A list of the most recent deficiencies for Delmar Gardens North. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-06 | 2023-12-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-06 | 2023-12-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-10-06 | 2023-12-16 | 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 | 2023-10-06 | 2023-11-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-06 | 2023-11-15 | 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 | 2023-10-06 | 2023-11-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-06 | 2023-11-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-06 | 2023-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-06 | 2023-11-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-10-06 | 2023-11-15 | Y |
| 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 | 2023-10-06 | 2023-11-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-06 | 2023-11-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-06 | 2023-11-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-06 | 2023-11-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-06 | 2023-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-06 | 2023-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-03 | 2023-03-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-03-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-30 | 2022-09-29 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-15 | 2022-07-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-26 | 2021-10-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-30 | 2021-10-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-30 | 2021-08-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-19 | 2021-05-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-08 | 2020-02-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-01-08 | 2020-02-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-08 | 2020-02-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-08 | 2020-02-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-08 | 2020-02-21 | 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 | 2020-01-08 | 2020-02-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-08 | 2020-02-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-01-08 | 2020-02-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-08 | 2020-02-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-08 | 2020-02-21 | 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 | 2020-01-08 | 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 | 2020-01-08 | 2020-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-08 | 2020-02-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-01-08 | 2020-02-21 | 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 | 2020-01-08 | 2020-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-08 | 2020-02-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-08 | 2020-02-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-21 | 2019-04-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-21 | 2019-04-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-02-21 | 2019-04-16 | 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 | 2019-02-21 | 2019-04-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-02-21 | 2019-04-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-21 | 2019-04-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-21 | 2019-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-21 | 2019-04-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-21 | 2019-04-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-21 | 2019-04-16 | N |
| Provide activities to meet all resident's needs. | Health | 2019-02-21 | 2019-04-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-21 | 2019-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-21 | 2019-04-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-21 | 2019-04-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-02-21 | 2019-04-16 | 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 | 2019-02-21 | 2019-04-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-02-21 | 2019-04-16 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-02-21 | 2019-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-21 | 2019-04-16 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-02-21 | 2019-04-16 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-21 | 2019-04-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-21 | 2019-04-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-21 | 2019-04-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-21 | 2019-04-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-21 | 2019-04-16 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-21 | 2019-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-21 | 2019-04-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-21 | 2019-04-16 | N |
