Dexter Health Care

In the surveyor’s words

From the most serious findings on record at Dexter Health Care, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 26, 2025

  Based on review of the facility's policy's, review of the Nursing Facility Reportable Incident Form, review of the facility investigative report, review of the clinical record, and staff interviews, the facility failed to ensure a resident's right to be free from mental abuse, physical restraint, and involuntary seclusion. Specifically, Registered Nurse #1 (RN1) engaged in multiple abusive behaviors, including yelling at the resident repeatedly in response to the resident banging on the door and requesting to go outside, resulting in the resident being transferred to an acute care hospital. For 1of 2 residents sampled (Resident #1[R1]) for abuse. […]

• Actual harm, isolatedF760Oct 31, 2024

  Based on a complaint report, clinical record reviews, and interviews, the facility neglected to protect a resident from receiving another residents medications resulting in the resident being transported to an Acute Care Emergency Department and later admitted to the hospital for evaluation, monitoring and treatment of low blood pressure and syncope episodes. (Resident #31 [R31]). Finding: During a recertification survey surveyors were made aware that R31 received another residents medications the morning of 10/28/24 which resulted in R31 having to be transported to the Emergency department for evaluation and treatment. […]

• No harm, potential for more than minimal, patternF755Sep 10, 2025

  Based on observations, Medication Administration Record (MAR) review, and interviews, the facility failed to ensure a Physician ordered medication was available for use for 1 of 14 residents observed during medication administration (Resident #12 [R12]).Findings:R12's clinical record contained a Physician order Lidocan External Patch 5 % (Lidocaine) [a patch that adheres to skin to decrease pain]. Apply to two patches lower back topically in the morning for pain. Apply one left side and one to right side remove after 12 hours - Start Date- 08/20/2025 0800. On 9/10/25 at 9:54 a.m. […]

• No harm, potential for more than minimal, patternF684Oct 31, 2024

  Based on record reviews and interviews, the facility failed to ensure that physician orders for medications and treatments were followed for 6 of 25 sampled residents medications reviewed (Resident #11 [R11]), R14, R15, R27, R30, R144, ). Findings: 1. On 10/30/24, a review of R15's clinical record was completed. Documentation in R15's nurse's notes indicated that on 10/9/24, R15 was sent to the Emergency Department due to respiratory concerns. On 10/11/24, R15 returned from the hospital with an order for Levaquin (an antibiotic) 750 milligrams (mgs) by mouth everyday for 7 days to treat pneumonia. […]

• No harm, potential for more than minimal, patternF880Oct 31, 2024

  Based on the Center for Disease Control and Prevention, Enhanced Barrier Precaution policy, Wound Care policy, record reviews, observations, and interviews the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections during pressure ulcer dressing changes for 2 of 2 residents requiring pressure ulcer dressing changes (Resident #17 [R17], and Resident #11 [R11]). In addition, the facility failed to follow Enhanced Barrier Precautions (EBPs) pertaining to a Resident with an indwelling urinary catheter for 1 of 1 resident observed for urinary catheter care (R17). […]