Doverwood Village

• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on July 24, 2025.

• Citation F0925. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on July 24, 2025.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on July 24, 2025.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on July 24, 2025.

  CMS has cited this home for F0842 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on July 24, 2025.

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• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 4.7 to 4.2 hours per resident per day.

CMS lists this as a complaint inspection.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on December 12, 2024.

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• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on January 18, 2024.

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CMS lists this as a complaint inspection.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on December 13, 2023.

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CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on November 7, 2023.

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CMS lists this as a standard inspection.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on October 18, 2022.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on October 18, 2022.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on October 18, 2022.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  CMS lists it as corrected on October 18, 2022.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on October 18, 2022.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on October 18, 2022.

• Citation F0675. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor each resident's preferences, choices, values and beliefs.

  CMS lists it as corrected on October 18, 2022.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on October 18, 2022.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on October 18, 2022.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on October 18, 2022.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 18, 2022.

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CMS lists this as a standard inspection.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on October 18, 2022.

  CMS has cited this home for K0345 2 times since 2020.

• Citation K0346. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on October 18, 2022.

• Citation K0354. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on October 18, 2022.

• Citation K0521. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on October 18, 2022.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on October 18, 2022.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on October 18, 2022.

  CMS has cited this home for K0222 2 times since 2020.

• Citation K0341. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install a fire alarm system that can be heard throughout the facility.

  CMS lists it as corrected on October 18, 2022.

• Citation K0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on October 18, 2022.

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CMS lists this as a standard inspection.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on February 28, 2020.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on February 28, 2020.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on February 28, 2020.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on February 28, 2020.

• Citation K0511. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on February 28, 2020.

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