Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dwelling Place At St Clares during CMS and state inspections, most recent first.
Ventilator circuits and filters for 12 residents were observed without dated labels or written dates, and the related circuit changes were not documented in the eMR. The residents had diagnoses including chronic or acute respiratory failure and tracheostomy status, with ventilator orders specifying modes such as PRVC/AC, AC, SIMV, VC/SIMV, and CPAP/PS. The RT and RD stated that suction setups were labeled and circuits were changed on a schedule, but the chart lacked documentation of the circuit changes despite the facility policy requiring ventilator monitoring and equipment changes to be documented.
Infection Control Breaches During Pressure Ulcer Wound Care: A resident with a stage 4 pressure ulcer and ventilator/trach status received wound care in which an RN used the same gloves after removing a soiled dressing, sprayed cleanser directly into the wound, cleansed from the periwound to the wound bed, handled a sterile calcium alginate dressing without no-touch technique, and did not disinfect the OBT or remove trash afterward. The DON confirmed the breaches, and the facility policy required a clean field, no-touch technique, and proper disposal of used items.
Unlabeled Tube Feeding Formula: A resident with a PEG tube was observed receiving an unidentified formula at 70 mL/hr, and the feeding bag lacked the resident’s name, formula type, date, and infusion rate. The resident had ALS, chronic respiratory failure, and dysphagia, with intact cognition and a care plan for dependent tube feedings. The RN and DON confirmed the bag should have been labeled per facility expectations, but the facility policy did not address labeling for products not in ready-to-hang bags.
Ventilator Circuits Not Dated or Documented
Penalty
Summary
The facility failed to maintain and document respiratory care and ventilator equipment for 12 of 12 residents reviewed who were receiving humidified, oxygen-enriched air via mechanical ventilation. During observation, each of the 12 residents was seen in bed or seated with a ventilator in place, and the ventilator circuit tubing and filters did not have a dated label or written date. The residents reviewed included individuals with diagnoses such as chronic respiratory failure, acute and chronic respiratory failure with hypoxia or hypercapnia, unspecified hypoxia, and tracheostomy status. The surveyor observed the ventilators for Residents #1, #2, #3, #4, #5, #6, #7, #8, #11, #17, #23, and #25 and found no dated label or written date on the circuit tubing or filters for any of them. The medical record review showed ventilator orders for each resident, including modes such as PRVC/AC, AC, CMV, SIMV, VC/SIMV, and CPAP/PS, with ordered settings for respiratory rate, tidal volume, PEEP, and FiO2. Some orders also included titration instructions to maintain specified oxygen saturation levels. Interviews with the floor respiratory therapist and the Respiratory Director showed that equipment changes were expected to be labeled and documented, with suction setups changed weekly and circuits changed every 28 to 30 days. The Respiratory Director stated that circuit changes were not documented in the chart and that tubing was not dated because there was a schedule. However, the surveyor reviewed the electronic record and found that circuit changes were not documented in the respiratory progress notes or equipment change section for the 12 residents. The facility policy stated that ventilator monitoring is to be documented in the electronic record and that the circuit should be maintained and changed when soiled and/or every 30 days.
Infection Control Breaches During Pressure Ulcer Wound Care
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after surveyors observed wound care for a resident with a stage 4 pressure ulcer on the left ischial area. The resident had been admitted with chronic respiratory failure and ventilator and tracheostomy status, had intact cognition with a BIMS score of 15, and had physician-ordered wound care that included cleansing the wound, applying calcium alginate, and covering it with an ABD pad daily and as needed. The care plan also addressed the reopened wound with weekly monitoring, specialty mattress use, treatment administration, and physician notification if changes were needed. During the wound treatment, the RN removed the soiled dressing, which had copious serous drainage, and then used the same gloves to spray wound cleanser directly into the wound and cleanse it from the periwound area to the wound bed. After removing her gloves and performing hand hygiene, she donned a new pair of gloves but handled the sterile calcium alginate by tearing it in half and touching multiple surfaces rather than using a no-touch technique. The RN also did not disinfect the overbed table after the treatment and did not remove and discard the trash from the resident's room. The RN acknowledged the infection control breaches when they were discussed with the surveyor, and the DON confirmed the breaches during interview. The facility policy for clean dressing changes required a clean field on the overbed table, no-touch techniques, cleansing the wound without contaminating other skin surfaces or the wound, and discarding disposable items and gloves into the appropriate trash receptacle. The deficiency was cited under NJAC 8:39-19.4(a); 27.1(a).
Unlabeled Tube Feeding Formula
Penalty
Summary
The facility failed to ensure appropriate management of gastrostomy enteral feeding formula for one resident receiving tube feedings. On 7/6/26, the resident was observed in bed with a gastrostomy enteral feeding tube pump administering an unidentified formula at 70 mL per hour. The 1000 mL feeding bag was unlabeled and did not include the resident’s name, formula type, date, or rate of infusion. The resident had been admitted with diagnoses including chronic respiratory failure, amyotrophic lateral sclerosis, and gastrostomy status, and the quarterly MDS reflected intact cognition with a BIMS score of 15 out of 15. The resident’s care plan identified a need for tube feeding related to dysphagia, with interventions including head of bed elevation during and after feeding and dependence on staff for tube feedings and water flushes. The physician order summary included an order for standard formula 1.4 oral liquid via PEG tube at 70 mL per hour for a total daily volume of 1120 mL, with feeding scheduled from midnight to 8 AM and again from noon to 8 PM. The assigned RN confirmed that the feeding tube should have been labeled with the resident’s name, formula type, infusion rate, date, time, and initials, and the DON also confirmed that all TF bags and bottles should be labeled in that manner. The facility policy stated that ready-to-hang bottles should be labeled with the patient’s name, date, and time hung, but it did not address labeling of products not in ready-to-hang bags.
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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) |
|---|---|---|---|---|
| Excel Care At Dover | 0.8 mi | ★★★★★ | 4 | 0 |
| Merry Heart Nursing Home | 4.4 mi | ★★★★★ | 13 | 0 |
| Morris View Healthcare Center | 4.6 mi | ★★★★★ | 20 | 1 |
| Holly Manor Center | 5.7 mi | ★★★★★ | 0 | 0 |
| Oaks At Denville, The | 5.8 mi | ★★★★★ | 1 | 1 |
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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 October 2026) and official state health department websites.