Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hennis Care Centre Of Dover during CMS and state inspections, most recent first.
A nurse performed a fingerstick blood glucose check on a resident with diabetes and cognitive impairment at the dining room table while other residents were present and eating. The nurse confirmed that this procedure should not have been conducted in the dining area, as it compromised the resident's dignity.
A resident with multiple chronic conditions received additional daily hydration via PEG tube as ordered, but the facility failed to accurately code this intake in the MDS Nutritional Status section. The MDS assessments did not reflect the resident's average fluid intake by tube feeding, despite clear documentation in the MAR and confirmation by the dietician.
Staff failed to follow infection control protocols during medication administration for a resident, using bare hands to handle medication. Additionally, two residents with indwelling devices and wounds did not have Enhanced Barrier Precautions implemented as ordered, with staff not using required PPE or signage during high-contact care activities.
The facility's HVAC system has been non-functional since May 2024, leading to reliance on portable heat pump units to maintain temperatures. Initial failures in the system caused flooding, and despite receiving repair quotes in July 2024, approval and commencement of repairs were delayed until late 2024. As of December, repairs were incomplete, and the facility continued to use temporary heating units.
The facility failed to inform representatives of two residents about new skin impairments. A resident with Alzheimer's and heart failure had a knee laceration, and her representative was not notified until she was sent to the ER. Another resident with similar conditions sustained skin tears during a transfer, and his son was not informed. The facility's administration confirmed the lack of notification.
A resident with a complex medical history suffered a knee laceration after an STNA accidentally hit her with another resident's wheelchair. The nurse applied steri strips without a physician's order and failed to document the treatment or notify the family promptly. The resident was later sent to the hospital with additional diagnoses. The DON confirmed a missed wound dressing change documentation.
A facility failed to ensure 24-hour physician response, affecting a resident with a knee laceration. Despite attempts to contact the on-call nurse practitioner, no return call was received, leading to the resident being sent to the ER without a physician's order. The resident was later diagnosed with acute metabolic encephalopathy and other conditions. Interviews revealed ongoing issues with after-hours physician responsiveness and inadequate communication protocols.
A facility failed to maintain infection control practices during a wound dressing change for a resident with a complex medical history. An RN did not remove soiled gloves after taking off an old dressing and continued to cleanse the wound, violating the facility's policy. The RN acknowledged the error during an interview, which was identified during a complaint investigation.
Blood Glucose Check Performed in Dining Room Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a registered nurse performed a fingerstick blood glucose check on Resident #20 at the dining room table while other residents were present and eating their lunch. Resident #20, who had moderately impaired cognition and diagnoses including hemiplegia, type two diabetes, traumatic brain injury, and dementia, was observed sitting at the head of the table with four other residents during the procedure. The nurse used a disposable needle device to prick the resident's finger and applied a drop of blood to a glucose test strip in full view of the other residents. The nurse confirmed during interview that the blood glucose check should not have been conducted in the dining room at the table with other residents present.
Failure to Accurately Complete MDS Nutritional Status for Resident Receiving PEG Tube Hydration
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Nutritional Status section for a resident who was receiving additional fluid intake via a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had multiple diagnoses including paranoid schizophrenia, type 2 diabetes, major depression, personality disorder, hypertension, and osteomyelitis of the vertebra, was admitted and re-admitted to the facility and had physician orders for specific water flushes through the PEG tube for hydration and tube patency. Medical record reviews showed that the resident consistently received 200 ml to 400 ml of additional water per day via the PEG tube, as documented in the Medication Administration Record (MAR) over several months. Despite this, the quarterly MDS assessments did not reflect the resident's daily additional hydration in Section K (Swallowing/Nutrition Status), which is required to document the average fluid intake per day by tube feeding. The dietician confirmed that Section K was not coded to show the percentage of additional water intake the resident was receiving per PEG tube, even though the Resident Assessment Instrument (RAI) Manual specifies the method for calculating and coding this information. This omission resulted in inaccurate completion of the MDS for the resident's nutritional status.
Failure to Follow Infection Control and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency was identified when a registered nurse administered medication to a resident without following proper infection control practices. Specifically, the nurse used her bare fingers to extract Lyrica from its packaging and placed it into the resident's medication cup, which was then consumed by the resident. The nurse confirmed this action during an interview immediately following the observation. In another instance, a resident with a percutaneous endoscopic gastrostomy (PEG) tube had a physician's order for Enhanced Barrier Precautions (EBP), requiring gown and glove use during high-contact care activities. Despite this order, there was no evidence of EBP implementation, such as PPE carts, signage, or soiled linen bins in the resident's room. The unit manager confirmed that EBP was not in place, even though the resident had an indwelling medical device and the facility's policy required EBP for such cases. A third deficiency involved a resident with a urinary catheter and wounds, who also had a physician's order for EBP. During wound care, neither the registered nurse nor the unit manager wore gowns as required, and there was no EBP signage or PPE cart present. Both staff members confirmed that EBP was not followed during the care activity, despite the facility's policy and physician's order indicating its necessity for residents with indwelling devices or wounds.
HVAC System Failure and Delayed Repairs
Penalty
Summary
The facility failed to maintain a fully operational Heating, Ventilation, and Air Conditioning (HVAC) system, which had been non-functional since May 2024. This deficiency was identified during an onsite complaint survey initiated due to reports of a non-working heating system. Observations revealed that the facility was relying on approximately 12 portable heat pump units to provide heating, with air temperatures ranging from 74 to 78 degrees Fahrenheit. The facility's HVAC system, which utilized a water chilling tower, experienced an initial failure in May 2024 when the circulating pump malfunctioned, leading to busted water pipes and flooding. Temporary HVAC units were brought in to maintain appropriate temperatures. Despite initial repairs in June 2024, further issues were discovered, necessitating the system to be taken offline again. By July 2024, the facility had received quotes for installing 26 new multi-head ductless mini-split systems, but approval for these repairs was delayed until October 2024, with work commencing in November 2024. As of December 13, 2024, the repairs were incomplete, and the facility continued to depend on temporary heating units. Interviews with the Director of Nursing and the new Director of Maintenance confirmed the ongoing issues and lack of a fully operational permanent HVAC system, with no explanation provided for the delays in necessary repairs.
Failure to Notify Representatives of Resident Injuries
Penalty
Summary
The facility failed to notify residents' representatives of changes in condition, specifically regarding new skin impairments, affecting two residents. Resident #78, who had multiple diagnoses including Alzheimer's disease and congestive heart failure, suffered a laceration on her left knee. The injury was assessed by a nurse, but the resident's representative was not informed until the resident was sent to the emergency room hours later. The nurse admitted to not notifying the family, intending to inform them in person during a visit that did not occur. Similarly, Resident #11, with conditions such as Alzheimer's disease and chronic heart failure, sustained skin tears above his right elbow during a transfer. The incident was documented, and hospice was notified, but the resident's son was not informed about the injury. Interviews with the facility's Administrator and Director of Nursing confirmed that the family was not notified of the skin tear. This deficiency was investigated under a specific complaint number.
Failure to Provide Appropriate Treatment for Resident's Laceration
Penalty
Summary
The facility failed to provide appropriate treatment for a skin laceration on a resident's left knee. The resident, who had a complex medical history including Alzheimer's disease, congestive heart failure, and dementia, was found with a V-shaped laceration on her knee. The nurse on duty applied steri strips and a dressing without a physician's order and did not document the treatment in the medical record. The on-call nurse practitioner was paged but did not return the call, and the family was not notified of the injury until the resident was sent to the emergency room. The incident occurred when a State tested Nurse Aide (STNA) accidentally hit the resident's knee with another resident's wheelchair, causing the laceration. The nurse on duty did not follow up with a second call to the on-call physician due to being busy and did not document the incident until the following day. Additionally, the nurse filled out a hospital transfer form inaccurately, indicating the transfer time incorrectly. The Director of Nursing confirmed that a scheduled wound dressing change was not documented as completed. The resident was eventually sent to the hospital, where she was diagnosed with acute metabolic encephalopathy, acute kidney disease, and mild hypernatremia. The lack of timely and appropriate treatment, documentation, and communication with the family contributed to the deficiency identified in the report.
Failure to Ensure 24-Hour Physician Response
Penalty
Summary
The facility failed to ensure that physician services responded to requests for resident care 24 hours a day, affecting one resident and potentially impacting all 83 residents. Resident #78, who had a complex medical history including Alzheimer's disease, chronic atrial fibrillation, and other conditions, experienced a laceration on her left knee. Despite attempts to contact the on-call nurse practitioner, there was no return call, and the resident was eventually sent to the emergency room without a physician's order. The incident began when staff noticed bleeding from the resident's left leg and informed the nurse, who assessed the wound and attempted to contact the on-call nurse practitioner. The nurse applied steri strips and a dressing without an order due to the lack of response. The resident's condition worsened, leading to her being sent to the hospital, where she was diagnosed with acute metabolic encephalopathy, acute kidney disease, and mild hypernatremia. Interviews with facility staff revealed ongoing issues with the responsiveness of physician services after hours, which had been previously addressed in their Quality Assurance and Performance Improvement program. The facility's communication protocol did not provide direct contact numbers for the physician or medical director, complicating efforts to obtain timely medical intervention. The resident's representative expressed concern over the delay in communication and the extent of the injury when finally informed.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during a wound dressing change for a resident with a complex medical history, including Alzheimer's disease, chronic atrial fibrillation, and other conditions. The resident, who resided in a secured memory care unit, had a laceration on the left knee that required regular dressing changes. During an observation, a registered nurse (RN) was noted to have improperly handled the dressing change by not removing her soiled gloves after taking off the old dressing. Instead, she continued to cleanse the wound with the same gloves, which is against the facility's Dressing Change policy. The RN acknowledged during an interview that she did not follow the correct procedure of removing gloves and washing hands after removing the soiled dressing. The facility's policy, reviewed in June 2016, clearly states that gloves should be discarded after removing a soiled dressing, hands should be washed, and new gloves should be worn before proceeding with the dressing change. This oversight was identified during a complaint investigation, highlighting a lapse in adherence to infection control protocols.
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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) |
|---|---|---|---|---|
| Park Village Health Care Center Inc | 0.3 mi | ★★★★★ | 9 | 0 |
| Country Club Center I | 2.3 mi | ★★★★★ | 43 | 1 |
| New Dawn Rehabilitation And Healthcare Center | 2.3 mi | ★★★★★ | 7 | 0 |
| Amberwood Manor | 4.1 mi | ★★★★★ | 0 | 0 |
| Park Village Hc Np Llc | 5.5 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.