Dove Healthcare - Fennimore

In the surveyor’s words

From the most serious findings on record at Dove Healthcare - Fennimore, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 20, 2023

  Based on observation, interview, and record review the facility failed to protect residents right to be free from verbal and physical abuse by Resident (R1). This has the potential to affect all 12 residents who reside on the 100 unit with R1. The facility failed to protect residents right to be free from physical abuse by Registered Nurse (RN U) for 2 of 3 residents reviewed for abuse. R1 has a history at the facility of resident-to-resident incidents including slapping a resident, shaking a resident, grabbing the shirt of a resident, and yelling and swearing at other residents. In addition, R1 has grabbed arms and throat of staff, threw staff against the wall, and punched and hit staff during cares and when walking in the hallway. […]

• Immediate jeopardy, patternF678Jul 20, 2023

  Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring emergency care for 1 of 3 Residents (R3) reviewed for code status. Additionally, the facility does not have a process for ensuring a CPR certified staff member is available on each shift. This has the potential to affect 10 full code residents that reside in the facility. R3 was a full code (wanted cardiopulmonary resuscitation) and was found pulseless and nonbreathing on [DATE]. […]

• Immediate jeopardy, isolatedF678Aug 1, 2024

  Based on interview and record review, the facility failed to ensure basic life support measures including cardiopulmonary resuscitation (CPR) were in place immediately, when needed, for a resident requiring emergency care for 1 of 2 residents (R35) reviewed during closed record review. R35 was a full code (wanted CPR). On [DATE], R35 stated she had chest pain rating at a ,d+[DATE] or ,d+[DATE]. RN E (Registered Nurse) gave Tums and Tylenol which were not effective for R35's chest pain. R35's blood pressure was below R35's baseline. R35 continued to complain of chest pain. After 1 hour and 43 minutes from R35's initial complaint of chest pain, the facility called 911 for emergency medical services (EMS). […]

• Immediate jeopardy, isolatedF689Feb 24, 2022

  Based on observation, interview and record review, the facility did not ensure 1 (R1) of 2 supplemental residents on specialized diets received food in an assessed consistency so as not to create a hazardous environment and received supervision to prevent a choking accident. Facility staff did not follow the care plan for 1 of 1 supplemental residents (R26), which led to a fall that resulted in a [CONDITION(S)], and did not review and revise the care plans of 2 of 15 sample residents (R20 and R10) after they had multiple falls. R1 has [CONDITION(S)] and dysphagia and is at risk for choking. R1 is to receive a pureed diet and is to be cued while eating. On 2/9/22 and 2/10/22 R1 was given meals that were not pureed. In addition, R1 was left alone in his room to eat. […]

• Actual harm, isolatedF689Sep 10, 2025

  Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents (R7) reviewed for falls out of a total sample of 12.R7 had a history of falls including one that resulted in a T11 spinal fracture and another that resulted in a laceration with 2 staples and a subdural hematoma. The facility did not complete a thorough root cause analysis on the falls or ensure that care planned interventions were in place for R7.As evidenced by:Facility policy, titled Fall Prevention Program, with last revision date of 8/2024, includes, in part: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the… […]