Dugan Memorial Home

In the surveyor’s words

From the most serious findings on record at Dugan Memorial Home, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 16, 2025

  Based on staff interview, observation of video camera footage, record review, and facility policy review, the facility failed to ensure a resident's right to be free from sexual abuse by another resident for one (1) of four (4) residents sampled. (Resident #1) Specifically, the facility failed to prevent Resident #2, a cognitively intact resident with mental health diagnoses, from engaging in non-consensual sexual contact with Resident #1, a severely cognitively impaired resident, in a supervised common area of the facility. […]

• No harm, potential for more than minimal, widespreadF812Jul 13, 2023

  Based on observations, staff interview and facility policy review, the facility failed to store food items in a manner that maintains the safety of the food as evidenced by uncovered, unlabeled and undated food in the refrigerator and freezer for one (1) of two (2) kitchen tours. Findings include: Record review of the facility policy titled Storage of Food and Supplies with a revision date of [DATE] revealed, Description: all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Also revealed under, Method/How To/Procedure: . […]

• No harm, potential for more than minimal, isolatedF550Mar 18, 2026

  Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were provided with a dignified dining experience when one (1) of three (3) residents at the table did not receive their meal at the same time. Resident #11 Findings include: Record review of facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes dated March 2025, revealed, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. […]

• No harm, potential for more than minimal, isolatedF552Mar 18, 2026

  Based on record review, staff interview, and facility policy review, the facility failed to ensure informed consent was obtained prior to the initiation of a psychotropic medication for one (1) of five (5) residents reviewed for unnecessary medications. Resident #9 Findings include:Record review of facility policy titled, Use of Psychotropic Medications, with an implemented date of 10/2025, revealed, .9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medications .11. […]

• No harm, potential for more than minimal, isolatedF578Mar 18, 2026

  Based on resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure a cognitively intact resident was provided the opportunity to participate in and make informed decisions regarding her advance directive, including end-of-life preferences for one (1) of 24 advance directives reviewed. (Resident #1) Findings Include:Review of the facility policy titled Advance Directives Policy and Acknowledgment, updated 9/3/25, revealed, Resident has the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.Record review of the facility's Advance Directives/Medical Treatment Decisions form, dated 2/17/22, revealed Resident #1 was designated as Do Not… […]