Delmar Gardens South

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) received adequate assistance to prevent accidents when staff performed a Hoyer (mechanical lift) transfer with a torn Hoyer sling on 05/06/26 after staff observed a tear in one of the straps of the Hoyer sling. All four Hoyer straps ripped during the transfer and the resident fell to the floor which resulted in fractures to both of the resident's femurs (the upper leg bone, that is the longest and strongest bone in the human body and is the structural link between the hip and knee) that required surgery. The sample was 6. The census was 232 with 174 residents in certified beds. The Administrator was notified on 06/11/26 of the Immediate Jeopardy (IJ) past non-compliance, which occurred on 05/06/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label and store medications according to acceptable standards of practice, for two of seven medication carts reviewed. The facility failed to date insulin pens when removed from the refrigerator and placed in the medication cart. In addition, the facility failed to ensure narcotic medications were always maintained under double lock when not under direct supervision. The facility identified 14 medication/treatment carts. The census was 240 with 184 in certified beds. Review of the facility's Insulin Administration via Pen Devices Policy, reviewed on 5/21, showed: -Purpose: To safely administer insulin via pen devices according to physician orders and the facility's Policy and Procedure recommendations; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents when a Certified Nursing Assistant (CNA) failed to ensure two staff were present before providing care, which resulted in a fall where the resident suffered a skin tear to the left upper extremity (LUE), a purple bruise purple above his/her left eye with a laceration on top of the bruise (Resident #33). The census was 240 residents, with 184 in certified beds. Review of the facility's Transfer and Lift Policy (butterfly), dated February 2020, Reviewed on May 2021, showed: -Policy: [...]

Inspectors wroteBased on observation and interview, the facility failed to post in a place readily accessible to residents, family members, legal representatives of residents and visitors the results of the most recent survey and complaint investigations. The census was 240 with 184 in certified beds. Observations on 9/11, 9/12, 9/13 and 9/16/24, showed no visible survey results maintained at the entrance of the building, in the lobby of the building or at the desk with the receptionist. No visible signs were posted for the location of the survey results and/or availability of the last survey or complaint investigations. During a group interview on 9/13/24 at 10:54 A.M., nine residents, who the facility identified as alert and oriented, attended the group meeting. Eight residents said they did not know where the survey binder was located and had never viewed it. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1) who required staff assistance with transfers and mobility when toileting. On 1/15/24, after the resident asked for privacy in the bathroom, staff did not ensure the resident was in a safe position. The resident fell and sustained an L2 (second lumbar spinal vertebrae in the human body) compression fracture (the fracture occurs when the bone collapses, and the front (anterior) part of the vertebral body forms a wedge shape). The sample size was 3. The census was 229 with 171 in certified beds. Review of the facility's Following Physician Orders policy and procedure, dated 6/29/21, showed: -Purpose: [...]

Inspectors wroteBased on observation and interview, the facility failed to follow their policy when staff failed to acknowledge audible and visual call light signals located above the resident's door or answer call lights promptly for three residents (#1, #4 and #7). The census was 224. Review of the facility's Call Lights Answering policy, reviewed 6/2021, showed: -Purpose: To get to the resident when he/she calls for assistance; -To assist the nurse in meeting the resident's request; -Procedure: 1. Go to the resident as soon as he/she calls. Answer within 5-15 minutes. Emergency lights should be responded to immediately to prevent injury; 2. Ask the resident, in friendly manner, what he/she needs; 3. Turn off the call light so that others will know that it has been answered; 4. If you can, do what the resident asks you. Be sure that what he/she wants is permitted; 5. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to monitor and manage administration of intravenous (IV) vancomycin (used to treat serious bacterial infections) for 1 (Resident #103) of 1 residents reviewed for IV vancomycin.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to label and date food. In addition, the facility failed to ensure that expired food items were discarded. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 215 with 127 in certified beds. 1. Observations of the kitchen on 10/21/19 at 8:56 A.M., 10/22/19 at 11:23 A.M., and 10/24/19 at 10:56 A.M., showed the following: -Walk in cooler: A plastic gallon container, one fourth filled, with garlic. Best if used by 10/20/19, labeled on the container; -Walk in freezer: A brown paper bag wrapped in plastic wrap, not labeled and without a date; -Storage room downstairs: -A gallon of Kens Supreme Honey Mustard, dated 12/5/18, with a manufactured date of October 2018; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to accurately code the Minimum Data Set regarding the use of oxygen, indwelling urinary catheter (a tube inserted into the bladder for purpose of continual urine drainage) use, falls, diagnoses, and discharge status for five of 25 sampled residents including two closed records (Residents #49, #31, #64, #69 and #115). The census was 215 with 127 in certified beds. 1. Review of Resident #49's electronic physician order sheet (ePOS), showed orders dated 8/11/19 for oxygen per nasal cannula (NC) at 3 liters per minute (LPM), continuous. Staff may adjust the amount to keep oxygen saturations (percentage of oxygen in the blood) above 90 percent (%). Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/23/19, showed: -Cognitively intact; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received services to maintain good personal hygiene by failing to provide complete perineal care (peri-care, cleansing from the front of the hips, between the legs and buttocks to the back of the hips) for one of two perineal care observations (Resident #77) in certified beds. The census was 215 with 127 in certified beds. Review of the facility's perineal policy, revised 1/2017, showed: -Purpose: To establish routine practices for providing perineal care, which will cleanse to prevent skin breakdown, prevent infection and prevent odors. [...]