Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Park Village Health Care Center Inc during CMS and state inspections, most recent first.
Food was stored and served in a manner that did not follow professional standards. Expired sandwich bread was found on the meal-service bread rack, and during lunch prep, cups of water, juice, and milk were left uncovered on the counter without ice or another cooling method. Temperatures of milk and juice were above the safe cold-holding range, and a dietary staff member was observed carrying drink cups by the rims with fingers inside two cups.
A hospice-enrolled resident with multiple chronic conditions had scheduled Ativan and Dilaudid orders from the hospice medical director for symptom management. Facility staff administered early doses but did not document giving several later doses despite recorded pain levels, and the medical record contained no rationale for holding the medications. A hospice LPN later documented that an RN had withheld doses based on her own judgment, even after the resident’s family agreed with hospice’s recommendation to administer medications as ordered. There was no evidence the facility notified hospice of any change in condition or sought revised orders, contrary to facility policy and the hospice contract requiring documented communication and prohibiting unilateral changes to the hospice plan of care.
PASARR Documents Did Not Reflect Residents’ Diagnoses: The facility failed to ensure PASARR documents accurately reflected the diagnoses of two residents. One resident had Parkinson’s disease, dementia, anxiety, delusions, hallucinations, and depression, but the PASARR did not include several of those psychiatric diagnoses; another resident had severe dementia and delusional disorder, but the PASARR did not list dementia or delusional disorder. The SSD confirmed the omissions, and MDS assessments documented cognitive impairment in both residents.
The facility failed to disinfect shared resident care equipment and failed to follow glove and hand hygiene practices during incontinence care. An RN used a BP cuff and pulse oximeter on two residents without disinfecting the devices between uses, and two CNAs provided incontinence care to a resident without changing gloves or washing hands during the care process, despite the facility policy requiring those steps.
The facility failed to properly store food in the refrigerators, affecting 73 residents. Observations revealed a thawed and leaking pan of chicken, rusty shelving, expired milk, and undated peanut butter and jelly sandwiches. The Dietary Manager confirmed these findings.
The facility failed to complete a PASRR for a resident after the expiration of a Hospital Exemption. The resident, admitted with multiple diagnoses including dementia and major depressive disorder, did not have a level two PASRR completed by the 29th day after admission, as required by the facility's policy. The Social Services Director confirmed the oversight during an interview.
A resident with congestive heart failure, cerebrovascular accident, and dementia was prescribed and administered an antibiotic for aspiration pneumonia without proper indication. The medication was discontinued after a chest x-ray revealed no evidence of pneumonia, and the facility's policy for antibiotic use was not followed.
The facility failed to provide a written bed hold notice to a resident upon her transfer to the hospital. The resident, who had diagnoses including hyponatremia and altered mental status, was not given the required notice because the facility only provided it to Medicaid recipients. The facility's policy did not specify the notification process.
Food Storage and Beverage Handling Deficiency
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards to prevent foodborne illness. During an initial kitchen tour, four full loaves and one half loaf of sandwich bread with a use-by date of 04/14/26 were found on the bread rack used for meal service on 04/19/26. The bread was observed during the tour and was verified at the time of observation by Dietary DC #513, who removed it and discarded it in the trash. During observation of lunch meal preparation and service, cups containing water, juices, and white and chocolate milk were lined up on the counter without lids or coverings and without any ice bath or other means to keep the fluids cold. Temperature checks showed milk from two cups at 47 degrees Fahrenheit and 50 degrees Fahrenheit, and apple juice at 44 degrees Fahrenheit. Later, a dietary staff member was observed carrying three cups of juice, milk, and water to a tray by holding the top rims, with fingers inside the rim of two cups. These observations were verified by Dietary Manager #408, who directed the staff member to throw the drinks out and get new ones.
Failure to Follow Hospice Medication Orders and Communicate with Hospice
Penalty
Summary
The deficiency involves the facility’s failure to effectively communicate with a hospice agency and to follow hospice medication orders for a hospice-enrolled resident, as required by the hospice contract and facility policy. The resident, admitted in early March with diagnoses including muscle weakness, anxiety disorder, major depressive disorder, hypertension, and unspecified vascular dementia, was on hospice care with care plan interventions to administer medications as ordered by hospice and to maintain safety and comfort. On a specific date in late May, the hospice medical director ordered scheduled Ativan 1 mg by mouth every three hours starting at 3:00 A.M. and Dilaudid 4 mg every two hours starting at 2:00 A.M. Review of the Medication Administration Record showed that the resident received the early morning doses of Ativan and Dilaudid as ordered, but the midday doses of both medications were not documented as given. Specifically, the 12:00 P.M. and 3:00 P.M. Ativan doses and the 10:00 A.M. and 12:00 P.M. Dilaudid doses were not recorded as administered, even though the MAR documented pain levels of one and two at 10:00 A.M. and 12:00 P.M., respectively. The resident’s medical record contained no documentation explaining why these doses were held, and there was no evidence of communication with the hospice agency regarding any change in condition, medication concern, or rationale for altering the ordered regimen. An LPN confirmed that there was no indication or rationale in the record for holding the medications. Hospice records for the same date also showed no communication from the facility reporting a change in condition or requesting changes to the medication regimen. A hospice LPN documented that she visited the resident for periods of apnea and found the resident unresponsive to verbal and tactile stimuli and noted that the resident was receiving scheduled Ativan and Dilaudid, but that the facility RN had held doses based on her judgment that the resident did not need them. The hospice LPN discussed medication administration with the resident’s daughter, who stated she wanted the resident kept comfortable and agreed with hospice’s recommendation to administer medications as ordered. The hospice LPN then discussed the family’s wishes and the ordered medications with the facility RN, who remained unwilling to give the medications, and with the DON, who voiced understanding of the family’s request. The facility’s hospice contract required both parties to document communications, prohibited the facility from modifying the hospice plan of care without consulting hospice, and required immediate notification of hospice for changes in condition or inconsistent physician orders; these requirements were not met in this case, leading to the cited deficiency.
PASARR Documents Did Not Reflect Residents’ Diagnoses
Penalty
Summary
The facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) documents accurately reflected residents’ medical diagnoses for two residents reviewed. Resident #9 was admitted with diagnoses including Parkinson’s disease, dementia, anxiety, delusional disorders, and depression. Review of the resident’s most recent PASARR document showed Section E did not include hallucinations, delusions, depression, and anxiety, and the quarterly MDS assessment documented severe cognitive impairment. The Social Service Director confirmed the PASARR did not include those diagnoses. Resident #69 was admitted with diagnoses including severe dementia, delusional disorder, anxiety disorder, major depressive disorder, and heart failure. Review of the resident’s most recent PASARR document showed Section D did not indicate dementia and Section E did not indicate delusional disorder. The admission MDS assessment documented moderate cognitive impairment. The Social Service Director confirmed the PASARR did not accurately reflect the resident’s diagnoses of dementia and delusional disorder. The facility policy stated PASARR is to be completed prior to admission and updated following a significant change of condition or the addition of a new psychiatric diagnosis and/or medication.
Failure to Disinfect Shared Resident Care Equipment and Follow Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to provide routine cleaning and disinfection of resident care equipment shared among residents, including a wrist blood pressure cuff and pulse oximeters. During medication administration, RN #442 took the blood pressure of Resident #67 with a wrist BP cuff and then placed the cuff back on the medication cart without sanitizing it before it was used on another resident. The same RN later checked the heart rate of Resident #7 with a pulse oximeter and did not disinfect the device before or after use, then returned it to a basket with other pulse oximeters on the medication cart. RN #442 confirmed during interview that she had not disinfected the manual BP cuff or pulse oximeter prior to or after use and stated she did not disinfect equipment as a general practice. The facility also failed to ensure proper glove use and hand hygiene during incontinence care for Resident #71. Two CNAs performed incontinence care, including removing the soiled brief, cleansing the perineal area, applying a clean brief, replacing bed clothes, straightening the room, and taking out the trash. During the observation, the aides sanitized their hands and donned gloves before care, but did not wash their hands or change gloves at any point during the care process, and only removed their gloves and washed their hands after the task was completed. The DON confirmed the expectation was to follow the facility policy, which required hand washing and glove changes during specific steps of incontinence care.
Improper Food Storage in Refrigerators
Penalty
Summary
The facility failed to properly store food in the refrigerators, which had the potential to affect 73 of 74 residents who receive meals from the kitchen. Observations revealed a large pan of chicken on the bottom shelf of the meat refrigerator that had thawed and leaked, as well as rusty shelving. Additionally, a gallon of milk was found to be expired, and a gallon Ziploc bag of peanut butter and jelly sandwiches was not dated. The Dietary Manager confirmed these findings. The facility's policy on date marking and disposal of ready-to-eat potentially hazardous foods indicated that such foods must be marked with the date of preparation and consumed or discarded within seven calendar days after the original package is opened.
Failure to Complete PASRR for Resident After Hospital Exemption Expired
Penalty
Summary
The facility failed to ensure that Resident #57 had a Pre-Admission Assessment Screening (PASRR) in place after the expiration of a Hospital Exemption. Resident #57 was admitted to the facility with multiple diagnoses, including cerebral atherosclerosis, dementia with psychotic disturbance, congestive heart failure, anxiety disorder, delusional disorders, hallucinations, neurocognitive disorder with Lewy bodies, and major depressive disorder. A significant change minimum data set (MDS) dated [DATE] revealed that Resident #57 did not have a level two PASRR, which is necessary to ensure appropriate placement and determine if specialized rehabilitative services are required. The Hospital Exemption for Resident #57 expired on 03/29/23, and there was no evidence of a PASRR being completed prior to admission or the expiration of the 30-day Hospital Exemption. An interview with the Social Services Director (SSD) on 04/02/24 confirmed that new PASRRs are typically completed within the first 30 days for residents coming from the hospital. However, the SSD acknowledged that a PASRR was not completed for Resident #57, although a hospital exemption was in place. The facility's PASRR policy, dated 03/24/20, mandates that PASRRs should be completed for all residents prior to admission, except for those with a hospital exemption, in which case the PASRR should be completed by the 29th day after admission. The policy also states that all PASRRs should be reviewed and signed by the Director of Nursing, and a new resident review should be conducted following a significant change in the resident's condition. Despite these guidelines, the facility did not adhere to the policy, resulting in the deficiency for Resident #57.
Inappropriate Antibiotic Use Without Proper Indication
Penalty
Summary
Resident #54, who had diagnoses including congestive heart failure, cerebrovascular accident, and dementia, was prescribed the antibiotic amoxicillin-potassium clavulanate for aspiration pneumonia. The prescription was made on 03/21/24 and the medication was administered as ordered from the evening of 03/21/24 to the morning of 03/23/24, totaling four doses. However, a chest x-ray completed on 03/23/24 revealed no evidence of pneumonia, leading to the discontinuation of the antibiotic on the same day. An antibiotic assessment completed on 03/23/24 indicated that the criteria for antibiotic use were not met due to the negative chest x-ray results. This resulted in the resident receiving four doses of an antibiotic without an appropriate indication for its use. The facility's policy, titled Antibiotic Surveillance Policy and Procedure, reviewed in October 2023, mandates that a McGeer's assessment be initiated when a resident shows signs and symptoms of an infection. If the criteria are met, the physician is to be notified, and if an antibiotic is ordered without an assessment, the nurse must notify the practitioner for the reasoning behind the antibiotic usage. In this case, the policy was not followed as the antibiotic was started before obtaining a chest x-ray and without completing a McGeer's assessment. This was verified by an interview with RN #101 on 04/04/24, who confirmed that the antibiotic was started prior to obtaining the chest x-ray and was discontinued after the negative result.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to Resident #72 upon her transfer to the hospital. Resident #72, who was admitted with diagnoses including hyponatremia, altered mental status, and paroxysmal atrial fibrillation, was sent to the hospital on 01/31/24 and did not return to the facility. The Director of Nursing confirmed that the facility only provides written bed hold notices to residents with Medicaid as their payer source, which was not the case for Resident #72. The facility's policy on Discharge/Transfer did not specify how or when the bed hold notice should be provided to the resident or their representative.
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 441 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hennis Care Centre Of Dover | 0.3 mi | ★★★★★ | 0 | 0 |
| Country Club Center I | 2.2 mi | ★★★★★ | 43 | 1 |
| New Dawn Rehabilitation And Healthcare Center | 2.2 mi | ★★★★★ | 7 | 0 |
| Amberwood Manor | 4.1 mi | ★★★★★ | 0 | 0 |
| Park Village Hc Np Llc | 5.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Park Village Health Care Center Inc.
100% money-back within 48 hours.
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.