Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dover Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, anxiety, and urinary retention had an indwelling catheter documented in physician orders, TARs, and the care plan, and was observed with a catheter bag in a dignity bag. However, the admission MDS and quarterly MDS did not document the catheter, and the RN MDS acknowledged the assessments were inaccurate while the DON and Administrator stated the MDS should have captured all resident information.
Failure to Provide Individualized Activities: A resident with Parkinson’s disease, polyneuropathy, and speech/language deficits, who was cognitively intact, stated he liked books and wanted to go to the library, but staff did not provide the reading-related activities reflected in his preferences. The care plan listed general activities and assistance to attend them, but did not include reading, and staff interviews showed multiple team members were unaware of the resident’s interest in books or whether he was taken to the library or offered the book cart.
A resident with acute respiratory failure with hypercapnia and COPD had a physician order for oxygen at 2 LPM via NC, but staff observed the concentrator set at varying levels, including 3.5 LPM, 2.5 LPM, and 1.5 LPM. The resident was seen adjusting the oxygen concentrator without authorized staff present, and the care plan lacked documented interventions to monitor the flow level or educate the resident about self-adjusting oxygen. An LPN did not monitor the setting, and the DON and Administrator were unaware the resident was not receiving the ordered oxygen.
Missing annual performance evaluation for an SRNA. Review of the employee file showed no documentation that the aide received a performance review within 12 months of hire, and the facility also had no policy documentation addressing staff performance evaluations. The SRNA believed an evaluation may have occurred, but the DON/Administrator could not locate any record or training documentation.
The facility failed to store food safely in nourishment refrigerators on the A and B Units. Observations showed opened and unlabeled food items, including applesauce, pudding, grapes, and Chinese food, as well as lemon glycerin swab sticks stored improperly. The temperature monitoring log for the B Unit refrigerator lacked documentation for three days. Interviews with staff revealed that night shift nurses were responsible for recording temperatures, and the importance of labeling and dating food was emphasized.
A facility failed to secure and properly store medications, as observed with an unlocked medication cart and improperly stored latanoprost ophthalmic solution. The cart was left unattended, and the medication was not refrigerated or dated as required. Staff interviews revealed a lack of adherence to the facility's medication storage policy, potentially affecting medication efficacy.
MDS Assessments Omitted Indwelling Catheter
Penalty
Summary
The facility failed to ensure an assessment accurately reflected Resident 52’s status for the admission MDS and the quarterly MDS. Review of the admission assessment dated 08/18/2025 and the quarterly assessment dated 02/14/2026 showed no documentation of the resident’s indwelling catheter, even though the resident had diagnoses including dementia, anxiety, and urinary retention and was observed on 03/18/2026 sitting in a wheelchair with a catheter bag below, enclosed in a dignity bag. The resident’s physician orders dated 08/18/2025 included an indwelling catheter, and the TAR documented catheter care every shift from 08/18/2025 through 03/01/2026. The care plan dated 09/23/2025 addressed urinary catheterization and identified use of a 16 French Foley catheter with a 10 ml balloon related to obstructive uropathy. The RN MDS stated the admission and quarterly MDS should have documented the catheter if it was present on admission and acknowledged the assessments were inaccurate, and the DON and Administrator stated they expected the MDS assessments to capture all resident information, including the indwelling catheter.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to ensure an ongoing activities program that supported a resident’s choice of activities and met the resident’s interests and physical, mental, and psychosocial well-being. The resident, admitted with Parkinson’s disease, polyneuropathy, and speech and language deficits, had a BIMS score of 13 out of 15, indicating cognitive intactness. The care plan directed staff to provide an activity calendar and assistance getting to and from activities, but it did not include reading as an activity, despite the resident’s stated interest in books and reading. Review of the activity log showed that reading-related activities were not checked for multiple months. During observation, the resident was found lying in bed with the television remote within reach and stated the remote did not work. He said he used to have books about horses, liked to look at books, had told staff he wanted books, and had not received them. He also stated the activity sheet listed library day and that he would have gone if staff had taken him. Staff interviews showed the LPN did not know whether the resident had books, the SRNA did not know he liked to read or wanted to go to the library, the AA could not verify the book cart visited him, and the Activities Director stated he was not visited during the scheduled library time and was unaware he liked books. The DON stated she was unaware he did not get to go to the library activity, and the Administrator stated she was unaware of the issue.
Incorrect Oxygen Flow Monitoring and Resident Self-Adjustment
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care received oxygen therapy consistent with the physician order, the care plan, and professional standards of practice. The resident was admitted with diagnoses including acute respiratory failure with hypercapnia, chronic osteomyelitis of the right ankle and foot, and type 2 diabetes mellitus with other diabetic ophthalmic complications. The quarterly MDS showed a BIMS score of 14 out of 15, indicating the resident was cognitively intact. A physician order dated 01/09/2026 ordered oxygen at 2 LPM via nasal cannula, but observations on 03/17/2026 through 03/19/2026 showed the oxygen concentrator set at 3.5 LPM, 2.5 LPM, and 1.5 LPM at different times. The resident was observed adjusting the oxygen concentrator to 3.5 LPM without an authorized staff member present, and later observations showed no authorized staff member monitoring the oxygen flow level. The care plan addressed oxygen therapy related to ineffective gas exchange, respiratory illness, COPD, obstructive sleep apnea, and acute respiratory failure with hypercapnia, but it did not include documented interventions to monitor the oxygen flow levels or educate the resident about self-adjusting the flow. An LPN stated she had not made monitoring attempts to observe the concentrator setting, and the APRN stated the resident and roommate had been adjusting the concentrator without medical consent or staff authorization. The DON and Administrator stated they were unaware the resident was not receiving the correct oxygen LPM and that too much oxygen could cause harm to a resident with COPD.
Missing Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to ensure nurse aides received a performance review at least once every 12 months for 1 of 4 employee files reviewed, SRNA 6. Review of the facility's policies revealed no documentation of a policy addressing staff performance evaluations. Review of SRNA 6's employee file showed she was hired on 06/04/2024, but there was no documentation of a performance evaluation completed within 12 months of the hire date. SRNA 6 stated she thought she had a performance evaluation in August 2025, but no completed evaluation was available upon request. The Administrator stated she was unable to locate a performance evaluation or training records for SRNA 6 and could not produce documentation of a performance evaluation completed within 12 months of the employee's date of hire.
Failure to Store Food Safely in Nourishment Refrigerators
Penalty
Summary
The facility failed to store food safely in two nourishment refrigerators on the A Unit and the B Unit. Observations revealed that the B Unit refrigerator contained an opened container of applesauce and an opened pudding cup, along with grapes and a container of Chinese food that were not dated or labeled. Additionally, the freezer door contained two boxes of lemon glycerin swab sticks, a half cup of ice cream, and 36 popsicles that were also not dated or labeled. The facility's policy required that foods from outside sources needing refrigeration or freezing be labeled with the resident's name and date. Furthermore, the temperature monitoring log for the B Unit refrigerator showed no documentation of temperatures for three consecutive days. Interviews with the Dietary Manager, LPNs, the Director of Nursing, and the Administrator revealed that the night shift nurses were responsible for recording the refrigerator and freezer temperatures. The Dietary Manager stated that she removed food from the resident refrigerators weekly if they were not dated or labeled. The Director of Nursing explained that the lemon glycerin swabs were kept in the freezer for Hospice residents, as there was no freezer in medication storage. Both the Director of Nursing and the Administrator emphasized the importance of recording temperatures to prevent food spoilage and stated that opened and unlabeled food should be discarded.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents, as well as stored properly, specifically concerning the B Wing Upper medication cart. On multiple occasions, the medication cart was observed to be unlocked and unattended, allowing potential access to medications by unauthorized individuals. A registered nurse assigned to the cart was unaware that she had left it unlocked, which was against the facility's policy that required medication carts to be locked when not actively in use. Additionally, the facility did not adhere to proper storage requirements for latanoprost ophthalmic solution, a medication used to treat glaucoma. An unopened box of latanoprost, labeled for refrigeration, was found in the medication cart, and an opened box was undated. The facility's policy required medications to be stored according to the manufacturer's recommendations, which for latanoprost included refrigeration for unopened bottles and dating once opened. The failure to refrigerate and date the medication was acknowledged as an oversight by the nursing staff. Interviews with various staff members, including the RN, LPN, DON, and the Administrator, revealed a lack of adherence to the facility's medication storage policy. The staff admitted to overlooking the undated and unrefrigerated medication, which could potentially affect the medication's efficacy. The Administrator was not initially aware of the issue but planned to address it in a Quality Assurance Performance Improvement meeting.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Georgetown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Healthcare Of Georgetown | 2 mi | ★★★★★ | 0 | 0 |
| The Willows At Citation | 9.3 mi | ★★★★★ | 0 | 0 |
| The Home Place At Midway | 10 mi | ★★★★★ | 8 | 0 |
| Cambridge Nursing & Rehabilitation Center | 11 mi | ★★★★★ | 6 | 0 |
| Homestead Post Acute | 11.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.