Delmar Gardens on the Green

Inspectors wroteBased on interview and record review, the facility failed to obtain and document initial and weekly measurements of pressure ulcers (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device) for one resident (Resident #4). The sample was 8. The census was 118. The Administrator was notified on 11/26/25 of the past non-compliance. The facility has changed their process on how they assess residents at risk for pressure ulcers, as well as their process to document measurements of wounds for residents at risk. Staff were in-serviced on the new process. The deficiency was corrected on 11/17/25. Review of the facility's Pressure Injury Prevent and Wound Documentation policy, dated October 2025, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order when nursing staff on multiple occasions did not collect a physician ordered urine sample from a resident who had been admitted to the facility with a urinary tract infection (UTI) and who had a history of recurrent UTIs. The sample size was 3. The census was 111. Review of the facility's Following Physician Orders policy, effective date 6/29/25, showed:-Purpose: It is the policy of the community to ensure that all Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) and other healthcare professionals, follow physician orders in accordance with State, Federal regulations and their respective practice acts;-Procedure: -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the residents medical record; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation after a facility nurse discovered a resident (Resident #1), who was confused, with a bruise on his/her chest, an abrasion above his/her right eye, a skin tear on his/her nose and an abrasion on his/her right elbow. The resident could not tell the nurse how he/she sustained the injuries. The sample was 3. The census was 105. Review of the facility's Injury of Unknown Source policy, revised May 2021, showed: -Indicators of physical abuse may include but are not limited to: -Bruises and/or hematomas; -Injuries of unknown source-no abuse/neglect suspected; -If a logical/reasonable explanation of the source of the injury cannot be determined, notify your local state agency within two hours of discovery; -Staff must provide a statement as to their knowledge or lack of knowledge of the injury; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice where met, when staff failed to transcribe one resident's new treatment order onto the electronic treatment administration record (eTAR), resulting in the new treatment order not being administered from 7/24/24 to 8/2/24 as ordered by the physician for one resident (Resident #8) resulting in the wound showing signs and symptoms of infection. The sample was 18. The census was 96 with 83 residents in certified beds. Review of the facility's Following Physician Orders Policy, dated June 29, 2021, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity when staff left a resident exposed and visible from the hallway (Resident #10) and another resident in a hospital gown in the main dining room (Resident #21). In addition, staff failed to ensure two residents' (Resident #8 and #285) catheter bags (urine drainage bag) were not visible in the hallway from the residents' rooms. Staff also entered resident rooms without knocking (Resident #30 and #46). The sample size was 18. The census was 96 with 83 in certified beds. Review of the facility's undated Resident's Rights policy, showed: -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 a right to expect that we will: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents with a transfer notice when transferred to the hospital, for seven of seven residents investigated for hospital transfers (Residents #12, #45, #20, #43, #32, #81, and #8). The Census was 96 with 83 residents in certified beds. Review of the facility's undated Residents' Rights Policy, showed: -Admission, Transfer, discharge: The residents have the right to due notice of the reasons for transfer or discharge if such occurrence takes place. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 9/13/24, showed: -Should a brief interview for mental status be conducted? No; -Both long-term and short-term memory loss; -Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice to the resident, or their legal representative of the facility bed hold policy at the time of transfer to the hospital, for seven of seven investigated residents for hospital transfers (Residents #12, #45, #20, #43, #32, #81 and #8). The Census was 96 with 83 residents in certified beds. Review of the facility's undated Bed Hold Policy, showed: -Purpose: to notify the resident or representative of the Bed-Hold Policy in writing at the time of admission, upon discharge or revision and when transferred to a hospital or during therapeutic leave, as well as the intent of 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 establish a system of records of receipt and disposition of all controlled drugs in a sufficient detail to enable accurate reconciliation. The facility failed to ensure accuracy and monitoring for controlled substances for one of four electronic narcotic counts reviewed. The census was 96 with 83 in certified beds. Review of the facility's Medication Administration policy, effective date January 2021, showed: -All inventoried drugs are to be counted by licensed/certified personnel at each shift change. Any discrepancy must be called to the attention of the Director of Nursing (DON). Review of the facility's electronic narcotic count system reviewed on 9/30/24 at 1:39 P.M., showed the electronic screen showed a count 120 tablets of tramadol (opioid) 50 milligrams (mg) and the card in the cart showed 114 tablets. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, five errors occurred resulting in a 16.67% error rate (Residents #50, #74, #19 and #26). The census was 96 with 83 residents in certified beds. Review of the facility's Insulin Administration via Pen Devices policy, effective date 5/21, showed: -Purpose: To safely administer insulin via pen devices according to physician orders and the facility's Policy and Procedure recommendations; -Procedure: Prime the pen immediately before injection. Priming is dialing up two units of insulin and pressing the bottom on the pen to shoot some insulin into the air. You should see a drop of insulin at the end of the needle. More than one prime may be required for a new pen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. Problems were noted in one of three identified facility medication rooms and in one of four medication administration carts. The facility census was 96 with 83 residents in certified beds. Review of the facility's Storage of Drugs policy, updated 12/21, showed: -Drugs and medications are to be stored in the original container in which they were received. Refrigerator, freezer, and control room will be available in the pharmacy for medications requiring specific storage; -No discontinued, outdated, or deteriorated drugs or medications are stored in the facility over thirty (30) days. Review of the facility's Pharmacy Responsibility, dated 12/20, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the main kitchen floors, appliances and food storage areas were clean and free from debris. In addition, the facility failed to ensure outdated food was discarded. This affected all residents who ate at the facility. The census was 96 with 83 residents in certified beds. Review of the facility's undated Dining Services Clean-Sanitize-Disinfect policy, showed: -Policy: This facility will store, prepare, distribute and serve food under sanitary conditions to ensure proper cleanliness and food handling practices to prevent the outbreak of food-born illnesses is attained continuously; -Cleaning: The process of removing visible debris, dirt and dust and organize a space. Observation of the kitchen on 9/30/24 at 11:08 A.M., showed: -The floors throughout the entire kitchen contained white specs, dust, grease and water stains; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards when staff failed to perform hand hygiene between glove changes and/or between residents for four residents observed. (Resident #50, #19, #26 and #74). In addition, staff left the catheter bag for one resident (Resident #12) on the floor without a protective barrier, and failed to wear appropriate personnel protective equipment (PPE) for residents who required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs, bacteria or fungi resistant to multiple antimicrobials (an agent that kills microorganisms or stops their growth)); [...]

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 three of three sampled residents who expired and had money in their accounts longer than 30 days (Residents #301, #302 and #300). The census was 96 with 83 in certified beds. The deficiency was changed to past non-compliance after an Informal Dispute Resolution conference where both parties agreed the deficient practice was corrected prior to the survey. Facility staff realized in mid-April, 2024 that some discharged residents still had funds in the resident trust account. The facility completed the proper documentation for those discharged residents and the remaining trust fund balances were refunded to the proper authority. The past-noncompliance was corrected on [DATE]. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to position one resident safely (Resident #20) when staff turned the resident on the shower bed resulting in a fall, in which the resident was sent to the hospital and received 14 sutures. The sample was 18. The census was 96 with 83 residents in certified beds. The Administrator was notified on 10/4/24 at 3:00 P.M., of the past non-compliance, which occurred on 3/4/24. The facility provided training and in-servicing that began on 3/6/24 and ended on 3/18/24, for all staff regarding their policies on proper transfers and body mechanics. The past non-compliance was corrected on 3/18/24. Review of the facility's Transfer and Lift Policy (butterfly), dated reviewed 5/21, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident was free from verbal abuse and intimidation (Resident #1). On 8/19/23 between 3:30 P.M. and 4:30 P.M., during medication pass, Certified Medication Technician (CMT B) was observed by Certified Nurse Aide (CNA) C and Nurse A standing chest to chest with the resident, yelling/cursing at the resident, and/or throwing a towel at the resident. CMT B initially refused to leave the resident's room when Nurse A instructed him/her to do so and continued to yell and curse at the resident who was visibly upset. Furthermore, the facility failed to follow their policy, state and federal regulations when staff failed to ensure CMT B was removed from the building when he/she was seen by staff sitting in the resident smoking area and walking through the building unsupervised. The census was 103. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation, and failed to maintain documentation that a thorough investigation was conducted for an allegation of verbal abuse of a resident (Resident #1) and a staff member (Certified Medication Technician (CMT) B). Staff reported witnessing CMT B cursing/yelling and making intimidating statements while standing chest to chest with Resident #1. The facility census was 103. Review of the facility's Freedom from Abuse, Neglect and Exploitation Policy, most recently revised in 9/2022, showed: -Resident Safety Position Statement: It is the policy to maintain a living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, or mental); -Providing a safe environment for the resident is one of the most basic and essential duties of the facility. [...]

Inspectors wroteBased upon interview and record review, the facility failed to ensure residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice, when the facility failed to identify, assess and provide supportive interventions for (Resident #1) who had a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event/either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). Staff failed to identify the resident's past history of trauma, triggers which could cause re-traumatization and use approaches that were culturally competent and/or are trauma informed. [...]

Inspectors wroteBased on interview and record review, the facility failed maintain documentation that staff had notified residents and/or responsible parties in a timely manner when a resident's account was within the $200 Social Security (SSI) limit ($5,301.85) or when the resident's account was over the SSI limit ($5,301.85) per their policy. This affected two of six residents reviewed who received Medicaid benefits (Residents #3 and #35). The census was 100 with 83 in certified beds. Review of the facility's Policy on Protection of Resident Funds, dated 1/20/22, included: -The facility must establish and maintain a system that assures a full, complete and separate accounting system for each resident's personal funds entrusted to the facility on the resident's behalf; [...]

Inspectors wrote- Based on observation, interview and record review, the facility failed to ensure staff followed infection control prevention practices for two sample residents when one staff member adjusted a resident's oxygen tubing after he/she removed a soiled sheet from under a resident (Resident #15) and when another staff member placed a clean brief under a resident after he/she removed the old one with the same gloves (Resident #59). In addition, the facility failed to implement facility policies and procedures to ensure all employees who work 10 or more hours per week were screened appropriately for tuberculosis (TB), in accordance with the Division of Community and Public Health. The facility failed to ensure the two-step purified protein derivative (PPD) was completed for seven of 10 employee files reviewed. The sample was 25. The census was 100 with 83 in certified beds. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents have the right to make choices about aspects of their life in the facility that are significant to the resident, when the facility's staff failed to put one resident back to bed. The resident waited over an hour for assistance back to bed after he/she requested it (Resident #69). The sample was 25. The census was 100 with 83 in certified beds. Review of the Resident Rights handbook (found in the facility's admission packet) included: -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: -Treat you as an individual and assist you in getting the most out of the programs and services we offer; -Make sure your surroundings are safe, clean, and comfortable; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable and homelike environment for one resident (Resident #1), whose bathroom had a commode that contained feces and was unflushed, the floor was dirty with feces on it, and a lawn chair was inside of the bathtub. In addition, the facility failed to maintain the cleanliness of the resident shower rooms on the 100 and 300 units. The sample size was 25. The census was 100 with 83 in certified beds. Review of the facility's infection control policy and procedure manual, effective date 10/2019, showed: -Tile floors shall be wet-mopped daily, using approved sanitizing solution. Spills shall be attended to immediately; -Bathrooms shall be cleaned daily and special attention given to disinfecting the commodes, all grab bars, handles and door knobs; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received the necessary services to maintain good personal hygiene for one resident observed during perineal care (cleansing of the area between the legs to include the buttocks and genitals), who was left soiled for an extended period of time (Resident #59). The sample size was 25. The census was 100 with 83 in certified beds. Review of Resident #59's care plan, revised 12/26/22, in use during the time of the investigation, showed: -Problem: Resident is at risk for skin tears/bruises/pressure ulcers related to bowel incontinence, reduced mobility, and his/her need for assistance with all activities of daily living and transfers. Redness to scrotum and groin; redness/moisture related skin alteration to under right arm and neck; -Goal: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed post the results of the most recent survey in a place readily accessible to residents, family members and legal representatives of residents. Furthermore, the facility failed to maintain survey reports with respect to any surveys, certifications and complaint investigations made during the three preceding years, any plans of correction in effect with respect to the facility and/or post notice in a prominent location of the availability of the reports for any individual to review upon request. The census was 100 with 83 in certified beds. Observations throughout the survey on 3/30/23 through 3/31/23 and 4/3/23 through 4/4/23, showed no survey results maintained at the entrance of the building, in the lobby of the building or at the desk with the receptionist. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's order and meet professional standards of quality by not administering vitamin D as ordered, provide the location of the affected area for a treatment and inconsistently documenting a resident's output in the medical record, for three of 25 sampled residents (Residents #77, #61 and #101). The census was 142 with 125 residents in certified beds. 1. Review of Resident #77's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/14/19, showed the following: -No cognitive impairment; -Tired with little energy, poor appetite and trouble concentrating; -Independent with most activities of daily living (ADL's); -Lower extremity impairment on one side; -Diagnoses included anemia, high blood pressure and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with physician's orders for restorative therapy (RT,a program developed by a skilled therapist and carried out by nursing staff (usually a Certified Nurse Aide (CNA) or a restorative aide (RA)) services received those services. The facility identified 50 residents currently receiving restorative therapy, four were sampled and none of them received restorative therapy services as ordered (Residents #16, #5, #61 and #77). The sample size was 25. The total census was 142 with 125 residents in certified beds. 1. Review of Resident #16's medical record, showed the following: -admission date of 2/19/19; -Diagnoses included high blood pressure and congestive heart failure (CHF, impaired heart function). [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the floors free from food crumbs, debris, and stains and ensure equipment was kept clean during five of five days of observation. In addition, the facility failed to ensure the garbage disposal was wiped off and that the floor was free of dirty, free-standing water surrounding the garbage disposal. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 142 with 125 residents in certified beds. 1. Observations on 6/19/19 at 10:40 A.M., 6/20/19 at 1:43 P.M., 6/21/19 at 7:00 A.M., 6/21/9 at 11:17 A.M., 6/24/19 at 7:07 A.M., and 6/25/19 at 7:32 A.M. of the kitchen, showed the following: - The floor noticeably dirty with food crumbs, dirt, debris and stains; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff changed their gloves and washed their hands during incontinence care. Five residents receiving incontinence care were observed and problems were found with one (Resident #65). In addition, during the meal service, the facility failed to ensure staff wore hair restraints, changed their gloves and washed their hands after removing gloves. The sample was 25. The census was 142 with 125 residents in certified beds. 1. Review of Resident #65's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/30/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Limited assistance required for bed mobility and personal hygiene; -Occasionally incontinent of bowel and bladder; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate perineal care (peri-care, cleaning the front of the body from hips, between legs and the buttocks) for two of five residents observed (Resident #65 and #327) for personal care. The sample size was 25. The census was 142 with 125 residents in certified beds. 1. Review of Resident #65's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed the following: -No cognitive impairment; -Unable to ambulate; -Limited assistance required for bed mobility and personal hygiene; -Occasionally incontinent of bowel and bladder; -Diagnoses included heart failure, respiratory failure and diabetes. Observation on 6/21/19 at 5:40 A.M., showed the resident lay in bed on his/her back. Certified Nurse Aide (CNA) C entered the room, closed the door and donned gloves. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two residents (Resident #327 and #57) from potential harm by not following the facility policy for transferring with a Hoyer (mechanical) lift for two of five Hoyer transfers observed. The sample size was 25. The facility census was 142 with 125 residents in certified beds. Review of the facility's Mechanical Full Body Lift Policy, dated 9/2014 and last revised 1/2017, showed the following: -Purpose: To ensure that all nursing staff are using proper transfer techniques to minimize the risk of injury to resident and staff, while using full body lift; -Procedure: -Make sure you are using the correct pad for the lift selected; -Secure the assistance of another Certified Nurse Aide (CNA) or qualified employee; -Explain procedure and provide privacy; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all antipsychotic (a class of medication primarily used to manage psychosis, principally in schizophrenia and bipolar disorder) medications had supporting diagnoses to show the necessity for the medication and failed to document the residents' behaviors and the response to the antipsychotic medications for two residents (Residents #95 and #89). The sample size was 25. The census was 142 with 125 residents in certified beds. 1. Review of Resident #95's significant change Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/15/19, showed the following: -Cognitive impairment; -No behaviors; -Required staff assistance with transfers, toileting, bathing, hygiene and dressing; -Special services received as a resident: Hospice; [...]