Dove Healthcare - Superior

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 9, 2021

  Based on observation, record review, policy review, and interviews the facility did not provide adequate assistive devices to prevent accidents for 1 (R1) out of 3 sampled residents reviewed for safe mobility using a power wheelchair. R1 has used a power wheelchair for greater than [AGE] years due to [CONDITION(S)] following a motor vehicle accident in 1998. R1 had no sensation and no movement of self from the lower chest area down and was taking a blood thinner to prevent blood clots. R1 was dependent on staff for transfers in and out of the power wheelchair. Once seated in the power wheelchair, R1 required 2 leg straps, one around the mid thigh and the other around the mid calf, to keep legs together and on the foot platform due to paraplegic status. […]

• Actual harm, isolatedF686Dec 1, 2022

  Based on observation, interview and record review, the facility did not ensure 3 of 3 residents reviewed for pressure injuries (R69, R59 and R39), received care consistent with professional standards of practice in relation to prevention or worsening of pressure injuries (PI). - R59 developed two Stage 3 pressure injuries while in the facility that then became unstageable. R59 had no care plan for pressure injuries and did not have heel suspension boots provided for Stage 3 heel pressure injuries. The facility did not provide an appropriate mattress to promote healing. - R69 has a history of Stage 3 pressure injuries (PIs) to his heels. The facility did not encourage repositioning or protective device placement to prevent decline. […]

• No harm, potential for more than minimal, widespreadF812May 13, 2026

  The facility did not prepare food in accordance with professional standards for food service safety which had potential to affect all 58 residents. -Foods items in kitchen not labeled with an expiration or use-by date.-Thermometers in 3 kitchen freezers were not functioning properly.-Cook K washed dishes, contaminating [NAME] K's clothes while prepping/serving food.-Cook M touched food with contaminated gloves while preparing ready to eat food.-Cook K prepared lunch meals without taking the temperature of all foods before serving.This is evidenced by: Example 1 Surveyor reviewed the facility policy titled Food Safety Requirements dated last revised 02/26 which states: .1. B. […]

• No harm, potential for more than minimal, widespreadF814May 13, 2026

  Based on observation, interview, and record review, the facility failed to ensure the garbage in dumpster was covered. This had the potential to affect all 58 residents residing in the facility.Findings include: Surveyor reviewed facility policy titled Disposal of Garbage and Refuse dated last revised 06/13/25 which states: .7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded so insect/rodent attractions are minimized. During the kitchen tour and observation of garbage dumpsters with [NAME] K on 05/11/26 at approximately 9:28 AM, two dumpsters for garbage were located at the backside of the building with their lids opened. […]

• No harm, potential for more than minimal, widespreadF908May 13, 2026

  Based on observation, interview, and record review, the facility did not maintain mechanical and/or electrical equipment in safe operating condition, having the potential to affect all 58 residents in the facility. Surveyor observed top of a freezer in the kitchen broken with orange duct tape and being held shut with syrup bottles to keep the lid closed. Findings include: On 05/11/2026 at 9:38 AM, Surveyor toured kitchen with [NAME] K. Surveyor observed 3 freezers sitting in an extra room down the hall from the kitchen. [NAME] K walked Surveyor into room and explained the 3 freezers are for kitchen use in storing frozen food for all residents in the facility. […]