Deficiency Records for Dover Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Dover Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-09-09 | 2022-10-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-09 | 2022-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-09 | 2022-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-10-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-29 | 2021-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-29 | 2021-08-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-03 | 2021-08-23 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-06-03 | 2021-08-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-03 | 2021-08-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-03 | 2021-08-23 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2021-06-03 | 2021-08-23 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-06-03 | 2021-08-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-08 | 2020-11-17 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-10-08 | 2020-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-08 | 2020-11-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-10-08 | 2020-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-08 | 2020-11-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-10-08 | 2020-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-08 | 2020-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-08 | 2020-11-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-10-08 | 2020-11-17 | N |
| Post nurse staffing information every day. | Health | 2020-10-08 | 2020-11-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-10-08 | 2020-11-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-10-08 | 2020-11-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-10-08 | 2020-11-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-10-08 | 2020-11-17 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2020-10-08 | 2020-11-17 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-10-08 | 2020-11-17 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-10-08 | 2020-11-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-10-08 | 2020-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-08 | 2020-11-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-09-29 | 2020-11-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-09-29 | 2020-11-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-09-29 | 2020-11-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-29 | 2020-11-16 | N |
