Delmar Gardens of Chesterfield

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities, two errors occurred, resulting in an 8% medication error rate (Residents #45, and #145). The census was 171 with 166 with certified bed. Review of the facility's Medication Administration-General Guidelines Policy, revised 1/2021, showed: Policy: Only a Registered Nurse (RN), License Practical Nurse (LPN), Certified Medication Aide, or Certified Medication Technician (CMT) are assigned responsibility for preparing, administering and/or record the administration of medications. Medications must be administered in accordance with a physician's order (i.e., the right resident, the right medication, the right dosage, the right route and the right time). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage and labels on medications. For three out of four certified medical technician (CMT) carts checked and one of four medication storage rooms checked. The census was 171 with 166 with certified bed. 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which they were received;-Only the charge nurse or medication nurse has access to the narcotics keys;-No discontinued, outdated, or deteriorated drugs or medications are stored in the facility over the thirty (30) days;-Medications which require refrigeration are kept in the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 one discharged resident's (Resident #131) Oxycodone (narcotic used to treat pain) and one resident's (Resident #185) discontinued Ativan (used to treat anxiety) were appropriately destroyed in accordance with the facility's policy and free from medication misappropriation. The facility started the investigation when the Assistant Director of Nursing (ADON) questionably destroyed a resident's discontinued Hydrocodone (Resident #113). The ADON admitted to taking the discontinued medications of Resident #131 and Resident #185 for personal use. She provided the card of Oxycodone and the bottle of Ativan at the time of questioning. The census was 177 with 166 in certified beds. The Administrator was notified on 8/6/25, of the past non-compliance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff maintained safe resident transfer techniques during a Hoyer (used for persons who are non-weight bearing) lift (Resident #12) and during a gait belt transfer (Resident #157). The sample was 33. The census was 177 with 166 in certified beds. Review of the transfer and lift policy, reviewed 5/2021, showed:-Purpose: to provide communication to staff regarding the resident's transfer abilities and to assure all precautions are taken to maintain safety of the resident. -Policy: -Upon admission each resident will be assessed by the inter-disciplinary team on the capabilities of how the resident transfers. This will be re-assessed with changes in condition; -A butterfly magnet will be placed inside the resident room on the overhead light or the door frame of the room indicating how the resident transfers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #6) received gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids and medications) feedings at the specified times as ordered by the physician and to ensure the resident's head of bed (HOB) was elevated to prevent aspiration (choking). The sample was 33. The census was 171 with 166 in certified beds. Review of the facility's Tube Feeding policy, revised June, 2021, showed:-Purpose: to deliver a continuous, regulated drip feeding to gastrostomy tube-fed residents using an enteral (delivering nutrition and medications through the gastrointestinal system) pump;-Procedure: -Equipment: Enteral pump, enteral feeding bag and administration set, prescribed feeding, and a pole; -Review the physician's orders; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented actions taken to address irregularities noted by the pharmacist for one of three residents sampled for medication regimen reviews (Resident #7). The sample was 33. The census was 171 with 166 in certified beds. Review of the facility's Pharmacist Consultant Duties and Responsibilities policy, reviewed May 2021, showed:-Purpose: To ensure that drug regimen reviews, medication pass observations, and medication audits are performed in accordance with state and federal regulations;-Drug regimen review (DRR):-Policy: The consultant pharmacist reviews the medications for each resident for any irregularities and to: verify appropriateness of the medications involved; evaluate disease state management; ensure appropriate medication monitoring to maximize safety and efficacy; [...]

Inspectors wroteBased on observation, interview and record review, staff failed to following policies and procedures regarding hand hygiene and enhanced barrier precautions (EBP) prior to applying protective personal equipment (PPE) and touching the resident (Resident #12). The sample was 33. The census was 177 with 166 in certified beds. Review of the enhanced barrier precautions (EBP) policy, revised 8/2024, showed:-Purpose: to reduce the spread of multi-drug resistant organisms (MDRO, various bacteria that are resistant to various antibiotic therapies);-Definitions: -EBPs are indicated for residents with any of the following: -Infection or colonization with a MDRO when contact precautions do not apply; -Wounds even if the resident is not known to be infected or colonized with a MDRO;-Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge summary was completed, including a recapitulation of the resident's stay and final summary of the resident's status at the time of discharge (Resident #7). The sample was 14. The census was 168. Review of the discharge or transfer policy, dated January 2021, showed: -Purpose: -To provide prompt and safe discharge/transfer of a resident from the facility and to ensure continuity of care through provisions of pertinent resident information; -To provide orientation for a resident being discharged /transferred to ensure a safe and orderly transition home or to a new living environment; -Procedure: -A discharge summary observation will be completed for all residents who: -Discharge to a private residence/home or independent retirement community; -Transferred to another facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy to provide the necessary care to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one resident who was at high risk for pressure ulcers and developed a new pressure ulcer (Resident #10) and for a resident who was at risk for pressure ulcers and had an existing pressure ulcer (Resident #11). The sample size was three. The census was 168. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure as follows: -Stage I: [...]

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the Administrator's Job Description, the facility failed to ensure good faith attempts were made to correct quality deficiencies through their Quality Assurance and Performance Improvement (QAPI) process. The Administration had not implemented any QAPI programs to address the ongoing COVID-19 and respiratory syncytial virus (RSV) outbreaks. Additionally, the administration failed to identify sufficient staffing as a possible quality deficiency. These failures placed all facility residents at risk for transmission of COVID-19 and RSV and accidents, unmet needs, and lack of incontinence care related to insufficient staffing.

Inspectors wroteBased on observations, interviews, record reviews, review of the Centers for Disease Control (CDC) guidelines, and facility policy review, the facility failed to: 1. Wear appropriate personal protective equipment (PPE) when providing care to residents on transmission-based precautions. 2. Doff (take off) soiled PPE prior to exiting the resident's room. 3. Complete resident testing upon new positive cases of COVID-19 in the building. 4. Complete contact tracing for staff that were in close contact with COVID-19 positive residents or exposed to Respiratory Syncytial Virus (RSV) positive residents 5. Provide evidence of staff testing done during an outbreak of COVID-19. 6. Ensure appropriate cohorting of residents within close contact to other COVID-19 and RSV positive residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected 15 residents who expired and had money in their accounts (Residents #509, #505, #502, #503, #511, #504, #501, #508, #510, #506, #512, #517, #513, #516, #515). The sample size was 17. The census was 179. 1. Review of Resident #509's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $927.44; -No documentation of a TPL. 2. Review of Resident #505's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $150.07; -TPL completed on [DATE]. 3. Review of Resident #502's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $4238.47; -TPL completed on [DATE]. 4. [...]

Inspectors wroteBased on observations, staff and resident interviews, record reviews, and review of monthly Resident Council meeting minutes, the facility failed to ensure sufficient staffing to meet the needs of the 180 residents in the facility. Several residents and staff members voiced concerns regarding sufficient staffing, and the facility exhibited failures related to a lack of sufficient staffing throughout the survey.

Inspectors wroteBased on observation, interview, review of Resident Council Meeting notes, and policy review, the facility failed to serve hot foods at palatable temperatures for seven of 40 sampled residents (Resident (R) 6, R64, R57, R75, R123, R143, and R146). This failure had the potential to contribute to decreased intake by residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure the advance health care directive of one (Resident (R) 147) of six residents reviewed for advance directives was honored. This failure had the potential to result in unwanted provision of cardio-pulmonary resuscitation (CPR) resulting in possible pain, injuries such as broken ribs, and altered mental status.

Inspectors wroteBased on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a comprehensive assessment including assessment of mood and daily activity preference for two (Resident (R) 100 and R147) of 40 sample residents. These failures created a potential for specific resident needs related to mood and/or daily and activity preference to go unidentified.

Inspectors wroteBased on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a quarterly assessment including assessment of cognitive patterns and mood for one (Resident (R) 118) of 40 sampled residents. These failures created a potential for specific resident needs related to cognition and mood to go unidentified.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Level 1 pre-screening of a resident for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility was completed for one of one resident (Resident (R) 23) reviewed for Level 1 (one) Pre-admission Screening and Resident Review (PASARR).

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure two (Resident (R) 100 and R147) of four residents reviewed for activities of daily living (ADLs) received assistance with incontinence care and/or using the toilet as needed. These failures created a potential for skin problems, urinary tract infections, or increased incontinence for these two residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two (Resident (R) 147 and R151) of five residents reviewed for activities were assessed for activity interests and needs and received a program of activities to meet their needs. These failures placed R147 and R151 at risk for increased feelings of depression, helplessness, and boredom.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure the physician acted upon the notification of irregularities in the medication regimen for one (Resident (R) 53) of five residents reviewed for unnecessary medications. This failure created the potential for unnecessary antipsychotic medication use, which could lead to adverse consequences such as over-sedation, mental status changes, or involuntary movements.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure the drug regimen of one (Resident (R) 53) out of five residents reviewed for unnecessary medications contained adequate indication for use of an anti-psychotic medication. This failure placed R53 for potentially avoidable adverse effects of the drug, including over-sedation, mental status changes, or involuntary movements.

Inspectors wroteBased on observation, interview, and review of the United States (US) Food and Drug Administration (FDA) Food Code, the facility failed to ensure dishware stored at the ice machine was covered or inverted for storage in a clean, dry location not exposed to dust or other potential contamination.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to ensure one resident's room (room [ROOM NUMBER]-1) was clean and in good repair for one room observed on the 200 Hall.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided with dignity and respect by failing to administer insulin injections in a private area for three residents (Residents #341, #340 and #342) and by failing to sit next to one resident while assisting the resident with a meal (Resident #77). The sample was 24. The census was 155 with 137 residents in certified beds. 1. Review of Resident #341's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/30/20, showed: -admission date of 12/30/15; -Severe cognitive impairment; -Diagnoses included diabetes, dementia, Alzheimer's disease and depression; -Insulin injections received 7 of 7 days. Review of the resident's November 2021 medication administration record (MAR), showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their transfer or discharge policy by not providing to the resident and/or their representative the written transfer notice at the time of the resident's facility initiated transfer, for 4 residents (Residents #84, #72 #135, and #71). The sample was 24. The census was 155 with 137 in certified beds. Review of the facility's Hospital Transfer of Resident policy, revised January 2019, showed: -Purpose: To provide prompt and safe transfer of resident from the facility and to ensure continuity of care through provision of pertinent resident information; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or resident representative of the bed hold requirements at the time of transfer to the hospital for various medical reasons for four of the 24 residents sampled (Resident #84, #72, #135, and #71). The census was 155 with 137 residents in certified beds. Review of the facility's Bed Hold Policy, undated, showed: -Purpose: To notify the resident and/or representative(s) of the Bed Hold Policy in writing at the time of admission, upon change or revision and when transferred to a hospital or during therapeutic leave, as well as the intent for readmission according to state and federal regulations; -Procedure: The facility will also give a copy of this policy to the resident and/or representative if transferred to a hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment of residents at least annually for nine residents (Residents #20, #5, #339, #284, #338, #136, #28, #335 and #334). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of Resident #20's medical record, showed admitted on [DATE]. Review of the residents Minimum Data Set (MDS, a federally required assessment instrument completed by facility staff) record, showed: -An annual assessment dated [DATE]; -A quarterly assessment dated [DATE]; -No annual assessment completed [DATE]. 2. Review of Resident #5's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 3. Review of Resident #339's medical record, showed admitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess a resident using the quarterly review instrument not less frequently than once every 3 months for six residents (Residents #20, #41, #8, #284, #335 and #334). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of Resident #20's medical record, showed admitted on [DATE]. Review of the residents Minimum Data Set (MDS, a federally required assessment instrument completed by facility staff) record, showed: -An annual assessment dated [DATE]; -A quarterly assessment dated [DATE]; -No quarterly assessment completed [DATE]. 2. Review of Resident #41's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An admission assessment dated [DATE]; -No quarterly assessment completed [DATE]. 3. Review of Resident #8's medical record, showed admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for five of 24 sampled residents (Residents #61, #71, #135, #11 and #84). The census was 155 with 137 residents in certified beds. 1. Review of Resident #61's admission Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 10/15/21, showed: -Moderate cognitive impairment; -No behaviors; -Required the assistance of one staff for walking, transfers, dressing, toileting and personal hygiene; -Always continent of bowel and bladder; -Diagnoses included high blood pressure, diabetes, dementia and depression. Review of the resident's November 2021 electronic physician order sheet (ePOS), showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess two residents for medication self-administration and obtain physician's orders (Resident #384 and #492), obtain physician's orders for a wanderguard (a device worn by a resident that triggers alarms and can lock monitored doors to prevent the resident leaving unattended) for one resident (Resident #61) and obtain oxygen orders for one resident utilizing oxygen (Resident #33). Facility staff also failed to provide showers as ordered for one resident (Resident #1), provide treatments as ordered for two residents (Resident #203 and #53) and perform weekly skin assessments for one resident (Resident #53). The sample was 24. The census was 155 with 137 residents in certified beds. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were knowledgeable about hazardous chemical protocol with utilization of safety data sheets (SDS) when one resident (Resident #339) ingested alcohol-based hand sanitizer. The facility staff failed to lock the medication/treatment cart when not in direct sight of the staff, failed to complete a smoking assessment for one resident (Resident #284) and failed to complete fall follow up for four residents (Residents #61, #490, #487 and #5). The sample was 24. The census was 155 with 137 residents in certified beds. Review of the facility's Emergency Safety Procedures for Hazardous Chemicals policy, effective November 2021, showed: -Purpose: Manage potential or actual exposure to hazardous material. Provide directives regarding the best way to respond quickly and appropriately. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the quality of the labs obtained when they failed to meet the applicable requirements for obtaining their own labs. The facility failed to ensure accurate results of the blood glucose test machines by not completing daily quality control checks and then used expired control check solution. The census was 155 with 137 in certified beds. Observation of the 700 hall treatment cart on [DATE] at 1:45 P.M., showed two boxes of control solution (solution used to test the accuracy of the blood glucose machine). The two boxes showed expiration dates of [DATE] and [DATE]. Each box had two bottles of control solution, one bottle of normal solution and one bottle of high control solution, used to test the accuracy of the glucometer. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff would follow the resident's wishes to request or refuse lifesaving treatments in the event the resident was found with no signs of life, by failing to ensure the resident's code status was consistently documented in the medical record, for two residents (Residents #134 and #136). In addition, the facility failed to have a written policy to implement advanced directives. The sample was 24. The census was 155 with 137 in certified beds. During an interview on [DATE] at 11:20 A.M., the administrator said the facility does not have an advance directive policy. 1. Review of Resident #134's electronic medical record, showed: -An electronic face sheet with an admission date of [DATE]; -A physician order dated [DATE], for cardio pulmonary resuscitation (CPR, lifesaving measures are to be performed); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the appropriate Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notices (SNF ABN) for two of two residents sampled as part of the Beneficiary Notice review who remained in the facility after being discharged from skilled services (Residents #7 and #43). The census was 155 with 137 residents in certified beds. 1. Review of the list of residents discharged from skilled services within the last six months, provided by the facility, showed Resident #7 discharged from skilled services on 7/5/21, and remained in the facility. Review of the notices provided to the resident, showed no SNF ABN notice provided. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their grievance policy by not ensuring a prompt resolution to a grievance regarding a missing tablet computer for one resident (Resident #338). The sample was 24. The census was 155 with 137 residents in certified beds. Review of the facility's Grievance Procedure, reviewed June 2021, showed: -Purpose: Residents and resident representative(s) are always encouraged to visit with administration any time they have input or concerns. In the majority of instances, the concern will be resolved. For those wishing to file a grievance, the following procedure would apply; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff failed to provide treatments as ordered by the physician for one resident who had a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) (Resident #336) and failed to routinely assess one resident who was at risk for developing pressure ulcers (Resident #84). The sample was 24. The census was 155 with 137 in certified beds. Review of the facility's Wound Care Protocol, revised 8/2018, showed: -Goals of assessment: Provide uniform description, facilitate communication among staff, adequate monitoring of progress or deterioration; -How to assess/document: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free from any significant medication errors, for one resident (Resident #28) who was administered two different insulins more than two hours after they were ordered to be administered. The census was 155 with 137 in certified beds. Review of the facility's medication administration policy, revised January 2021, showed: -Medications are to be given at the time ordered, within sixty minutes before or after designated time, or according to liberalized medication pass time. Review of Resident #28's electronic Physician Order Sheet (ePOS) showed: -An order dated 9/28/20, for Lantus-Solostar U-100 (long-acting insulin), 28 units twice a day, 7:30 A.M. and 4:30 P.M.; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the transmission of infection, when staff failed to clean glucometer machines (used to check blood sugar levels) before and/or after use and failed to clean the injection site prior to administering an insulin injection for two residents (Residents #134, and #75). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of the facility's Medication Administration policy, dated January 2021, showed: -Wash your hands before and after each resident contact. An alcohol based wash may be substituted; -The policy did not address injectable medication such as insulin. Review of #134's medical record, showed: [...]