A list of the most recent deficiencies for Dove Healthcare - St Croix. 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? |
|---|---|---|---|---|
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-11-06 | 2023-12-06 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-11-06 | 2023-12-06 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-12 | 2023-08-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-12 | 2023-08-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-12 | 2023-08-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-12 | 2023-08-21 | 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 | 2023-07-12 | 2023-08-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-12 | 2023-08-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-12 | 2023-08-21 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-07-12 | 2023-08-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-12 | 2023-08-21 | 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 | 2023-07-12 | 2023-08-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-12 | 2023-08-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-12 | 2023-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-12 | 2023-08-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-10 | 2023-08-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-10 | 2023-08-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-05 | 2023-06-23 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-05 | 2023-06-23 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-05 | 2023-06-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-05 | 2023-06-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-05 | 2023-06-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-21 | 2023-03-21 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-10-17 | 2022-11-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-17 | 2022-10-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-07 | 2022-08-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-07 | 2022-08-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-07 | 2022-08-04 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-07 | 2022-08-04 | 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 | 2022-07-07 | 2022-08-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-07 | 2022-08-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-07 | 2022-08-04 | 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 | 2022-07-07 | 2022-08-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-07 | 2022-08-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-07 | 2022-08-04 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-07 | 2022-08-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-07 | 2022-08-04 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-07-07 | 2022-08-04 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2022-07-06 | 2022-08-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-06 | 2022-08-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-06 | 2022-08-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-06 | 2022-08-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-06 | 2022-08-04 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-07-06 | 2022-08-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-06 | 2022-08-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-26 | 2022-05-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-26 | 2022-05-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-22 | 2022-03-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-19 | 2021-11-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-12 | 2021-06-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-12 | 2021-06-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-05-12 | 2021-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-12 | 2021-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-12 | 2021-06-25 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-05-12 | 2021-06-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-11 | 2021-06-25 | 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 | 2021-05-11 | 2021-06-25 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-05-11 | 2021-06-25 | N |
