Dover Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Dover Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 3, 2021

  Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigative report, it was determined the facility failed to have an effective system to maintain an environment free from physical and verbal abuse for ten (10) of twenty-two (22) sampled residents, Residents #1, #2, #3, #4, #6, #7, #8, #9, #10, and #11. On 05/03/2021, Personal Care Attendant (PCA) #6 reported she witnessed Licensed Practical Nurse (LPN) #8 commit physically and verbally abusive acts toward Residents #1, #2, and #3. According to PCA #6, LPN #8 committed the abuse over the past two (2) months, but she could not provide exact dates she witnessed the resident abuse. […]

• Immediate jeopardy, patternF835Jun 3, 2021

  Based on observation, interview, record review, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being for four (4) of twenty-two (22) sampled residents (Residents #1, #2, #3, and #4). On 05/03/2021, Patient Care Attendant (PCA) #6 came forward to report abusive treatment committed by night shift nurse, Licensed Practical Nurse (LPN) #8, toward Residents #1, #2, and #3. In addition, PCA #6 told the State Survey Agency (SSA) Surveyor that LPN #8 gave marijuana (a psychoactive drug used for medical or recreational purposes) to Resident #4 during the weekend of 04/23/2021 to 04/25/2021. […]

• Immediate jeopardy, isolatedF657Jul 29, 2021

  Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who had knowledge of the resident and his/her needs for two (2) of ten (10) sampled residents (Resident #1 and Resident #2). The facility's failed to closely supervise the residents' exit-seeking behaviors, Resident #1 exited the facility, on 07/10/2021 at approximately 4:40 PM, without staff knowledge. Resident #1 was found by police at an apartment building next door. The resident was short of breath and needed medical treatment. […]

• Immediate jeopardy, isolatedF689Jul 29, 2021

  Based on observation, interview, record review, review of the facility's policies, review of the facility's investigation, and review of a Local Weather document, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for two (2) of ten (10) sampled residents (Resident #1 and Resident #2). The facility admitted Resident #1, on 10/20/2020, with diagnoses that included Cognitive Communication Deficit, Chronic Obstructive Pulmonary Disease (COPD), Schizophrenia, and Need for Assistance with Personal Care. Resident #1 was independent with mobility. Interviews and record review revealed the resident exhibited exit-seeking behaviors. […]

• Immediate jeopardy, isolatedF607Jun 3, 2021

  Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigative report, it was determined the facility failed to have an effective system to protect residents from abuse, by not implementing its abuse prevention policies to promptly investigate and report staff-to-resident physical and verbal abuse of four (4) of twenty-two (22) sampled residents (Residents #1, #2, #3, and #4). On 05/03/2021, Personal Care Attendant (PCA) #6 reported she witnessed Licensed Practical Nurse (LPN) #8 abuse Residents #1, #2, #3, and #4, verbally and physically. PCA #6 stated LPN #8's abuse of the residents occurred over the past two (2) months, but she could not provide exact dates when she observed LPN #8 commit the abusive acts. […]