Delmar Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review it was determined that for one (R1) out of three residents reviewed for allergies, the facility failed to ensure a resident with severe food allergy was not served food containing an allergen. The facility's failure placed the residents at risk for a serious adverse outcome including respiratory depression, anaphylaxis or even death from consuming food with a severe allergy. Due to this failure an Immediate Jeopardy (IJ) was called on 7/15/26 at 3:00 PM. The IJ was abated on 7/16/26 at 12:00 AM.

Inspectors wroteBased on interview and record review, it was determined that for one (R1) out of three residents in the investigative sample, the facility failed to develop a comprehensive resident centered care plan for an identified care area.

Inspectors wroteSurveyor: [NAME]Based on interview, record review, document review, and facility policy review, the facility failed to ensure staff reported allegations of abuse immediately to the Administrator/designee and the administrative staff timely reported allegations of abuse to the state survey agency for 4 (Residents #19, #42, #88, and #93) of 8 sampled residents reviewed for abuse.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of resident property for 1 (Resident #67) of 8 sampled residents reviewed for abuse. Beginning on 07/05/2025 until 08/14/2025, the facility failed to protect and prevent misappropriation of medication with past non-compliance.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to implement their abuse policy when they failed to obtain witness statements from involved staff for 3 (Residents #19, #77, and #80) of 8 sampled residents reviewed for abuse.

Inspectors wroteSurveyor: [NAME]Based on interview, record review, and facility policy review, the facility failed to ensure a pharmacy recommendation was implemented for 1 (Resident #37) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on personnel file review and interview, the facility failed to ensure a qualified Dietary Manager (DM) was in place with appropriate competencies and skills to carryout the functions of the food and nutrition service with the potential to affect all 82 census residents.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to ensure the three-pan sink had adequate plumbing, the insulated plate dome covers were in good condition, the kitchen was maintained in a clean manner, and the sanitizer bucket and three-pan sink had adequate sanitizer levels in accordance with professional standards for food safety. The failure has the potential to contribute to food-borne illness and cross contamination for 82 census residents.

Inspectors wroteBased on record review, interview, and review of the facility's policy, the facility failed to ensure residents' Minimum Data Set (MDS) assessments accurately reflected the residents' status for one (Resident (R) 24) of 23 sampled residents. R24's most recent MDS indicated the resident had the serious mental illness (SMI) of bipolar disorder; however, there was not documented evidence in the resident's medical record to confirm the diagnosis. This failure placed the resident at risk for inaccurate and unmet care needs.

Inspectors wroteBased on observation, interview and record review it was determined that for two (R58 and R14) out of two residents reviewed for pressure ulcers, the facility failed to provide care and services to promote healing and prevent pressure ulcers. For R58 the facility failed to prevent an avoidable deep tissue injury from developing to the left heel and a stage 4 pressure ulcer to the right ankle causing harm. For R14 the facility failed to ensure that the resident was turned and repositioned to prevent pressure ulcers.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the correct concentration of sanitizing solution required to ensure proper sanitization of food preparation surfaces.

Inspectors wroteBased on interview and record review, it was determined that for three (R10, R12 and R16) out of three residents reviewed for PASARR, for R10, R12, and R126 the facility failed to ensure that a referral for a PASARR screening was completed following a new diagnosis of psychotic disorder which was not listed on the previous PASARR.

Inspectors wroteBased on observation, interview, and record review, it was determined that for three (R53, R58 and R67) out of eighteen (18) residents reviewed for care plans, the facility failed to accurately assess and document R53's dental status. For R67 and R58 the facility failed to include the use of heel boots and pxygen use.

Inspectors wroteBased on interview and record review, it was determined that for two (R15 and R46) out of eighteen residents reviewed for care plans, the facility failed to update these residents' care plans to reflect the use of insulin. 1. Review of R46's clinical record revealed: 2/17/20 - Resident was admitted to the facility. 3/9/21 - R46's care plan for diabetes was completed. 12/1/22 - A medication order was entered, as follows: Levemir FlexTouch U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen .: inject 4 units by subcutaneous route once daily. 8/29/23 - R46's most recent care plan meeting was convened. 10/4/23 untimed - Review of R46's care plan revealed there was no reference to insulin usage. 10/5/23 at approximately 10:25 AM - During an interview with E2 (DON), she confirmed there was no care plan for R46's use of insulin. 2. Review of R15's clinical record revealed: [...]

Inspectors wroteBased on observation, interview and record review, it was determined that for two (R14 and R58) of four residents reviewed for ROM/mobility, the facility failed to provide care to maintain or prevent further decline in function/mobility.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R67) out of three residents reviewed for respiratory care, the facility failed to ensure that R67 oxygen tubing was changed.

Inspectors wroteBased on observation and interview, it was determined that one medication room out of one medication reviewed the facility failed to maintain medications narcotics under a double locks for one out of one medication rooms. In addition, the facility failed to monitor refrigerator temperatures.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure sanitary disposal of garbage.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps in the MRR process.