Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Dexter Health Care during CMS and state inspections, most recent first.
A resident with a wound vac had an MD order for dressing changes every 48 hours, but the facility did not complete the scheduled changes on time. The hospital SW reported the facility lacked wound vac supplies and that dressing changes had not been done, and the TAR showed the first documented change was not until several days later, with the expected changes not coded as completed.
A resident who returned from surgery with a drain in place had the drain removed by nursing staff one day after arrival, despite orders for it to remain until a follow-up visit. Documentation did not include a written or verbal order from the medical provider authorizing the removal, and this omission was confirmed by the DON.
A CNA failed to wear a gown while providing care to a resident on Enhanced Barrier Precautions (EBP) due to open wounds and an ileostomy, despite facility policy and posted signage requiring gown and glove use for high-contact care activities.
Physician-Ordered Pain Patch Not Available: A resident’s ordered lidocaine 5% patches were not available for administration, and the CNA-M documented that the nurse was aware. The resident stated he/she had not received the pain patches for more than a week, and MAR review showed multiple missed doses totaling 11 days. The DON confirmed the facility had lidocaine 4% patches while the resident’s order remained for 5% patches.
A resident receiving tube feedings required Enhanced Barrier Precautions, and the facility’s policy identified feeding tubes as an example of when these precautions apply. A surveyor observed an EBP sign outside the resident’s room, and the DON confirmed the care plan had not been updated to reflect EBP.
A resident was involved in a significant medication error when a CNA-M prepared Metoprolol Succ ER at double the ordered dose during a med pass observation. The EHR showed an order for 50 mg tablets, 2 tabs daily, but the medication card on the cart was labeled 100 mg tablets, and the CNA-M placed 2 tablets into a medication cup before the surveyor stopped the pass.
A facility failed to ensure a contract was in place between the facility and a hospice agency for a resident receiving hospice services. The resident had signed a hospice agreement while at the hospital and continued receiving hospice care at the facility, but the Administrator stated the facility did not have a copy of the contract and the hospice agency had not provided one.
An LPN failed to follow EBP for a resident receiving tube feedings by performing feeding tube care with gloves only and no gown, despite an EBP sign posted outside the room and PPE available. The DON confirmed that gowns and gloves were required for feeding tube care.
A resident with paraplegia and chronic pain reported that an LPN refused scheduled pain medication and publicly mocked the resident by saying the resident did not need pain medicine because the resident could not feel pain. Witness statements corroborated the account, and the DON confirmed the resident's dignity was not protected during the incident.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight by the facility.
A resident exhibiting exit-seeking and agitated behavior was placed in their room by an RN, who then held the door shut, preventing the resident from leaving. Multiple staff witnessed the incident, which involved the resident kicking and yelling to get out. This action violated facility policy prohibiting seclusion.
A deficiency was identified when an RN physically restrained a resident by holding their arms and hands down to prevent movement during an altercation, contrary to facility policy. Staff statements confirmed the RN used body contact to limit the resident's actions after the resident attempted to leave, became agitated, and tried to strike staff.
After staff reported concerns about an RN's escalating and potentially abusive behavior toward a resident, including physical and verbal actions, the DON did not immediately remove the RN from resident care or promptly initiate a thorough investigation. The RN continued to provide care to the resident throughout the weekend, and written statements detailing the incident were not collected until two days later.
Staff failed to promptly notify the State Agency about an alleged abuse incident involving a resident and an RN, where the RN escalated the resident's behavior, resulting in physical altercations and concerning staff conduct. The DON received multiple reports and concerns from CNAs about the RN's actions, but the facility delayed both the investigation and required notification.
A resident with dementia who was at risk for elopement became agitated and attempted to leave the facility. Staff failed to follow the care plan interventions, including using a calm approach and providing diversions, and the section for the resident's preferences was left blank. Instead, an RN escalated the situation by yelling and mimicking the resident, resulting in increased agitation and disruption.
A resident's clinical record was incomplete and inaccurate following a hospital transfer for behavioral evaluation. The record lacked documentation of resident representative notification, charge nurse notes on behaviors as required by the TAR, and information on the resident's return from the hospital. Staff interviews confirmed that required documentation was not entered into the clinical record.
A resident was hospitalized after receiving another resident's medications due to a failure to confirm identity during medication administration. The error involved an Adult Education CNA-M instructor and student who, without proper login credentials, administered medications including Gabapentin, Hydroxyzine, and Metoprolol, leading to adverse effects such as nausea and syncope. The facility's policy to confirm resident identity was not followed.
The facility failed to follow physician orders for medications and treatments for several residents, resulting in missed doses and improper care. One resident did not receive an antibiotic for five days due to authorization delays, while another missed doses of Macrobid due to record errors. A resident with a rash did not receive daily treatment as ordered, and another received incorrect Protonix dosing due to a system error. Additionally, a resident's unwitnessed fall was not properly assessed, and no care orders were found for a resident with an ileostomy.
The facility failed to adhere to infection prevention protocols during pressure ulcer dressing changes for two residents. An LPN and CNAs did not wear protective gowns as required by Enhanced Barrier Precautions (EBPs) for a resident with a Stage IV pressure ulcer and an indwelling urinary catheter. Another LPN also neglected to wear a gown during a dressing change for a resident with a pressure ulcer, and there was no EBP sign outside the resident's room.
A resident's preference for regular showers was not honored, as documented evidence showed missed showers in August and September, and no showers recorded in October after a system transition. Despite being scheduled for weekly showers, the resident only received one per week, with staff claiming the resident did not need additional showers. The DON confirmed missing and incomplete documentation, indicating a failure to support the resident's choice.
A facility failed to implement a care plan intervention for a resident requiring weekly weighing as part of their nutrition care plan. The care plan, established in July 2023, was not followed as weights were not documented for specific weeks in October 2024. This deficiency was confirmed by a surveyor and the RAI Coordinator during a review.
A facility failed to follow a physician's order for a pressure ulcer dressing change. An LPN mistakenly applied a dressing to the wrong toe of a resident's right foot, despite the order specifying the third toe. The error was identified by a surveyor, and the LPN corrected it by applying the dressing to the correct toe.
A facility failed to ensure timely physician review and signature of a resident's medication and treatment orders. The resident's block orders, last signed on July 11, required review by September 19. Despite a physician visit on September 9, the orders remained unsigned, resulting in a 41-day delay confirmed by a surveyor and the DON.
The facility did not maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. On two weekend shifts, there was no evidence of an RN present for the required hours, as confirmed by a review of staffing schedules and interviews.
A facility failed to obtain a physician-ordered renewal for a PRN Lorazepam prescription when transitioning to a new electronic charting system. The medication was entered without a stop date, making it available for administration beyond the intended period. This oversight was confirmed during a review, as the medication remained available without a renewal order.
The facility failed to label thawed health shake supplements with a thaw date and did not remove expired coleslaw from the refrigerator. Additionally, the kitchen's exhaust fan and window casings were heavily dust-covered and remained uncleaned over several days.
The facility failed to maintain accurate clinical records for three residents due to errors during the transfer of physician orders to a new electronic charting system. These errors included incorrect medication dosages, missing discontinuation orders, and significant discrepancies in weight records, complicating accurate resident assessments.
The facility failed to maintain a sanitary and well-maintained environment, as observed during environmental tours. Issues included faded and chipped furniture, dirty and damaged wheelchairs, a flickering bathroom light, and chipped surfaces, all contributing to unsanitary conditions.
Failure to Complete Ordered Wound Vac Dressing Changes
Penalty
Summary
The facility failed to follow a physician’s order for wound vac dressing changes every 48 hours for one resident. The resident had been admitted with a wound vac, and the hospital discharge summary documented the order for dressing changes every 48 hours. A hospital Social Worker stated the facility called on 5/4/26 requesting wound vac supplies because none were available and that the wound vac dressing changes had not been completed as of that date. The Social Worker also stated the last wound vac dressing change had been completed on 4/29/26. Review of the resident’s TAR showed the first dressing change at the facility was not documented until 5/5/26, and the scheduled changes that would have been due on 5/1/26 and 5/3/26 were not coded as completed. The Administrator confirmed that the ordered wound vac dressing changes did not occur on those scheduled dates.
Incomplete Clinical Record for Surgical Drain Removal
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident who returned from surgery with a surgical drain in place. Upon review, it was found that there was a physician's order for daily dressing changes and for the drain output to be recorded every 12 hours, with instructions for the drain to remain in place until the resident's follow-up clinic visit in approximately one week. However, documentation showed that the drain was removed at the facility just one day after the resident's return, following a phone call to the surgical center nurse, but without any written or verbal order from the medical provider or surgical team authorizing the removal. The clinical record lacked evidence of such an order, and this was confirmed during interviews with the charge nurses and the Director of Nursing.
Failure to Follow Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
A deficiency occurred when staff failed to implement required infection control practices for a resident with open wounds and an ileostomy who was on Enhanced Barrier Precautions (EBP). Facility policy required staff to wear gowns and gloves when providing high-contact care to residents on EBP, including those with chronic wounds or indwelling catheters. During an observation, a Certified Nursing Assistant (CNA) entered the resident's room to empty a catheter bag without donning a gown, despite a sign posted outside the room indicating EBP precautions were in place. The CNA acknowledged forgetting the need to wear a gown for this resident, and the surveyor confirmed the lapse at the time of the observation.
Physician-Ordered Pain Patch Not Available
Penalty
Summary
The facility failed to ensure a physician-ordered Lidocan External Patch 5% was available for use for Resident #12, who had an order to apply two lidocaine patches to the lower back in the morning for pain and remove them after 12 hours. During a medication administration observation, the CNA-M reviewed the order and stated the medication was not available and that the nurse was aware. The CNA-M then documented in the electronic health record that the medication was not available and the nurse was aware, and later told the resident there were no pain patches yet. The resident told the surveyor that he/she had not had pain patches in more than a week and did not know why, and stated that he/she uses two patches, one on the right lower hip and one on the back near the left kidney for pain. Review of the MAR showed the lidocaine patch was not administered on multiple days, including several consecutive days and a total of 11 days. The DON reviewed the MAR and confirmed the facility had Lidocaine 4% patches, while the resident’s order remained for Lidocaine 5% patches.
Care Plan Not Updated for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to revise the care plan for Resident #6, who was receiving tube feedings and required Enhanced Barrier Precautions. The facility’s policy, revised in 3/2025, stated that Enhanced Barrier Precautions are to be used when providing device care or use such as a feeding tube. On 9/8/25, review of the resident’s clinical record showed that the resident received tube feedings. On 9/9/25 at 2:01 p.m., a surveyor observed an Enhanced Barrier Precaution sign on the wall outside the resident’s door, and on 9/9/25 at 2:19 p.m., the DON confirmed that the resident’s care plan had not been updated for Enhanced Barrier Precautions.
Significant Medication Error with Metoprolol Dose
Penalty
Summary
A resident was involved in a significant medication error during medication administration observation when the facility failed to ensure the resident received the physician-ordered dose of Metoprolol Succinate ER. The electronic health record showed an order for Metoprolol Succinate ER 50 mg, 2 tablets by mouth one time a day, but the CNA-M retrieved a medication card labeled Metoprolol Succ ER 100 mg, 1 tablet by mouth daily from the medication cart and popped 2 tablets into a medication cup. The surveyor stopped the medication pass before administration and confirmed that the CNA-M was preparing to give 2 tablets of 100 mg each, totaling 200 mg, instead of the ordered 2 tablets of 50 mg each, totaling 100 mg.
Missing Hospice Contract
Penalty
Summary
The facility failed to ensure a contract was signed between the facility and St. [NAME] Hospice for one resident receiving hospice services. The resident was admitted to the facility in April 2025 and was transferred to St. [NAME] Hospital, where the resident signed a contract with St. [NAME] Hospice on 4/29/25 to provide hospice services while at the facility. As of 9/9/25, the resident was still receiving hospice services at the facility from St. [NAME] Hospice. During interviews, the Administrator stated that she did not have a copy of the contract between the facility and St. [NAME] Hospice and had contacted the hospice agency for a copy. On 9/10/25, the Administrator stated that she had contacted the hospice agency, but no contract had been provided, and the surveyor confirmed this finding.
Failure to Follow EBP During Feeding Tube Care
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed for one resident who was on EBP and receiving tube feedings. The facility policy, revised 3/2025, stated that EBP are to be used during device care or use such as a feeding tube and include wearing a gown and gloves. The resident's clinical record showed tube feedings, and a surveyor observed an EBP sign outside the resident's room with disposable gowns and gloves available inside the room. During observed feeding tube care, an LPN washed her hands and put on gloves but did not put on a gown before checking the feeding tube placement, flushing the tube, and attaching the feeding setup. When asked, the LPN stated she was supposed to wear a gown, and the DON later stated that gowns and gloves were to be worn when doing care to the resident's feeding tube.
Failure to Protect Resident Dignity During Pain Medication Incident
Penalty
Summary
The facility failed to protect a resident's right to a dignified existence for 1 of 1 resident reviewed for abuse. The resident had active diagnoses including paraplegia and chronic pain. During an interview, the resident stated that an LPN refused to administer scheduled pain medication when requested and shouted in a public setting that the resident did not need pain medicine because the resident is paraplegic and cannot feel pain anyway, and the resident stated that everyone could hear. Written witness statements reviewed by the surveyor corroborated the resident's account. The DON later stated that the resident and the LPN did not get along, that the LPN was usually assigned to another unit, and that the LPN was terminated following the incident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Resident Subjected to Involuntary Seclusion by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) involuntarily secluded a resident by placing the resident in their room and holding the door shut, preventing the resident from leaving. The incident was witnessed by multiple staff members, who provided written and verbal statements confirming that the RN held the door closed while the resident, who was exhibiting exit-seeking behavior and escalating agitation, attempted to get out by kicking and yelling. The facility's policy, revised in March 2025, explicitly prohibits seclusion, defined as placing a resident alone in a room, and this action was in direct violation of that policy. The resident involved was described as being angry, yelling, and attempting to leave the facility, with staff unsuccessfully attempting to redirect the behavior prior to the seclusion. Staff accounts consistently indicated that the RN moved the resident to their room and physically held the door closed for a period of time, during which the resident was observed kicking the door from inside. The duration of the seclusion was not precisely determined, but staff confirmed the resident was confined against their will. The incident was reported to the Division of Licensing and Certification, and the RN was placed on leave pending investigation.
Use of Physical Restraint by RN on Resident
Penalty
Summary
A deficiency occurred when a Registered Nurse (RN) used physical restraint on a resident by holding the resident's arms and hands down to limit voluntary movement. The incident took place after the resident attempted to leave the facility, banged on a door, and threw a cup of coffee at the RN. Multiple staff statements and interviews confirmed that the RN held the resident's arms down from behind the wheelchair, and at one point, placed her arms around the resident's upper chest while wheeling the resident away from the door. The RN and the resident were engaged in a verbal altercation, and the RN was observed to be frustrated during the incident. The facility's policy, revised in March 2025, defines physical restraints as any manual method or device that restricts freedom of movement and cannot be easily removed by the individual. The RN's actions were documented in a Performance Correction Notice and corroborated by written statements and interviews from Certified Nursing Assistants (CNAs) who witnessed the event. The resident was actively resisting and attempting to hit staff, leading the RN to physically restrain the resident, which was not in accordance with the facility's restraint policy.
Failure to Protect Resident After Staff Reported Alleged Abuse by RN
Penalty
Summary
Staff reported concerns regarding the behavior of a Registered Nurse (RN) towards a resident who was agitated. On the day of the incident, multiple staff members notified the Director of Nursing (DON) via text messages that the RN was engaging in escalating behavior with the resident, including flapping her arms at the resident and verbally provoking the resident to hit her. Written statements later indicated that the RN physically put her hands on the resident, placed the resident in their room, closed the door, and held it shut. Despite these reports, the DON's initial response was to instruct the RN to complete an incident report and follow up with Work Health, without immediately removing the RN from resident care or initiating a thorough investigation at that time. The RN continued to provide care to the resident throughout the weekend following the incident, as confirmed by timecard records and staff interviews. The DON did not begin collecting written statements from involved staff until two days after the incident, delaying the facility's investigation. The resident was sent to the hospital following the incident, and upon return, care was reassigned, but the RN insisted on continuing to care for the resident. The facility failed to protect the resident after being notified of staff concerns about the RN's behavior, allowing the RN to remain in direct care of the resident despite allegations of abuse.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to notify the State Agency (Division of Licensing and Certification) in a timely manner regarding an allegation of abuse involving a resident and a registered nurse. On the date of the incident, staff reported to the Director of Nursing (DON) that a resident was agitated and that a registered nurse escalated the situation, resulting in the resident biting the nurse. Additional information was reported to the DON, including that the nurse placed the resident in their room, closed the door, and held it shut for several seconds up to one minute during the resident's escalating behaviors. Text messages from certified nursing assistants to the DON expressed concerns about the nurse's behavior, including the nurse flapping her arms at the resident and encouraging the resident to hit her. Despite these reports and concerns, the facility did not initiate an investigation or notify the State Agency until two days after the incident occurred.
Failure to Implement Comprehensive Care Plan for Agitated Resident with Dementia
Penalty
Summary
The facility failed to fully develop and implement a comprehensive care plan for a resident with dementia who was identified as an elopement risk and exhibited agitated behaviors. The care plan included interventions such as offering pleasant diversions and approaching the resident in a calm manner, but the section for the resident's preferences was left blank. On the day of the incident, staff observed a Registered Nurse (RN) yelling at the resident and mimicking their behavior, rather than using the calm approach specified in the care plan. Multiple staff statements indicated that the RN's actions escalated the resident's agitation, leading to a disruptive situation where both the RN and the resident were yelling at each other. Interviews with staff revealed that the resident, who has dementia, was triggered and became increasingly agitated when their desire to go outside was not accommodated. Staff noted that the situation could have been defused by taking the resident outside, but this was not done due to a busy period. The care plan's interventions to distract and calm the resident were not effectively implemented, and the lack of documented resident preferences further limited the staff's ability to address the resident's needs appropriately during the incident.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who experienced an incident resulting in hospital transfer for evaluation of increased behaviors. The clinical record did not contain documentation of notification or attempted notification of the resident's representative regarding the hospital transfer. Additionally, there was no documentation from the charge nurse in the nurses/progress notes about the resident's behaviors, as was required by the Treatment Administration Record (TAR). Although the TAR indicated that behaviors were monitored, there was no corresponding narrative documentation in the clinical record. Further review revealed that the clinical record lacked information indicating when the resident returned to the facility after the hospital transfer. Interviews with staff confirmed that the LPN had called and left a message for the resident's representative but did not document this action in the clinical record. The RN acknowledged documenting on the TAR but failed to update the clinical record with details of the behaviors or the resident's return from the hospital. These omissions resulted in incomplete and inaccurate clinical records for the resident involved in the incident.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to protect a resident from receiving another resident's medications, leading to the resident being transported to an acute care emergency department and later admitted to the hospital. The incident occurred when a Certified Nursing Assistant-Medication Aide (CNA-M) allowed an Adult Education CNA-M instructor and a student to pass medications without confirming the resident's identity. As a result, the resident received a combination of medications intended for another resident, including Gabapentin, Hydroxyzine, Metoprolol, and others, which led to adverse effects such as nausea and syncope episodes. The error was identified when the resident, who had received the wrong medications, reported feeling unwell and exhibited symptoms such as nausea and a syncope episode. The nursing staff documented the incident, noting that the resident's blood pressure and pulse were affected by the medications, particularly the combination of Gabapentin and Hydroxyzine, which can be sedating, and Metoprolol, which can significantly lower blood pressure and pulse. The resident was subsequently sent to the emergency room for further evaluation and treatment. Interviews with the facility staff revealed that the Adult Education CNA-M instructor and the student did not have their own login for the computer system and relied on the CNA-M to log in for them. They failed to confirm the resident's identity before administering the medications, leading to the error. The facility's policy on administering oral medications clearly states the need to confirm the identity of the resident, which was not followed in this instance. The resident remained hospitalized for treatment following the incident.
Failure to Follow Physician Orders and Administer Medications
Penalty
Summary
The facility failed to ensure that physician orders for medications and treatments were followed for several residents. One resident was sent to the Emergency Department due to respiratory concerns and returned with an order for Levaquin to treat pneumonia. However, the resident did not receive the antibiotic until five days after the physician ordered it due to a delay in obtaining prior authorization and a lack of follow-up with the physician. Another resident had a written order to change the duration of Macrobid treatment from 14 days to 5 days, but missed three doses due to a failure to update the Medication Administration Record (MAR) and administer the medication as ordered. A resident with a rash on their stomach had orders for daily cleaning and application of cream, but the treatment was not performed daily as required. The Treatment Administration Record (TAR) incorrectly listed the treatment as 'as needed,' resulting in missed treatments. Additionally, another resident had an order for Protonix to be administered twice a day, but due to an error during the transfer of orders to a new electronic system, the medication was only given once a day for several weeks without a physician's order to change the frequency. Further deficiencies included a resident who experienced an unwitnessed fall and did not receive the required neurological assessments, as well as a resident with an ileostomy for which no active care orders were found. These lapses in following physician orders and ensuring proper documentation and administration of medications and treatments highlight significant deficiencies in the facility's care processes.
Infection Control Lapses in Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during pressure ulcer dressing changes for two residents. Resident #17, diagnosed with multiple sclerosis and a chronic Stage IV pressure ulcer, was observed during a dressing change where the attending LPN and CNAs did not adhere to Enhanced Barrier Precautions (EBPs) by failing to wear protective gowns. Despite being aware of the EBP sign on the resident's room entrance, the staff did not comply with the necessary precautions, which are crucial for residents with wounds or indwelling medical devices. Similarly, for Resident #11, who had a physician's order for a daily pressure ulcer dressing change, the attending LPN did not follow the facility's EBP and wound care policies by only wearing gloves and not a gown during the procedure. The absence of an EBP sign outside Resident #11's room further indicates a lapse in the facility's adherence to infection control protocols. These observations highlight the facility's failure to implement and follow established infection prevention measures, particularly for residents at increased risk of MDRO acquisition.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice regarding bathing preferences, specifically for a resident identified as R3. During an interview, a resident representative expressed concerns that R3 was not receiving scheduled showers, with staff indicating that R3 did not need a shower because they had already been washed. R3 reportedly enjoys showers but was only receiving one per week. A review of R3's electronic clinical record showed that R3 was scheduled to receive a shower on Saturdays during the day shift. However, documentation revealed that R3 missed five showers in August and September, and there was no evidence of any showers being provided in October after the facility transitioned to a new electronic charting system. The Director of Nursing confirmed the missing and incomplete documentation regarding R3's showers, indicating that the resident's preferences were not being honored.
Failure to Implement Weekly Weighing for Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident reviewed for nutrition. The care plan for the resident included an intervention added on July 13, 2023, under the care area of Nutrition, which required the resident to be weighed every week. However, during a review on October 30, 2024, it was found that the resident's weights were not documented weekly in the electronic system for the periods from September 29, 2024, to October 5, 2024, and from October 13, 2024, to October 19, 2024. This lack of documentation was confirmed during a review by a surveyor and the Resident Assessment Instrument (RAI) Coordinator.
Failure to Follow Physician's Order for Pressure Ulcer Care
Penalty
Summary
The facility failed to follow a physician's order for a pressure ulcer dressing change for a resident. On October 29, 2024, a surveyor observed an LPN perform a dressing change on the resident's right foot. The physician's order specified that the dressing should be changed daily on the resident's Stage II pressure ulcer located on the right third toe. However, the LPN mistakenly applied the dressing to the second toe instead of the third. Upon being informed by the surveyor, the LPN confirmed the error and corrected it by applying the dressing to the correct toe.
Physician's Delay in Signing Orders
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including signing orders for medications and treatments, in a timely manner. The resident's clinical record showed block orders signed by the physician on July 11, 2024. These orders required review and the physician's signature by September 19, 2024, including a 10-day grace period. Although the physician visited on September 9, 2024, they did not sign the block orders. As of October 30, 2024, the orders were 41 days overdue, as confirmed by a surveyor during an interview with the Director of Nursing.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of daily staffing schedules and interviews conducted by a surveyor on 10/31/24. Specifically, on two weekend shifts, 10/13/24 and 10/20/24, there was no evidence of an RN being present in the building for the required 8 consecutive hours.
Failure to Renew PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure a physician-ordered renewal for a PRN psychotropic medication before transitioning to a new electronic charting system (PCC). This oversight involved a resident who had a previous order for Lorazepam, an anti-anxiety medication, to be administered as needed at bedtime until a specified date. However, when the facility switched to the new system, the medication order was entered without a renewal from a physician and lacked a stop date, making it available for administration beyond the intended 14-day period. During the review, it was confirmed that there was no renewal order for the PRN Lorazepam, yet the medication remained available for use.
Deficiencies in Food Labeling and Kitchen Cleanliness
Penalty
Summary
The facility failed to properly label thawed health shake supplements with a thaw date, as observed by a surveyor in the walk-in refrigerator. The storage and handling instructions on the carton specified that the supplements should be used within 14 days after thawing, but the absence of a thaw date made it impossible to determine their usability. This issue was confirmed with the Dietary Manager, who acknowledged the lack of labeling. Additionally, the facility did not remove expired food items from the walk-in refrigerator. A surveyor found individual serving cups of coleslaw that were past their use-by date, yet still available for use. This was confirmed with the Dietary Manager, who acknowledged the presence of expired coleslaw. Furthermore, the kitchen's cleanliness was compromised by a heavily dust-covered exhaust fan and window casings in the dishwashing room, which remained uncleaned over multiple days of observation.
Inaccurate Clinical Records and Data Entry Errors
Penalty
Summary
The facility failed to ensure that clinical records contained complete and accurate information for three residents during a review. For one resident, an order for Protonix was incorrectly entered into the new electronic charting system (PCC) as once a day instead of twice a day during the transfer of physician orders. Another resident's record lacked evidence of a discontinued order for Trazodone, which was omitted during the same transfer process. Additionally, this resident's weight records showed inconsistencies, with significant discrepancies noted in the recorded weights over several months, making it difficult for the dietician to assess the resident's nutritional status accurately. For a third resident, multiple data entry errors were identified in the transfer of orders from the old electronic charting system (ECS) to PCC. These errors included missing dosage information for Calcium Carbonate, incorrect dosage for artificial tears, an active order for Lorazepam that should have been stopped, and a duplicate entry for Miconazole powder. The Director of Nursing confirmed these errors during the review, and there was no order found to renew the Lorazepam as needed.
Facility Fails to Maintain Sanitary and Well-Maintained Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building and resident equipment in good repair and in a sanitary condition. During environmental tours, it was observed that several pieces of furniture in residents' rooms were in disrepair, with issues such as faded veneer, chipped wood, and missing handles. Additionally, some residents' wheelchairs were found to be dirty, with missing foam pieces and cracked armrests, creating uncleanable surfaces. A bathroom ceiling light was flickering, and a bedside table surface was chipped, further contributing to the unsanitary conditions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dexter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hibbard Skilled Nursing & Rehabilitation Center | 10.9 mi | ★★★★★ | 4 | 0 |
| Sanfield Rehab & Living Center | 13 mi | ★★★★★ | 0 | 0 |
| Cedar Ridge Center | 26.7 mi | ★★★★★ | 12 | 0 |
| Westgate Center For Rehab & Alzheimers Care | 28 mi | ★★★★★ | 5 | 0 |
| Bangor Nursing & Rehabilitation Center | 28 mi | ★★★★★ | 24 | 0 |
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