A list of the most recent deficiencies for Delmar Gardens West. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-17 | 2024-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-17 | 2024-02-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-17 | 2023-12-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-17 | 2023-12-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-17 | 2023-12-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-17 | 2023-12-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-17 | 2023-12-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-17 | 2023-12-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-17 | 2023-12-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-17 | 2023-12-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-21 | 2023-07-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-05 | 2022-05-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-05 | 2021-12-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-05 | 2021-12-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-05 | 2021-12-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-05 | 2021-12-13 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-05 | 2021-12-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-15 | 2020-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-15 | 2020-03-02 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-01-15 | 2020-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-15 | 2020-02-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-15 | 2020-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-15 | 2020-02-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-15 | 2020-02-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-12-05 | 2019-02-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-12-05 | 2019-02-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-12-05 | 2019-01-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-05 | 2019-01-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-05 | 2019-01-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-12-05 | 2019-01-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-12-05 | 2019-01-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-05 | 2019-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-05 | 2019-01-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-05 | 2019-01-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-05 | 2019-01-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-05 | 2019-01-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-12-05 | 2019-01-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-12-05 | 2019-01-11 | N |
