A list of the most recent deficiencies for Delmar Gardens of O'fallon. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-25 | 2023-05-23 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-27 | 2023-04-27 | 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 | 2022-10-27 | 2022-11-23 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-27 | 2022-11-23 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-27 | 2022-11-23 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-27 | 2022-11-23 | 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 | 2022-10-27 | 2022-11-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-27 | 2022-11-23 | N |
| Meet other general requirements. | Fire Safety | 2022-10-27 | 2022-11-23 | 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 | 2022-10-27 | 2022-11-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-10-27 | 2022-11-23 | 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 | 2022-10-27 | 2022-11-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-10-27 | 2022-11-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-24 | 2022-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-10 | 2022-04-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-15 | 2021-10-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-15 | 2021-10-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-15 | 2021-10-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-15 | 2021-10-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-15 | 2021-10-24 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-10-16 | 2019-11-27 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-16 | 2019-11-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-16 | 2019-11-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-16 | 2019-11-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-16 | 2019-11-27 | 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 | 2019-10-16 | 2019-11-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-16 | 2019-11-27 | 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 | 2019-10-16 | 2019-11-27 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-10-16 | 2019-11-27 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-10-16 | 2019-11-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-16 | 2019-11-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-16 | 2019-11-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-16 | 2019-11-27 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-09-13 | 2018-10-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-13 | 2018-10-27 | 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 | 2018-09-13 | 2018-10-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-13 | 2018-10-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-13 | 2018-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-13 | 2018-10-27 | 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 | 2018-09-13 | 2018-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-13 | 2018-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-13 | 2018-10-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-09-13 | 2018-10-27 | 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 | 2018-09-13 | 2018-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-13 | 2018-10-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-13 | 2018-10-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-13 | 2018-10-27 | N |
