Delmar Gardens West

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to cover food and failed to ensure that expired thickened dairy products were discarded. The facility also failed to ensure kitchen equipment was kept clean during three of five days of observation. In addition, the facility failed to maintain records of dish washing temperature logs as well as chloride testing logs. Furthermore, the facility failed to follow the puree recipes for six of the seven purees observed and failed to ensure dishes were properly washed in between use. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 181. 1. Observation of the kitchen walk in (left side) cooler on 4/7/25 at 11:12 A.M., 4/8/25 at 3:13 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 37 opportunities observed, five errors occurred resulting in a 13.51% error rate (Residents #67, #112, #157 and #141). The census was 181. Review of the facility's Insulin Administration via Pen Devices policy, last reviewed 5/2021, showed: -Purpose: To safely administer insulin via pen devices according to physician orders and facility recommendations; -Insulin pens containing multiple doses of insulin are meant for use on a single person only and should never be used for more than one person, even when the needle is changed. Insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable standards of practice. The facility identified five medication rooms. Issues were found in two of the three medication rooms checked. Staff failed to double-lock the refrigerated controlled medications. The sample was 35. The census was 181. Review of the facility's Medications, Controlled Drugs policy, last revised 2/2023, showed: -All controlled medications must be stored in separately locked area that requires a different key; -Refrigerated Ativan (Lorezepam) liquid and injectable medications require a small lock box for the refrigerator. Review of the facility's Storage of Drugs policy, updated 12/21, showed compartments and areas containing drugs are locked when not in use or when left unattended. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control practice during care of residents. Staff failed to follow Centers for Disease Control and Prevention (CDC) guidance for Personal Protective Equipment (PPE) use for one resident with a contagious form of diarrhea and failed to ensure the facility policy for isolation was held to the same standard as the CDC guidance (Resident #424). Staff failed to ensure insulin pens were only for single resident use for one resident (Resident #67) when staff prepared to administer a different resident's insulin pen to the resident, prior to being stopped by the surveyor. Staff failed to follow proper enhanced barrier precaution (EBP, precautions used on residents with high risk of getting infections, who are not infectious themselves) for one resident who received personal care (Resident #22). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable, home-like environment when staff did not ensure one resident's (Resident #53's) shower drainage was properly maintained to allow water to flow unobstructed. The sample size was 35. The census was 181. Review of Resident #53's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/25, showed the following: -Diagnoses included dementia and chronic obstructive pulmonary disease (COPD, lung disease); -Shower/bathe self with Partial to moderate assistance. Review of the resident's care plan, dated 3/11/25, showed a deficit in mobility and activities of daily living (ADL) functions with COPD, dementia with cognitive impairment, and the need for occasional supervision and cueing with ADLs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining proper body mechanics while transferring a dependent resident (Resident #67). Two Certified Nursing Assistants (CNAs) placed a gait belt around Resident #67's abdomen loosely, and both CNAs placed their arms directly up and under resident's arm pits to lift the resident. One CNA grabbed his/her waistband to pull him/her to a standing position. The sample was 35. The census was 181. Review of the facility's Gait belt policy, dated effective 7/2015, Reviewed 6/21, showed: -Wrap gait belt around resident's waist and pull the strap through the buckle to tighten; -4. Gait belt should be snug but not uncomfortable. Make sure you can slide your open flat hand between the belt and resident; -6. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure intravenous (IV) services provided were consistent with professional standards of practice when a Licensed Practical Nurse (LPN) removed a peripherally inserted central catheter (PICC line, a thin, soft, long catheter (tube) that is inserted into a vein in the arm, leg or neck that is used for IV medications and fluids) for one resident (Residents #142). The sample was 35. The census was 181. Review of the Rules of Department of Commerce and Insurance, Division 2200-State Board of Nursing, Chapter 6-Intravenous Infusion Treatment Administration, dated 5/31/24, showed: -Definitions: Administer: to carry out comprehensive activities involved in IV infusion treatment modalities that include, but are not limited to, the following: observing; performing; monitoring; discontinuing; maintaining; regulating; adjusting; [...]

Inspectors wroteBased on interview and record review, the facility failed to timely address the pharmacist recommendations from the Drug Regimen Review (DRR) for two residents (Residents #157 and #16). The sample was 35. The census was 181. Review of the facility's DRR policy, dated reviewed 5/21, showed: -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; and prioritize patient goals, safety, and quality of life; -Procedures: the consultant pharmacist reviews each resident chart to identify and address any irregularities: medication duration and medication monitoring; -The consultant pharmacist will review the chart of every resident each month and document the DRR as follows: [...]

Inspectors wroteSee Event ID 0G6G12 Based on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled residents (Residents #1) when staff failed to obtain daily weights and send them to the resident's cardiologist per the physician's order. The census was 180.

Inspectors wroteSee Event ID 0G6G12 Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents by failing to follow their transfer policy when Certified Nurse Aide (CNA) B, without assistance, attempted to transfer a resident using a Hoyer lift (mechanical lift) (Resident #1). The attempted transfer resulted in the resident sliding off of the lift and hitting the floor. The resident was sent to the hospital for evaluation. The census was 180.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent roaches and gnats in the kitchen, where residents' food was prepared and served. The census was 181. Review of the facility's Pest Control Policy, revised 08/2024, showed: -Purpose: To ensure that the facility is free to exposure to pests to include, but not limited to insects, cockroaches, rats, mice, bed bugs, etc; -Procedure: -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 Environment Service/designee and the contracted pest management professional. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled residents (Residents #1) when staff failed to obtain daily weights and send them to the resident's cardiologist per the physician's order. The census was 180. Review of the facility's Physician Orders, Following policy, dated 6/29/21, showed: -Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurse (RN)/Licensed Practical Nurse (LPN)) and other Healthcare Professionals, follow Physician Orders in accordance to State, Federal regulations and their respective practice acts; -Procedure included: -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 the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents by failing to follow their transfer policy when Certified Nurse Aide (CNA) B, without assistance, attempted to transfer a resident using a Hoyer lift (mechanical lift) (Resident #1). The attempted transfer resulted in the resident sliding off of the lift and hitting the floor. The resident was sent to the hospital for evaluation. The census was 180. Review of the facility's Transfer and Lift policy, reviewed 5/2021, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment by failing to ensure three sampled residents on the 100 unit had sufficient hot water for at least three months (Residents #1, #4 and #6). This had the potential to affect all 17 residents who resided on the 100 unit. The census was 185. 1. Review of Resident #1's admission Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, generalized anxiety disorder and pain in right hip due to osteonecrosis (occurs when part of the bone does not get blood flow and dies). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/23, showed: -Cognitively intact; -Able to make self understood; -Able to understand others. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was issued a 30-day discharge and known to be homeless, with a diagnosis of major depression, did not receive access to behavioral health services as an option to process emotional stressors (Resident #1). The census was 185. Review of the trauma informed care and behavioral health management policy, revised 9/2022, showed: -Purpose: the facility will treat all residents with love, care and understanding. The facility believes all behaviors have meaning and is often a way of communication of a need. Assist in the early identification of residents past traumatic events/behaviors and to develop and implement interventions to manage or deescalate those behaviors. The community provides behavioral health services to residents requiring such services; -Definition: Behavioral health: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide timely basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped) for one of four sampled residents, who had physician orders for CPR and was found by staff without a pulse (Resident #1). The resident expired. The census was 191. The Administrator was notified on [DATE], of the Immediate Jeopardy (IJ) past non-compliance, which occurred on [DATE]. The facility provided training and in-servicing for all staff regarding the facility's CPR policy and using proper definitions/verbiage when reporting on CPR/Death Reporting Form. The IJ was corrected on [DATE]. Review of the facility's CPR Initiation, When Indicated Policy, revised [DATE], showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to uphold residents' rights by turning off residents' call lights without helping the residents, resulting in residents having to wait long periods of time for help, including one sampled resident (Resident #11) and failed to provide a homelike environment when the residents were served meals on Styrofoam plates for an extended amount of time, including one sampled resident (Resident #182). The sample was 35. The census was 183. 1. Review of Resident #11's care plan, revised on 6/26/23, showed: -Problem: The resident is incontinent of bowel and bladder related to functional mobility deficit, wheelchair dependency and the need for staff assistance with care; -Goal: Staff will attempt to keep the resident dry and free of odors and infection through the next review; -Approach: Assist to toilet per scheduled plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by not completing post-fall documentation for two residents (Resident #10 and Resident #128). The facility also failed to follow their policy by not completing a self-administration assessment and obtain physician orders for one resident (Resident #127) that had medications located at his/her bedside. The sample was 35. The census was 183. Review of the facility's Post-Fall Assessment policy, revised October, 2021, showed: -The nurse on duty will complete a post-fall assessment event for each fall; -The charge nurse will implement any immediate interventions necessary to minimize risk of future falls. Be sure to note the date of the fall, any injuries and any new/revised interventions; [...]

Inspectors wroteBased on observation and interview, the facility failed to keep storage areas clear of trash, keep the kitchen floor, walk in fridge, ice cream storage, and fryer clean, and failed to ensure staff followed the facility's hairnet/beard net policy. This had the potential to affect all residents who consumed food prepared by the facility. The sample was 35. The census was 183. Review of the facility's cleaning rotation policy, dated 2014, showed: -Guideline: Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions. -Procedure: items cleaned daily: kitchen floors, stove top, exterior of large equipment; Items cleaned weekly: store rooms and shelves. 1. [...]

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 buttock and genitals), who was left soiled for an extended period of time (Resident #11). In addition, the facility failed to adequately groom one resident (Resident #90), who was observed with food in his/her beard. The sample size was 35. The census was 183. Review of the facility's Call Lights-Answering policy and procedure, revised January 2017, showed: -Purpose: To get to the resident when he/she calls for assistance. To assist the nurse in meeting the resident's request; -Procedure: -Go to the resident as soon as he/she calls. Answer within five to 15 minutes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory services were provided were consistent with professional standards of practice on one resident (Resident #128) when staff failed follow the facility policy and obtain physician orders related to cleaning the resident's Continuous Positive Airway Pressure machine, (C-PAP, a device that uses mild air pressure to keep breathing airways open while sleeping). The sample was 35. The census was 183. Review of the facility's C-PAP Respiratory Care policy, revised July 2021, showed: -Purpose: Obstructive sleep apnea (periods when breathing stops) is a sleep disorder that occurs when the airway is obstructed or blocked and as a result, no air moves into or out of the lungs; -Cleaning: -Daily: Wash mask with warm washcloth or C-PAP mask or wipes; -Weekly: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #127) was free from significant medication error by not notifying the physician and the pharmacy that the resident was refusing his/her Incruse Ellipta inhaler (a medication to treat chronic (long term) lung disease) that was dispensed in place of Spiriva Respimat (a medication to treat chronic lung disease). The sample size was 35. The census was 183. Review of the facility's Following Physician Orders policy, dated 6/29/21, showed: -Purpose: It is the policy of the community to ensure that all licensed professional nurses and other healthcare professional, follow the physician order in accordance to State, Federal regulations and their respective practice acts; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals at the proper temperature controls when the medication refrigerator thermometer in unit 100 medication room showed out-of-range temperatures. The facility identified having five medication rooms. The census was 183. Review of the facility's Pharmacy Policy/Procedures Storage of Drugs policy, dated revision 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; -Medication which require refrigeration are kept in a refrigerator in the locked medication room. Drugs stored under refrigeration are stored separately from food. All refrigerated areas and devices have a temperature between 36 - 46 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation and interview, the facility failed to post the most recent survey results in a place readily accessible to residents, family members and the public. Furthermore, the facility failed to post the plan of correction related to the most recent survey and post notice in prominent locations of the availability of the reports for any individual to review. The census was 235. Observation of the facility's front lobby on 1/7/20, 1/8/20, 1/9/20, 1/10/20, 1/13/20 and 1/14/20, showed the following: -A frame sat on a ledge behind the receptionist desk, contained an 8 1/2 inch by 11 inch sign which read For your review, a copy of the current facility inspection is located at the reception desk in a binder marked State Survey. Our administrative staff will be happy to answer any content questions you may have. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document if a registered dietician (RD) recommendation was given to a resident's physician, obtain a physician order to discontinue weekly weights, complete a resident assessment and/or vital signs upon readmission to the facility, obtain an order to care for a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall), date oxygen tubing, and conduct monthly blood pressures. In addition, the facility failed to obtain orders for tubi grips (tubular bandage that can be used to treat edema (swelling)) and to record urinary output from the catheter (a sterile tube inserted into the bladder to drain urine) each shift as physician ordered, for ten of 35 sampled residents (Resident #381, #15, #91, #141, #140, #160, #153, #20,#100 and #129). The census was 235. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect three residents (Resident #65, #129 and #203) from potential harm by not following the facility policy for transferring with a Hoyer lift (mechanical lift used to transfer a resident from one surface to another) for three of five Hoyer lift transfers observed. The sample size was 35. The facility census was 235. 1. Review of Resident #65's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/27/19, showed the following: -Severely impaired cognition; -Dependent on staff for mobility and personal hygiene; -Diagnoses included heart failure, dementia and chronic lung disease. Review of the electronic physician's order sheet (ePOS), showed an order, dated 11/23/15, for two person transfer assist with full body lift. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physicians addressed residents' pharmacist recommendations within an acceptable time frame for seven (Residents #94, #213, #28, #100, #187, #20 and #51) of 35 sampled residents. The census was 235. 1. Review of Resident #94's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/10/19, showed the following: -Limited assistance required for dressing; -Received dialysis (process for removal of waste and excess water from the blood due to kidney failure); -Diagnoses included orthostatic hypotension (decrease in blood pressure when standing), end stage renal disease (ESRD-chronic irreversible kidney failure), diabetes, hyperkalemia (higher than normal potassium level in the blood), depression and bipolar (mood swings between depression and mania) disorder. [...]

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to discard expired milk and failed to ensure that thickening products were used or discarded by the recommended date. The census was 235. 1. Observation of the middle cooler on 1/10/20 at 6:45 A.M. showed a whole gallon of whole milk with an expiration date of 1/7/2020. 2. Observations of the large storage room on 1/7/20 at 10:58 A.M. and 1/10/20 at 6:45 A.M., showed several individual boxes of Thick and Easy, nectar consistency containers, with best by dates of 11/12/19. 3. During an interview on 1/14/20 at approximately 10:30 A.M., with the corporate nurse, registered dietician, food services manager and the administrator, the food services manager said he would expect all food items to be properly labeled, dated and stored. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to follow acceptable infection control practices to prevent the spread of infections by not washing their hands and/or changing gloves during perineal care (peri-care, cleaning the front of the body from hips, between legs and the buttocks) and improper placement of urinary catheter tubing and drainage bag for five sampled residents (Residents #159, #280, #129, #213 and #200). The sample size was 35. The census was 235. 1. Review of Resident #159's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/19, showed the following: -Cognitively intact; -Extensive assistance required for toileting and personal hygiene; -Occasionally incontinent of bowel and bladder; -Diagnoses included diabetes, dementia and lung disease. [...]