A list of the most recent deficiencies for Delmar Gardens On The Green. 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? |
|---|---|---|---|---|
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-05 | 2023-05-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-05 | 2023-05-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-05 | 2023-05-12 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-04-05 | 2023-05-12 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-04-05 | 2023-05-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-05-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-05 | 2023-05-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-05 | 2023-05-12 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-04-05 | 2023-05-12 | 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 | 2023-04-05 | 2023-05-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-05 | 2023-05-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-04-05 | 2023-05-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-05 | 2023-05-12 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-04-05 | 2023-05-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-05 | 2023-05-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-05 | 2023-05-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-05 | 2023-05-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-09 | 2023-01-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2023-01-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-17 | 2022-11-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-17 | 2022-11-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-17 | 2022-11-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-17 | 2022-11-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-17 | 2022-11-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-10 | 2022-11-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-10 | 2022-11-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-10 | 2022-11-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-10 | 2022-11-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-10 | 2022-11-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-16 | 2022-04-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-16 | 2022-04-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-16 | 2022-04-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-16 | 2022-04-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-14 | 2021-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-07-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-23 | 2021-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-07-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-23 | 2021-06-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-23 | 2021-06-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-23 | 2021-06-04 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-04-23 | 2021-06-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-25 | 2019-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-25 | 2019-08-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-25 | 2019-08-08 | 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 | 2019-06-25 | 2019-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-25 | 2019-08-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-25 | 2019-08-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-25 | 2019-08-08 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-25 | 2019-08-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-25 | 2019-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-08-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-25 | 2019-08-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-25 | 2019-08-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-06-29 | 2018-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-29 | 2018-08-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-29 | 2018-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-29 | 2018-08-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-06-29 | 2018-08-10 | N |
| Use approved construction type or materials. | Fire Safety | 2018-06-29 | 2018-08-10 | 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 | 2018-06-29 | 2018-08-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-06-29 | 2018-08-10 | 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 | 2018-06-29 | 2018-08-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-29 | 2018-08-10 | N |
