Dobson Plaza

In the surveyor’s words

From the most serious findings on record at Dobson Plaza, in the surveyor’s own words.

• Actual harm, isolatedF689May 2, 2023

  Deficiency requires two deficient practice statements. 1. Based on interview and record review, the facility failed to have effective, resident-centered, fall interventions in place to prevent a fall and failed to adequately supervise a resident at risk for falls. This failure applied to one of one (R6) resident reviewed for falls with injury and resulted in R6 sustaining a fall, then being subsequently transferred to local hospital with diagnosis of right femur fracture and had to undergo surgery for repair. 2. Based on interview and record review the facility failed to ensure that one resident (R2) was properly assisted during repositioning in bed. […]

• Actual harm, isolatedF689Jul 21, 2022

  Based on observation, interview, and record review the facility failed to provide fall supervision for two residents that sustained unwitnessed falls and required emergent transfer to local hospital resulting in fractures. This failure affected two of 18 residents (R7 and R51) reviewed for falls and resulted in R7 obtaining a left wrist fracture and in R51 obtaining a fracture of the right leg. Findings include: R7 is an [AGE] year old male admitted to the facility 07/04/2020 with diagnoses that include, Dementia, Alzheimer's and history of falls. R7 is severely cognitively impaired with a BIMS score of 00 and requires dependent two-person physical assistance with transfers and extensive two-person physical assistance with ambulation. […]

• No harm, potential for more than minimal, widespreadF812Jun 13, 2024

  Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures by not properly labeling and storing food. This failure applies to all 77 residents in the facility who receive meals from the kitchen. Findings include: On [DATE] from 09:43 AM - 10:20 AM during kitchen observations observed an unlabeled partially closed bag of green beans stored in a freezer; Observed freezer number 5 outside thermometer temperature fluctuating from ,d+[DATE] degrees; Observed a large tub of ice-cream in freezer number 5 was soft; Observed 9 unlabeled packs of English muffins, and 9 unlabeled packs of plain bagels stored in the freezer; Observed one pack of raisin bagels with a sell by date of [DATE] stored in the freezer; Observed a large, opened pack of… […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2022

  Based on observation and interview, the facility failed to follow their kitchen sanitation practices by not wearing hair coverings properly while preparing food and while in the food preparation area and failed to practice proper hand hygiene while in the kitchen. This failure has the potential to affect all 82 residents currently in the facility. Findings include: 07/19/22 at 09:07 AM, observed V25 (Cook) hair exposed from hairnet on sides and back of head while preparing purees. 07/19/22 at 10:48 AM, observed V25's hair exposed from underneath her hair net while preparing meal trays; observed V7 (Dietitian) hair exposed from hairnet on the sides of her head while assisting with meal prep. […]

• No harm, potential for more than minimal, widespreadF761Apr 15, 2021

  Based on observation, interview, and record review, the facility failed to label medications with required information and failed to ensure that expired medications were disposed of per facility protocol. Findings Include: On 4/13/21 at 11:48 AM, noted unlabeled and expired medications in the bottom of the 3rd floor medication cart. 1. [MEDICATION(S)] inhalation spray 120 metered doses. Expired March 2021 Lot # 7A. V5 RN Registered Nurse stated, No label, the date is March 2021. 2. Additional vial of [MEDICATION(S)] inhalation spray 120 metered doses. Expired March 2021 Lot # 7A. V5 RN Registered Nurse stated, No label, the date is March 2021. 3. At 11:55 AM, R56 [MEDICATION(S)] sore throat [MEDICATION(S)] noted in the bottom of the 3rd floor medication cart. […]