Delmar Gardens North

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were treated with dignity and respect, ensuring their comfort, privacy, and personal rights are always upheld, when staff did not knock or announce their presence before entering the rooms of Residents #36, #50, #72, and #84, violating their right to privacy, when Residents #1, #2 and #28 were not provided with call lights within reach, limiting their ability to communicate their needs promptly and when staff failed to adjust the dining room temperature to a comfortable level, compromising their comfort for Residents #26, #72, #145, and #164. This affected the dignity standards to guarantee residents' physical comfort, autonomy, and respect in daily care for nine of 36 sampled residents. The census was 171. Review of the facility's undated Resident Right policy, showed:-Dignity and Respect: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean or organized medication cart and storage rooms within the facility. Four out of seven carts were checked. Staff failed to ensure proper storage and labels on medications on four Certified Medication Technician (CMT) medication carts. The census was 171. Review of the facility's Medication Storage Policy, dated December 2021, showed:-Drugs and medications are to be stored in the original container in which they were received;-Only the charge nurse or medication nurse has access to the narcotics keys,-Now discontinued, outdated, or deteriorated drugs or medications will be stored in the facility over thirty (30) days.-Medications which require refrigeration are kept in the refrigerator in the locked medication room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Against Medical Advice (AMA) discharge was documented in the medical record and appropriate information was communicated to the resident and/or responsible party. The facility also failed to maintain a copy of a signed AMA discharge form for one of three residents reviewed for voluntary and involuntary discharge procedures (Resident #178). The census was 171. Review of facility's admission Agreement, showed: -You may voluntarily end this admission Agreement and leave our facility at any time by giving us seven days advance written notice. If you leave against the advice of your physician, you agree to assume full responsibility of all results that follow. You also agree to pay all outstanding charges before you leave. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document assessments and failed to contact the resident's physician regarding a change of condition for one sampled resident (Resident #11). The sample was 36. The census was 171. Review of the facility's policy, Following Physician's Orders, dated 6/29/21, showed:-Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (LPNs) Registered Nurses (RNs) and other healthcare professionals, follow physicians in accordance with State, Federal regulations and their respective practice acts.-Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 6 sampled residents the facility identified with a catheter (medical device to allow for voiding) received appropriate catheter care. The facility failed to ensure one resident's catheter was stored properly while the resident was in bed (Resident #2) and failed to ensure one resident received proper catheter care (Resident #55). The sample was 36. The census was 171. Review of the facility's catheter care policy, dated 3/2021, showed:-Purpose: To keep indwelling catheter free of discharge and/or crusting which can cause infections;-Procedure: Check tubing for positioning. Coil on bed. Attach catheter bag to bed frame only.-Male catheter procedure: Apply gloves. Place protective pad or towel under the resident. Avoid unnecessary exposure. Moisten wash cloth with soap and water. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents received gastrostomy tube (a tube surgically inserted into the abdomen, used for liquid nutrition, fluids and medications) feedings at the specified times ordered by the physician (Residents #1 and #55). The sample was 36. The census was 171. Review of the facility's Tube Feeding policy, revised June 2021, showed:-Purpose: to deliver a continuous, regulated drip feeding to gastrostomy tube (g-tube) fed residents using an enteral pump;-Procedure: -Equipment: Enteral pump, enteral feeding bag and administration set; prescribed feeding; and a pole; -Review the physician's orders; The order should specify the amount and type of formula, and the flow rate. Review of the facility's Following Physician Orders policy, dated 6/29/21, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment as free of accident hazards as possible and to provide supervision and assistance to prevent falls for five of seven sampled residents (Residents #1, #3, #4, #5 and #6) by not implementing care planned fall interventions. On 12/31/24 Certified Nurse Aide (CNA) A failed to place Resident #1's bed in a low position. Resident #1 was found screaming and hanging off the bed holding onto the grab rail. A nurse assisted the resident to the floor. The resident sustained bilateral (both sides) fractured femurs (thighbones). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADL) care assistance for a dependent resident (Resident #1), during the evening shift on 12/3/24 and the overnight shift from 12/3/24 to 12/4/24. The sample was five. The census was 172. The Administrator was notified on 12/26/24, of the past non-compliance. The facility disciplined various staff members who failed to provide ADL care to the resident. The facility in-serviced current employees on the topics of rounding on residents, customer service, abuse and neglect, and grooming. The deficiency was corrected on 12/11/24. Review of Resident #1's Medical Record showed: -Diagnoses included Alzheimer's disease, diabetes and major depressive disorder; -Cognitively intact; -Resident required two staff members assistance with ADLs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent further potential abuse, neglect or mistreatment by not investigating an injury of unknown origin for one of three sampled residents (Resident #1). The census was 95. Review of the facility's Injury of Unknown Source - Investigative Protocol policy, undated, showed: -Purpose: The following indicators of abuse/neglect are provided to help determine if abuse/neglect should be suspected. Staff are mandated to report suspected abuse; -Indicators of physical abuse may include injuries of an unknown source; -The attached worksheet and directions are offered to assist facilities in their internal investigation. If a logical/reasonable explanation of the source of the injury cannot be determined, notify your local state agency within 2 hours of discovery. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' environment remained free of accident hazards by keeping an un-secured plastic container filled with insulin (used to control high blood sugar) pens (a small lightweight pen that is prefilled with insulin to inject under a person's skin) of 13 residents (Residents #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) on un-attended, unsupervised treatment/medication carts. [...]

Inspectors wroteBased on observation, interview and record review, staff failed to demonstrate proper use of hand hygiene and proper infection control during wound care for two of three sampled residents (Residents #2 and #4). The census was 95. Review of the facility's Infection Control Policy, dated 12/2016, showed: -Purpose: The community has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -Develop prevention, surveillance, and control measures to protect residents and personnel from healthcare-associated infections; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed their Abuse, Neglect and Exploitation, Freedom From policy by failing to immediately notify the Administrator/Designee or Director of Nurses (DON)/Designee and promptly begin an investigation regarding one resident's allegation on 10/24/23 around 4:30 P.M. to 5:00 P.M., of being slapped or hit in the face/mouth by Certified Nursing Assistant (CNA) A. In addition, the facility failed to ensure CNA A was immediately suspended from work pending the results of an investigation. CNA A continued to work on 10/24/23 until 10:38 P.M., returned to the facility on [DATE], and worked from 6:34 A.M. until 3:27 P.M., before being suspended from work. Six residents were sampled and problems were identified with one (Resident #3). The census was 145. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed their Condition Change, of the Resident policy. On the morning of 10/9/23, Nurse O (the day shift nurse) documented the night shift nurse reported at shift change one resident had a low blood pressure (BP), the physician was notified and gave orders to encourage fluids. The night shift nurse failed to document in the progress notes and/or on an SBAR (Situation, Background, Assessment, and Recommendation, assessment tool) communication form, the date or time the resident's BP was low, what the BP was, or the physician's order. In addition, Nurse O failed to document on-going assessments/monitoring of the resident throughout the day. On 10/9/23 at 5:00 P.M., the resident's family visited and requested the resident be sent to the hospital. [...]

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure: 1. the high temperature dish machine met proper temperatures and 2. the staff maintained a clean kitchen including items in the storage areas for all 133 residents who received meals from the kitchen. These failures had the potential to lead to food-borne illness among all facility residents.

Inspectors wroteBased on observation, interviews, review of manufacturer's instructions, policy review, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to train and ensure staff, including agency nurses, disinfected multi-use glucometers with an EPA registered disinfectant and removed used gloves for one of one resident observed receiving a fingerstick (Resident (R) 22) out of 39 residents receiving blood sugar monitoring. This failure increased the likelihood of transmission of blood-borne pathogens to residents receiving blood sugar monitoring.

Inspectors wroteBased on record review, interview and review of facility policies and procedures, the facility failed to ensure that two (Resident (R)72 and R247) of 31 sampled residents were informed and provided written information to formulate an advance directive.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to provide a baseline care plan within 48 hours of admission for one resident (Resident (R)100) of one resident reviewed for base line care plans out of 31 sampled residents.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure that care plans for one (Resident (R)96) was revised to reflect palliative services from a sampled 31 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and their policy by failing to ensure one resident's gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) feeding infused at the prescribed rate. In addition, the facility failed to ensure staff recorded a date/time on the package of a g-tube declogger (used to declog a g-tube) of when it was opened, and failed to ensure staff were aware of how long the g-tube declogger could be used prior to discarding it. The facility identified six residents with g-tubes. Four were sampled and problems were identified with one. (Resident # 1). The census was 138. Review of the facility Enteral Nutrition /Tube Feeding policy, dated 2014, showed: -Guideline: [...]

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to promptly intervene when a resident's respiratory equipment was missing for one (Resident (R) 34) of three residents reviewed for respiratory care/oxygen of 31 sample residents.

Inspectors wroteBased on record review, interview and review of facility policy, the facility Quality Assurance Performance Improvement (QAPI) program failed to identify problems with the admission process in that Advance Directives were not offered to two (Residents (R)247 and R333) from a sampled 31 residents.

Inspectors wroteBased on observation and interview, the facility failed to label and properly store opened food items and maintain the cleanliness of the deep fryer, stove, griddle, soup kettle, oven and kitchen floor during four of five days of observation. This deficient practice affected all residents who ate at the facility. In addition, the facility failed to ensure dietary staff were logging the temperatures of the refrigerators located in the kitchenettes. The census was 216 with 180 in certified beds. 1. Observation of the kitchen area on 1/2/20 at 8:23 A.M., showed: -An opened, unsealed and unlabeled bag of what appeared to be frozen chicken in the walk in freezer; -An opened, unsealed bag of frozen beef patties in the walk in freezer; -The deep fryer had a build-up of what appeared to be grease and brown, caked-on food on the sides of both of fryers; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life when staff left a resident exposed to the hall, talked disrespectfully to a resident, and called a resident's brief a diaper. One resident voiced staff frequently talk disrespectfully to residents (Residents #532, #284, #30 and #147). The census was 216 with 180 residents in certified beds. 1. Observation on 1/7/20 at 7:48 A.M., showed Resident #532 sat in his/her room on the side of the bed and faced the room door. Certified Nurse Aide (CNA) B, assisted the resident to dress. The privacy curtain was partially pulled but the resident was still visible from hall and exposed from the waist up. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide personal privacy during personal care for one resident (Resident #147). In addition, the facility failed to ensure privacy and confidentiality of resident personal and medical records during three of four days of dining room observations in three of four unit dining rooms on certified halls. The sample was 35. The census was 216 with 180 residents in certified beds. 1. Review of Resident #147's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/19, showed: -Diagnoses included seizure disorder; -Total assistance required for bed mobility, dressing, toilet use, and personal hygiene. Review of the resident's care plan, in use at the time of the survey, showed: -Category: Communication: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the services provided or arranged by the facility meet professional standards of quality, by failing to ensure staff followed facility policy after a resident's fall (Resident #38) and failing to follow the facility policy regarding weights that were outside of baseline range (Resident #153). In addition, the facility failed to follow physician's orders for one resident (Resident # 8), who had an order to wear a left elbow brace. The sample was 35. The census was 216 with 180 in certified beds. 1. Review of instructions unlicensed staff should follow when a resident is found on the floor, and reviewed with staff during their orientation, showed: I have received information and education on the fall policy and procedures for residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, for five of five narcotic count books reviewed on three of four certified halls. The census was 216 with 180 in certified beds. Review of the facility's Controlled Substance Audit policy, revised 2015, showed: -Purpose: To keep accurate records of all controlled substances in accordance with state and federal laws; -The Controlled Medication Shift Audit Record will be signed by the on/off going nurse/certified medication technician (CMT), inventory together at change of shift; -If non-compliance is found in the documentation of controlled substances staff will be required to date and initial medication cards each time it is administered until substantial compliance is achieved; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage included the provision of appropriate environmental controls in three of four medication storage rooms utilized by residents in certified beds. Staff failed to ensure one medication refrigerator had functional thermometers (100 hall) and that staff monitored the refrigerator temperatures in three medication room refrigerators (100, 200 and 500 halls). In addition, facility staff stored drinks in one medication refrigerator (200 hall). The census was 216 with 180 in certified beds. Review of the facility's Medication Storage policy, dated August 2018, showed: -Purpose: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff used acceptable infection control procedures during personal care for two of three residents observed receiving care (Residents #10 and #80). In addition, the facility failed to ensure they had signs posted at the entrance requesting visitors not to enter if they were experiencing a cold or the flu or had symptoms of either and the facility had no personal protection supplies such as gloves or masks for visitors to use if they chose to visit while experiencing cold or flu symptoms or if the facility was experiencing an outbreak among the residents. The census was 216 with 180 in certified beds. Review of the facility's Nursing Competencies, dated 1/2017, showed: -Purpose: The purpose of this policy is to ensure all nursing staff receives: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status at the time the assessment was completed for three residents (Residents #153, #147, and #183). The sample was 35. The census was 216 with 180 residents in certified beds. 1. Review of Resident #153's weight documentation, showed: -On 5/5/19, 179 pounds (lbs); -On 8/6/19, 173.8 lbs; -On 10/6/19, 174.6 lbs; -On 11/17/19, 151.8 lb, flagged red; -Weight change from 5/5/19 to 11/17/19, indicated a weight loss of 15.19% in 6 months; -Weight change from 8/6/19 to 11/17/19, indicated a weight loss of 12.65% in 3 months; -Weight change from 10/6/19 to 11/17/19, indicated a weight loss of 13% in 1 month. Review of the facility's Weight Monitoring policy, revised 11/2018, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction) receives necessary treatment and services, consistent with professional standards of practice, for one resident who developed a wound (Resident #153). The facility failed to monitor and documented the progress of the wound and/or notify the physician until two weeks after first identified, when the wound failed to respond to the ordered treatment. The facility identified 14 residents as having pressure ulcers. The sample was 35. The census was 216 with 180 in certified beds. Review of the facility's Pressure Ulcer Care and Documentation policy, revised 12/2006, showed: -Purpose: To prevent pressure ulcers and/or prevent deterioration of existing pressure ulcers; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter (a tube inserted into the bladder to drain urine) received care consistent with accepted standards of practice to prevent urinary tract infections and complications when a staff person held the catheter bag above bladder level during care (Resident #147). In addition, the facility failed to ensure residents who are incontinent receive appropriate treatment and services, for one resident left wet for an extended period of time (Resident #37) and one resident observed during personal care (Resident #120). The sample was 35. The census was 216 with 180 in certified beds. 1. Review of Resident #147's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/19, showed: -Indwelling catheter used; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to communicate weight loss and refusal of Juven (nutritional supplement) to the registered dietician (RD) and obtain weights, for one resident (Resident #232). The sample was 35. The census was 216 with 180 in certified beds. Review of the facility's weight policy, revised 1/2018, showed: -Purpose: To obtain accurate weight of each resident and maintain control of weight changes; -Residents are weighed on admission, weekly and monthly thereafter, unless otherwise ordered by nursing from the attending physician; -Facility designee will record weights in the individual resident's electronic medical record (EMR) under vital signs: -Any resident with a weight gain or loss of 5 pounds (lbs.) will be reweighed within 24 hours; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed acceptable standards of practice for one resident with a gastric tube (g-tube, a tube inserted into the stomach to provide food, fluid and nutrition). The facility identified seven residents as having a g-tube, six were included in the sample of 35 and issues were identified with one (Resident #153). The census was 216 with 180 residents in certified beds. Review of the resident's electronic physician order sheet (ePOS), showed an order dated 1/18/19 for Glucerna (liquid nutrition) at 60 milliliters (ml) per hour continuous. Observation on 1/2/20 at 10:42 A.M., showed the resident in bed. Glucerna administered at 60 ml per hour. The Glucerna bottle not labeled with the date and time hung. Further review of the resident's ePOS, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pain management is provided to residents who require such services for one resident observed to have pain when staff failed to inform the nurse the resident experience pain (Resident #147). The census was 216 with 180 residents certified beds. Review of Resident #147's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/19, showed: -Diagnoses included seizure disorder; -Total assistance required for bed mobility, dressing, toilet use, and personal hygiene. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Need for comfort measures in care due to significant change in condition; -Goal: Remain comfortable physically, emotionally, and spiritually; -Approach: [...]