Delmar Gardens of O'Fallon

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policies to monitor the water system and monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease, a bacterial disease commonly associated with water-based aerosols, in persons at risk) control that included specific control parameters based on the Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) standards and failed to develop procedures consistent with CDC guidelines to test residents with healthcare-associated pneumonia (pneumonia with onset 48 hours after admission) for Legionnaires' disease. The facility census was 157. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #17), in a review of 17 sampled residents, was free from a significant medication error, when staff administered antibiotic ear drops into the resident's right eye. The facility census was 165. Review of the facility policy, Medication Administration, revised January 2021, showed the following:)-Read labels on all medications three times: -a. Before removing medication from cart; -b. Before pouring; -c. After pouring;-Cross-check all medication orders that are new, or that you question; -a. Check physician's order against the electronic Medication Administration Record (eMAR); -b. Check eMAR against label on drug container; -c. Check label on drug container against the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer one resident (Resident #1), in a review of two sampled residents who transferred with a sit-to-stand lift. Staff identified Resident #1 was fatigued in the evening, and during transfer with the sit-to-stand lift, the resident's legs would not support his/her weight sufficiently. On the evening of 03/05/25, staff transported the resident in a sit-to-stand lift from his/her bathroom to his/her bed. Staff reported the resident's legs began to give way and the resident began to slide out of the lift sling (a sling that was positioned around the resident's back and under his/her arms), during a transport in the lift from the toilet to the bed. Staff rushed the resident to the bed while in the lift to prevent him/her from falling out of the sling. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective pest control program to address rodents in resident rooms. The facility census was 172. Review of the facility policy for Pest Control with a revision date of 10/2022 showed: -Purpose: to ensure that the facility is free of exposure to pests to include mice; -The Director of Environmental Services is the designated coordinator for this facility. This person acts as a liaison between the building occupants and the pest management provider; -Regular inspections will be performed by both the Director of Environmental Services/designee and the contracted pest management professional. They will note situations that are conducive to pest populations and recommend repairs, sealing of pest entry entries, clutter reduction, improved sanitation and monitoring procedures; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in accordance with professional standards for food service safety. Staff failed to label, date, and seal opened food items. Staff failed to store food items per manufacturer's label instructions, store food items off the floor, and store food items in an area separate from resident medications and related items. Staff failed to discard food items that were expired or showed visible signs of deterioration. Staff failed to properly clean ice machines, properly store ice scoops, and ensure an air gap was present at each ice machine drain. Staff failed to ensure food and beverage containers and utensils were in good condition and were handled, dried and stored in a sanitary manner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for five residents (Resident #78, Resident #26, Resident #140, Resident #87, and Resident #43) in a review of 35 sampled residents when call lights were not accessible at all times to the residents. The facility also failed to accommodate one resident's (Resident #121's) need for assistance, including assistance with toileting, which resulted in incontinence. The facility census was 149. Review of the facility policy, Call Lights, last reviewed 6/21, showed the following: -Purpose was to get to the resident when he/she calls for assistance and to assist the nurse in meeting the resident's requests; -Check to see that the resident's call light is within reach; -Go to the resident as soon as he/she calls. Answer within 5-15 minutes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for three residents (Resident #307, #309 and #403) in a review of 35 sampled residents. The facility census was 149. Review of the facility policy for Following Physician Orders, dated 7/29/21, showed: -It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurses (RN), Licensed Practical Nurses (LPN)) and other Healthcare Professionals, follow Physician Orders in accordance to State, Federal regulations and their respective practice acts; -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided eight residents (Resident #11, #89, #80, #83, #78, #306, #307 and #311) in a review of 35 sampled residents and one additional resident (Resident #120), activities of daily living (ADL) care, including showers, nail care, shaving, oral care, incontinence care and assistance at meal time. The facility census was 149. Review of the facility policy titled Shaving, dated 5/2021, showed the following: Purpose: -To remove excessive hair from the face; -To provide cleanliness; -To improve resident morale and appearance. Review of the facility policy titled Nails, Care of (Finger and Toe), dated 5/2021, showed the following: Purpose: -To provide cleanliness; -To prevent spread of infection; -For comfort; -To prevent skin problems; -NOTE: Fingernails of diabetic residents are to be cut by the nurse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care of a urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) for three residents (Resident #58, #20 and #11), in a review of 35 sampled residents. The facility census was 149. Review of the facility policy, Catheter Care, revised 3/2021, showed the following: Purpose: -To keep indwelling catheter free of discharge and/or crusting which can cause infections; -Attach bag to bed frame only; -Never lift bag above bladder level (source of infection). 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three additional residents (Resident # 39, #51, #109), who received insulin injections, were free from significant medication errors. Staff failed to prime (remove the air from the needle and cartridge) the Humalog Kwik pen (prefilled pen of fast acting insulin (medication injected under the skin used to treat diabetes)) needle as instructed by the manufacturer prior to administration of the medication, resulting in administration of less, or more than the ordered dose of Humalog. Staff failed to hold the needle against the resident's skin for the manufacturer's suggested time after the administration of the medication. The facility census was 149. Review of the facility policy, Insulin Administration, dated 05/2021, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use disposal methods for controlled medications that involved a secure and safe method to prevent diversion and/or accidental exposure. The facility failed to keep discontinued/outdated Schedule II medications (narcotic medications with a high potential for abuse) stored in containers or cabinets and under double lock in the medication room. The facility failed to ensure staff kept medications locked up or secured when staff left medications unattended and not within sight on the medication cart and at the nursing desk and left the medication cart unlocked. The facility census was 149. Review of the facility's policy, Disposal of drugs, revised 12/2020 showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served to meet the needs of the residents when staff failed to prepare and serve all items listed on the menu, failed to serve food items for each diet type according to the menu, and failed to serve the correct serving sizes per the menu. The facility census was 149. 1. Review of the diet spreadsheet menu for the lunch meal on 5/8/24 showed the following: -Staff was to serve fruit garnish (2 ounces) to residents with a regular, finger foods, low sodium, and no concentrated sweets (NCS) diet; -Staff was to serve a peach half (2 ounces) to residents with a mechanical soft diet; -Staff was to serve pureed peach (2 ounces) and pureed tomato (2 ounces) to residents with a pureed diet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and serve food at a safe and appetizing temperature and to conserve the flavor of food items. The facility census was 149. 1. Review of the facility's undated policy, Monitoring Food Temperatures for Meal Service, showed the following: -Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures; -The temperature for each food item will be recorded on the Food Temperature Log. Foods that required corrective action (such as reheating), will have the new temperature recorded with a circle around it next to the original temperature; -If the serving/holding temperature of a hot food is not at 135 degrees Fahrenheit (F) or higher when checked prior to meal service, the item will be reheated to at least 165 degrees F for a minimum of 15 seconds; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents, including those with a physician's order for a mechanical soft diet, received food items with the proper texture to allow for foods to be easily swallowed. The facility census was 149. 1. Review of the facility policy, admission Diet Orders, effective June 2021, showed the following: -Purpose: To ensure each resident has a diet order prescribed by the physician and documented in the medical health record. The safest diet for each resident will be ordered; -All diet orders will be reviewed upon admission by the charge nurse to assure that they conform to the language of the facility offered diets; -If there is a particular dysphagia diet that is not offered by the facility, the diet should be downgraded to a diet used in the community until a speech therapist can evaluate the resident; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow appropriate infection control and prevention procedures while providing care to 12 residents, (Resident #11, 58, 59, 74, 77, 78, 87, 89, 120, 121, 309 and 606), in a review of 35 sampled residents. Staff failed to use appropriate hand washing and gloving techniques while providing care, failed to wear appropriate personal protective equipment (PPE), failed to utilize enhanced barrier precautions (EBP) during care and failed to ensure proper infection control was utilized for respiratory care supplies. The facility census was 149. Review of the facility policy, Enhanced Barrier Precautions (EBP), revised 3/2024, showed the following: -Purpose was to reduce the spread of multi-drug resistant organisms (MDRO); -EBP was indicated for residents with any of the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal vaccine (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for three residents (Residents #26, #94 and #403), in a review of 35 sampled residents. The facility census was 149. Review of the facility policy Pneumococcal Vaccination of Residents dated 2/2022 showed the following: Purpose: -To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP); Policy: -Upon admission, residents will be assessed for need of pneumococcal vaccination. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three residents (Resident #80 and #403) in a review of 35 sampled residents, were treated in a manner to maintain dignity and respect. The facility census was 149. Review of the facility's undated Residents' Rights policy, showed the following: Dignity and Respect: -Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based. You have the right to expect that we will: 1. Treat you as an individual and assist you in getting the most out of the programs and services we offer; 4. Provide safeguards against any kinds of harsh or abusive treatment. 1. Review of Resident #403's care plan, dated 4/29/24, showed the following: -The resident is at risk for falls due to weakness; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #72), a resident with identified history of ingesting non-food items such as Styrofoam, in a review of 35 sampled residents, was served food on Styrofoam. Additionally, the facility failed to ensure staff safely transferred one additional resident, (Resident #306), with a gait belt, when staff assisted and lifted the resident for transfer by placing their hands underneath the resident's arms during the transfer. The facility census was 149. Review of the facility policy for Gait Belt Use, dated 7/2015, showed: -Purpose: to provide control and balance of a resident that required physical assistance for transfers and gait; -Gait belts should be used with all residents that require physical lifting assistance for transfers and/or ambulation; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide food in a form as ordered by the physician, monitor weights, notify the physician of the refusal of nutritional supplements and weights for two residents with significant weight loss, (Resident #59 and #305), in a review of 35 sampled residents. The facility census was 149. Review of the facility policy for Weight Monitoring, dated 11/2018, showed: -Purpose: to obtain accurate weight of each resident and maintain control of weight changes; -Residents are weighed on admission, weekly for the first four weeks and monthly thereafter, unless otherwise ordered by nursing order or the attending physician; -Residents are weighed upon admission and on a weekly basis for the first four weeks to establish a baseline weight; -Any resident with a weight gain/loss of five pounds will be re-weighed within 24 hours; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure equipment was maintained in good repair and safe operating condition so as not present a hazard to staff, residents, or visitors. The facility census was 149. Observation on 5/8/24 at 10:44 A.M., in the kitchen, showed the power cord of the food processor was frayed at the connection to the machine and was missing part of the cord's protective coating in an approximate one-inch long section. Observation on 5/7/24 at 12:54 P.M., in the 700 servery, showed the refrigerator compartment of a combination refrigerator/freezer unit was not working. The temperature on the unit read 105 degrees Fahrenheit. The door opened freely and felt warm inside the compartment. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold policy to the resident and/or resident representative for two residents (Resident #5 and #81), in a review of 35 sampled residents, when they were transferred to the hospital. The facility census was 149. Review of the facility's undated Bed Hold Policy, showed the following: -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 inform and give a written copy of this policy to the resident and/or representative upon admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently follow their policy to complete skin assessments to identify areas of concern to ensure timely implementation of interventions and treatment for one sampled resident, (Resident #2) of six sampled residents. The facility census was 167. Review of the facility policy for Pressure Ulcer Care and Documentation dated 7/21 showed: -Purpose: To prevent pressure injuries and/or prevent deterioration of existing pressure injuries: -Causes in part: impaired circulation, wrinkles,lumps in bedding and chairs; fragile skin caused by the aging process, pressure on bony prominence for example heels; -Warning signs: observe daily for the following signs of potential pressure injury signs and report accordingly: [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of food borne illness to 135 residents who resided in the facility and were able to consume meals. Concerns included: ensuring expired items were disposed of timely, proper dating and labeling of all food items, and providing proper training to all staff handling food.

Inspectors wroteBased on observation and interview, the facility failed to maintain ceiling vents free from a buildup of dust and failed to maintain ceilings in a clean condition. The facility census was 136. 1. Observations on 10/25/22 between 11:30 A.M. and 5:00 P.M., during the life safety code tour of the facility, showed the following: -In the 100 hall soiled utility room, two 4 inch by 4 inch vents and a 6 inch by 6 inch vent were covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; [...]

Inspectors wroteBased on record review, review of the Resident Assessment Instrument (RAI) Manual, and interviews, the facility failed to timely complete and submit quarterly Minimum Data Set (MDS) assessments for six (Residents (R) R5, R10, R24, R19, R6, R7) out of 41 sample residents. This deficiency had the potential of missed opportunities for care and services due to incomplete assessments done in a timely manner.

Inspectors wroteBased on record review, observation, and interview, the facility failed ensure one of three residents (Resident (R)1) reviewed for activities was provided an activity calendar and invited to attend activities.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure behavioral health services were provided for one of one sampled Resident (R)1 reviewed for behavioral health.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure medication, medication carts, and treatments cart were secured when unattended. This had the potential for medications to becaome diverted or for a cogntively impaired resident to potentially take the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the walk-in freezer at 0 degrees Fahrenheit (F) or below to keep items frozen solid; failed to ensure food items were labeled, dated, covered and discarded when expired; and failed to maintain an appropriate air gap on two ice machines. The total facility census was 183 with a certified census of 128. 1. Record review of the Refrigerator/Freezer Temperature Log sheet for the walk-in freezer located in the main kitchen, dated October 2019, showed the following morning and evening freezer temperatures: -October 1: 6 degrees F and 5 degrees F; -October 2: 14 degrees F and 6 degrees F; -October 3: 17 degrees F and 8 degrees F; -October 4: blank and 4 degrees F; -October 5: blank and 3 degrees F; -October 6: blank and 1 degree F. Observation on 10/07/19 at 11:03 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Resident #28 and #68), in a review of 25 sampled residents, and four additional residents (Residents #32, #115, #602 and #603) were treated with dignity and respect. The total facility census was 183 with a certified census of 128. 1. Review of the facility's undated policy, Resident Rights, showed the following: -Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based; -You will have the right to expect that we will treat you as an individual and assist you in getting the most out of the programs and services we offer. 2. During a group interview on 10/8/19 at 3:32 P.M., residents said the following: -Resident #115 said his/her table mate had to go to the bathroom and staff told this resident to go in his/her pants; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant to them for five residents (Residents #44, #51, #62, #424, and #426), in a review of 25 sampled residents, and for three additional residents (Residents #2, #58, and #601), when the facility failed to honor residents' preferences for time to awaken. The total facility census was 183 with a certified census of 128. 1. Review of the facility Resident [NAME] of Rights provided in the admission Agreement showed the following: -You are entitled to take part in planning your care and in being informed of all aspects of you care; -You may refuse any treatment you do not want. 2. Review of the facility policy, dated June 2002, titled Staff Assignments, showed the following: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure facility staff provided five of 25 sampled residents (Resident #28, #44, #16, #426, and #51) and one additional resident (Resident #601), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The total facility census was 183 with a certified census of 128. 1. Review of the facility's policy, Perineal Care, dated 01/2017, showed the following: -Purpose: to establish a routine for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection and prevent odors; -All residents will receive perineal care, as needed, in the morning before breakfast, every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent; -FEMALE: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ appropriate methods for repositioning for three additional residents (Residents #2, #600 and #601), when staff lifted and repositioned the residents under their arms and by the waist of the resident's pants. The facility also failed to ensure staff consistently implemented interventions identified to prevent falls for three residents (Residents #93, #77 and #426), in a review of 25 sampled residents. The total facility census was 183 with a certified census of 128. 1. Review of the Nurse Assistant in Long-Term Care Facility Student Reference, 2001 revision, Lesson Plan 3, Unit VII, titled Transferring Residents, showed: -The gait belt is a special belt that is placed around the resident's waist and provides the nurse assistant. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain urinary drainage bags (bag attached to a catheter to collect urine) below the level of the bladder and failed to keep catheter tubing and urinary drainage bags off of the floor or other surfaces for three sampled resident (Residents #51, #62, and #83), and for one additional resident (Resident #602). The total facility census was 183 with a certified census of 128. 1. Review of the facility policy, Catheter Care, dated October 2008 and last revised December 2009, showed the following: -Attach catheter bag to bed frame only; -Never lift bag above bladder level (source of infection). 2. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -The bladder is considered sterile. The catheter, drainage tubing, and bag are a sterile system; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for five residents (Residents #51, #425, #426, #62, and #93), in a review of 25 sampled residents and six additional residents (Resident #2, #58, #601, #603, #800 and #801). The total facility census was 183 with a certified census of 128. 1. Review of the facility assessment, reviewed with the Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement Plan Review (QAPI) committee, dated 9/11/19, showed: -There were 132 residents who required assistance from one to two staff with dressing, and 14 residents who were totally dependent on staff; -There were 115 residents who required assistance from one to two staff with bathing, and 38 residents who were totally dependent on staff; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served residents on a pureed diet the correct portion sizes of protein, and failed to serve residents on a regular diet full serving scoops of food items according to the spreadsheet menu. The total facility census was 183 with a certified census of 128. 1. Record review of the Order Report by Category, dated 10/7/19, showed three residents had a physician's order for a pureed diet. Review of the Diet Spreadsheet, Week 5, showed staff was to serve residents on a pureed diet a #6 serving (2/3 cup) of pureed Philly sandwich with bread. Observation on 10/7/19 at 12:19 P.M. of the 200 Hall servery steam table showed a #8 scoop (1/2 cup) sat in the pan of pureed Philly sandwich with bread. Observation on 10/07/19 at 12:20 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evening snacks for two residents (Resident #93 and #96), in a review of 25 sampled residents, and for four additional residents (Residents #23, #32, #60, and #115) who participated in a group interview. The total facility census was 183 and the certified census was 128. 1. Review of the facility policy Snack Availability from the Family Dining Services Policy and Procedure Manual, dated 2014, showed the following: -Evening snacks were offered to all residents unless contraindicated by the physician's order; -A variety of snacks were offered to residents at bedtime. The variety will include snacks for various textures and therapeutic restrictions; -The food service department will be responsible for supplying, refilling and discarding unused snacks in the designated snack area(s). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to turn and reposition two additional residents (Residents #2 and #601), who were at risk for developing pressure ulcers. The total facility census was 183 with a certified census of 128. 1. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -A pressure ulcer is an inflammation, sore, or lesion that develops over areas where the skin and tissue underneath are injured due to a lack of blood flow and oxygen supply to an area of the body; -This lack of circulation/blood flow and oxygen supply usually happens because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident is positioned; pressure is the main cause; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication regimen for one resident (Resident #53), in a review of 25 sampled residents, and for one additional resident (Resident #10), were free of unnecessary medications when their medical record lacked evidence the facility had a system to monitor the residents to ensure gradual dose reductions (GDR) were made in an effort to reduce or discontinue the medications. The facility also failed to ensure physicians orders for as needed (PRN) psychotropic medications were limited to 14 days as required except when an attending physician believed it was appropriate the PRN order be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the as needed order. The total facility census was 183 with a certified census of 128. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and implement a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease). The total facility census was 183 with a certified census of 128. 1. Record review of the facility policy and plan, Water Management Program, showed the following: -The program was developed to identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in the facility water systems; -The program was a multi-step process that required continuous review and actions to be taken during regularly scheduled intervals to prevent Legionella and other bacteria from developing in the water delivery system; [...]