Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Dover Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident was found self-administering Refresh tears and Fluticasone nasal spray without a clinical assessment or provider order, contrary to facility policy requiring evaluation and authorization for self-administration. Staff confirmed that the necessary assessment and orders were not completed.
A resident with a history of taking and concealing dangerous items, as well as threatening staff and other residents, did not have a care plan addressing these behaviors. Staff were aware of the resident's actions, and unsecured items like scissors were observed on the medication cart, but no interventions or goals were documented in the care plan to address the safety risks.
A medication cart was found with an unlabeled cup containing multiple pills, including a controlled substance, that had been pre-poured by a night shift LPN and left for a day shift RN to administer to a resident. The medications were not prepared and administered by the same nurse, and the controlled substance was not double locked, violating both professional standards and facility policy.
A resident with a history of wandering, taking items, and making threats was able to access and hide scissors on multiple occasions, including obtaining them from a medication cart left unattended by an RN. Staff confirmed that scissors were not always secured, resulting in an environment with accident hazards and insufficient supervision.
Pharmacist recommendations from monthly MRRs regarding medication necessity and monitoring for three residents were not reviewed or addressed by providers in a timely manner, as required by facility policy. Delays included recommendations for reviewing pain medication, ordering a lipid panel, and assessing the ongoing need for a GI medication, with some recommendations not addressed at all.
A resident was prescribed Seroquel for confusion and agitation despite no documented behavioral symptoms or significant psychiatric diagnosis. The medical record did not provide adequate justification for the ongoing use of the antipsychotic, contrary to facility policy requiring a specific indication for psychoactive medications.
A resident was given another resident's evening medications, including Lantus, Lyrica, and oxycodone, despite not having orders for all of these drugs and being prescribed a lower dose of insulin. The error occurred when staff failed to properly identify the resident before administering medications, as required by facility policy.
Surveyors found that medications, including inhalers and insulin, were not properly labeled with opening or expiration dates, and a medication cup containing a controlled substance was left unsecured in a medication cart. Nursing staff confirmed these lapses, which were not in accordance with facility policy or manufacturer instructions.
A resident reported waiting 30 minutes for their call light to be answered, self-ambulated to the bathroom, and fell. The nurse on duty was unhelpful and blamed the resident for the fall. The facility failed to report this allegation of neglect to the SSA as required by their policy.
A newly admitted resident did not receive their prescribed medications on the evening of their admission, despite the medications being available in the facility's automated dispensing machine. The facility's policy on handling unavailable medications was not followed, leading to this deficiency.
The facility failed to ensure a resident's environment was free from accident hazards by improperly applying seizure pads on the bed. Observations showed the pads were attached to the outside of the quarter rails, contrary to the physician's order and professional nursing standards. The resident had a diagnosis of epilepsy.
The facility failed to maintain infection prevention for a resident with a Foley catheter. Observations revealed the catheter drainage bag and tubing were on the floor, contrary to the care plan and CDC guidelines. Interviews confirmed these findings.
The facility failed to ensure complete and accurate resident records for three residents, with missing documentation of blood sugar values and insulin administration on multiple occasions. Staff confirmed these findings, which were not in compliance with the facility's Diabetes Management Protocol.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed to have a bottle of Refresh tears and Fluticasone nasal spray on their bedside table, which the resident reported self-administering 1-2 times daily since admission about a month prior. Despite these observations, there was no documentation in the resident's medical record of an assessment to determine if self-administration of these medications was clinically appropriate. Additionally, there were no physician orders for either medication. Further review of facility policy revealed that residents requesting to self-administer medications must undergo a self-administration evaluation by a licensed nurse to assess safety and understanding, and a healthcare provider's order is required. The policy also specifies that residents should be instructed on safe storage of medications, including the use of a locked box. Staff confirmed that these procedures were not followed for this resident.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Unsafe Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's behaviors that posed safety risks to themselves and others. Documentation showed that the resident repeatedly obtained and concealed potentially dangerous items such as scissors and a stapler, sometimes refusing to relinquish them when approached by staff. The resident also exhibited behaviors such as taking items from the medication cart, hiding them in their room, and threatening staff when attempts were made to retrieve these items. Additionally, the resident was observed attempting to access staff offices and locked cabinets, and had a documented history of being physically threatening to both residents and staff. Despite these incidents, a review of the resident's care plan revealed no documented focus, goals, or interventions addressing the resident's unsafe behaviors or the risk of physical threats. Staff interviews confirmed awareness of the resident's actions and history, yet no specific care plan strategies were in place to mitigate these risks. Observations further revealed that potentially dangerous items, such as scissors, were left unsecured on the medication cart, accessible to residents. The Director of Nursing confirmed the absence of appropriate care plan interventions for the resident's behaviors.
Failure to Follow Professional Standards for Medication Preparation and Administration
Penalty
Summary
A deficiency was identified when a medication cart was observed to contain an unlabeled medication cup with pills, including three unidentifiable pills, in the top drawer. The cup was tipped on its side, and the pills were not secured. Staff interviews confirmed that the medication cup was intended for a specific resident, and that the medications had been prepared by the night nurse but were administered by a different nurse on the day shift. The day shift nurse did not prepare the medications themselves, contrary to professional standards and facility policy, which require that nurses only administer medications they have prepared. Further review revealed that the medications included controlled substances such as Oxycodone, which was not double locked as required. The facility's policy explicitly prohibits pre-pouring medications and mandates that administration and documentation occur at the time of the medication pass. The night nurse admitted to preparing the medications in advance and leaving them in the cart for the day nurse to administer, resulting in a failure to follow both professional standards and facility policy for medication storage and administration.
Unsecured Scissors and Inadequate Supervision Lead to Accident Hazard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by not securing scissors when not in use, specifically for one resident with a history of wandering, taking items from others, and exhibiting physically threatening behavior. Observations showed that this resident was able to access and hide scissors in their room, and staff documented multiple incidents where the resident obtained scissors from various sources, including a medication cart and a family member. Staff also reported that the resident had threatened to stab a staff member, leading to changes in staff assignments. Additionally, during observation, scissors were found left unattended on a medication cart while a nurse was administering medication in another room. Staff confirmed that the scissors were not secured. The combination of unsecured sharp objects and a resident with a known history of wandering, taking items, and making threats contributed to the facility's failure to provide adequate supervision and prevent accident hazards.
Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that providers reviewed and addressed irregularities identified by the pharmacist during the monthly Medication Regimen Review (MRR) in a timely manner for three out of five residents reviewed for unnecessary medications. For one resident, the pharmacist recommended reviewing the continued necessity of Gabapentin for post-herpetic neuralgia, but the physician did not address this recommendation until nearly two months later. Another resident was receiving Lipitor, and the pharmacist suggested a lipid panel be considered with the next lab draw and at least annually, but this recommendation was also not addressed by the physician until almost two months after it was made. For a third resident, the pharmacist recommended considering tapering or discontinuing Protonix, or documenting the medical necessity and risk versus benefit of continued therapy. There was no documentation that the provider reviewed or addressed this recommendation, and the resident continued to receive Protonix for acid reflux. The facility's policy requires that pharmacist recommendations be communicated and acted upon in a timely fashion, with a response prior to the next MRR, but this was not followed in these cases. Interviews with the Director of Nursing confirmed that the recommendations were not reviewed or addressed as required.
Failure to Ensure Antipsychotic Medication Was Clinically Indicated
Penalty
Summary
A resident was prescribed Seroquel, an antipsychotic medication, at a dose of 25 mg daily for confusion and agitation. The resident's medical record indicated a diagnosis of mild vascular dementia with anxiety, but there was no significant past psychiatric history documented. Review of behavioral monitoring records showed that the resident did not exhibit any behavioral symptoms over a one-month period. Additionally, psychiatric evaluations noted the absence of significant psychiatric diagnoses and described the dementia as unspecified without behavioral disturbance and of low severity. Despite the ongoing prescription of Seroquel, there was no documented evidence of a specific condition or targeted behavior that warranted the use of this psychoactive medication, as required by the facility's policy. The family had refused a gradual dose reduction, but the clinical record lacked justification for the continued use of the antipsychotic. This failure to ensure an adequate indication for the antipsychotic medication resulted in the resident's drug regimen not being free from unnecessary drugs.
Resident Given Another Resident's Medications Due to Identification Failure
Penalty
Summary
A significant medication error occurred when a resident was administered another resident's evening medications, including 30 units of Lantus, 75 mg of Lyrica, and 5 mg of oxycodone, despite not having physician orders for Lyrica or oxycodone and only being prescribed 10 units of Lantus for diabetes. The error was documented in the nursing notes and confirmed by the Director of Nursing. The resident's medical record indicated that the medications were given along with the resident's usual nightly 4 ounces of scotch. Review of the facility's Medication Pass Policy revealed that staff are required to identify each resident prior to medication administration, but this protocol was not followed, resulting in the medication error.
Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not labeled and stored according to professional standards on two of three medication carts. Specifically, several residents' inhalers were found opened without a date of opening, and one inhaler was labeled with an expiration date that had already passed. Additionally, an insulin pen was labeled with an expiration date, but it was unclear if it was within the manufacturer's recommended usage period after opening. These findings were confirmed through interviews with nursing staff, who acknowledged the lack of proper labeling and dating on the medications. Further observations revealed that a medication cup containing pills, including a controlled substance (Oxycodone), was left unlabeled in the top drawer of a medication cart and was not double-locked as required for controlled substances. Interviews with both the day and night shift nurses confirmed that the night nurse had pre-poured the morning medications and left them unsecured for administration by the day nurse. Review of the facility's policies and manufacturers' instructions confirmed that these practices were not in compliance with established procedures for medication labeling, dating, and secure storage.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency (SSA) for one resident. The resident filed a grievance stating that they waited 30 minutes for their call light to be answered, ultimately self-ambulated to the bathroom, and fell. The resident also reported that the nurse on duty during the overnight shift was not helpful and blamed the resident for the fall. An interview with the facility's administrator confirmed that this allegation was not reported to the SSA. The facility's policy requires immediate notification to the Department of Public Health and Local Law Enforcement within two hours of an allegation involving abuse, which was not followed in this case.
Failure to Administer Prescribed Medications to Newly Admitted Resident
Penalty
Summary
The facility failed to follow physician orders for a newly admitted resident, identified as Resident #346. Upon admission in April 2024, the resident did not receive their prescribed medications that evening. The medications included Atorvastatin Calcium, Finasteride, Oxcarbazepine, Tamsulosin HCL, and Apixaban. A review of the Medication Administration Record (MAR) indicated that these medications were documented as not available, despite the fact that Atorvastatin Calcium, Oxcarbazepine, Tamsulosin, and Apixaban were available in the Omnicell automated dispensing machine. This discrepancy was confirmed by Staff C, the Unit Manager, who acknowledged that the medications were indeed available for administration at the time of the resident's admission. The facility's policy on unavailable medication, revised in May 2023, outlines procedures for promptly notifying the pharmacy and appropriate practitioners to obtain a new medication supply or order if a medication is unavailable. The policy also requires the Nursing Supervisor or Charge Nurse to check all possible storage areas for the medication, including the emergency box and the automated dispensing machine. If the medication is still not available, the policy mandates notifying the physician or nurse practitioner to obtain an alternate medication order or to hold the medication until delivery. These procedures were not followed in the case of Resident #346, leading to the failure to administer the prescribed medications.
Failure to Properly Apply Seizure Pads
Penalty
Summary
The facility failed to ensure that Resident #67's environment was free from accident hazards, specifically in the application of seizure pads on the bed. Observations on two separate occasions revealed that the seizure pads were attached to the outside of the quarter rails, with no padding between the bed rails and the resident's body. Resident #67 had a diagnosis of epilepsy and a physician's order for seizure pads to be applied every shift. An interview with the Unit Manager confirmed that the seizure pads should have been attached to the inside of the quarter rails towards the resident, as per professional nursing standards.
Failure to Maintain Infection Prevention for Catheter Care
Penalty
Summary
The facility failed to maintain infection prevention related to catheter care for a resident with a Foley catheter. The resident had a Foley catheter since admission in April 2024, and their care plan specified that the urinary collection bag should be kept off the floor. However, observations on two separate occasions revealed that the resident's Foley catheter drainage bag and tubing were resting on the floor and dragging on the floor while the resident was self-propelling in their wheelchair. Interviews with the resident and the Unit Manager confirmed these findings. Review of the CDC guidelines for Catheter-Associated Urinary Tract Infections (CAUTI) emphasized that the collecting bag should be kept below the level of the bladder and not rest on the floor.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for three residents. For Resident #34, the April 2024 Medication Administration Record (MAR) showed an order for HumaLOG Solution (Insulin Lispro) to be administered based on a sliding scale. However, on 4/7/24 at 6:30 a.m., there was no documentation of blood sugar being taken or insulin being administered. Additionally, there were no nursing notes explaining why the insulin was not given. Staff C confirmed these findings during an interview on 4/10/24. For Resident #24, the April 2024 MAR revealed orders for Insulin Glargine and Insulin Lispro to be administered at specific times. However, there was no documentation of blood sugar values or insulin administration on multiple occasions, including 4/4/24 at bedtime, 4/4/24 at 8:00 p.m., 4/7/24 at 6:30 a.m., and 4/8/24 at 6:30 a.m. Similarly, for Resident #67, the MAR showed an order for Basaglar KwikPen (Insulin Glargine) to be administered daily at 6:00 a.m., but there was no documentation of blood sugar values or insulin administration on 4/7/24 and 4/8/24. Staff C confirmed these findings as well. The facility's policy on Diabetes Management Protocol, revised in March 2023, requires documentation of finger stick results, insulin doses administered, and the site of administration, which was not followed in these cases.
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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 Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Rest Home | 2.6 mi | ★★★★★ | 12 | 0 |
| Langdon Place Of Dover | 2.7 mi | ★★★★★ | 0 | 0 |
| Saint Ann Rehabilitation And Nursing Center | 4.9 mi | ★★★★★ | 3 | 0 |
| Birch Healthcare Center | 6.4 mi | ★★★★★ | 7 | 0 |
| Rochester Manor | 6.7 mi | ★★★★★ | 4 | 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.