | Observed not wearing PPE with COVID positive resident |
| HS #32 | Housekeeping Supervisor/Activity Director | Reported verbal abuse incident and grievance process concerns |
| HSKP #56 | Housekeeper | Overheard verbal abuse incident involving SRNA #46 |
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 13, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the compliance and regulatory status of Dover Nursing & Rehabilitation Center.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 5
Sep 9, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, medication storage and administration, food safety, and infection prevention and control at Dover Nursing & Rehabilitation Center.
Findings
The facility was found deficient in ensuring residents' privacy regarding mail delivery, proper storage and administration of medications, appropriate labeling and storage of residents' food, and maintaining an effective infection prevention and control program, including proper handling of oxygen tubing for a resident with a roommate on contact precautions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure residents' privacy was respected and residents received mail delivery on weekends; residents' mail was sometimes opened prior to delivery. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store drugs and biologicals properly; Trulicity Injection Pens were improperly stored and frozen pens were used; medications left unattended on a resident's overbed table. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were not left unattended at the bedside and were properly administered and documented. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store residents' food in the nourishment refrigerator/freezer; food items were not dated or identified and staff food was stored in the same refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program; oxygen nasal cannula tubing was found in a resident's trash can and was reused without sanitizing, potentially exposing the resident to infectious organisms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of sampled residents with medication storage issues: 2
Number of medications administered to Resident #1 on 09/07/2022: 8
Number of residents affected by mail privacy deficiency: 3
Number of residents affected by infection control deficiency: 1
Number of residents affected by food storage deficiency: Some
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding improper storage and handling of Resident #47's Trulicity Injection Pens. |
| LPN #1 | Licensed Practical Nurse | Interviewed about medication administration and unattended medications found at Resident #1's bedside. |
| KMA #5 | Kentucky Medication Aide | Interviewed about medication administration compliance and food storage responsibilities. |
| RN #1 | Registered Nurse | Interviewed about medication administration procedures and handling of unattended medications. |
| RN #2 | Registered Nurse | Interviewed about medication administration and facility protocols. |
| Unit Manager (UM) of B Hall | Unit Manager | Interviewed about expectations for medication administration and infection control related to oxygen tubing. |
| Director of Nursing (DON) | Director of Nursing | Interviewed about oversight of medication administration, infection control, and facility policies. |
| Administrator | Facility Administrator | Interviewed about mail handling, medication administration policies, and infection control oversight. |
| Infection Preventionist (IP) | Infection Preventionist | Interviewed about infection control policies and oxygen tubing replacement procedures. |
| State Registered Nurse Aide (SRNA) #8 | State Registered Nurse Aide | Interviewed about food storage and labeling responsibilities. |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Interviewed about food storage and temperature log responsibilities. |
| Licensed Practical Nurse (LPN) Unit B Manager | Licensed Practical Nurse Unit Manager | Interviewed about food storage and refrigerator cleaning responsibilities. |
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