A list of the most recent deficiencies for Delmar Gardens of Green Valley. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-16 | 2023-07-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-16 | 2023-07-18 | 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 | 2023-06-16 | 2023-07-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-16 | 2023-07-18 | 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 | 2023-06-16 | 2023-07-18 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2023-06-16 | 2023-07-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Develop a communication plan. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-15 | 2023-07-11 | 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 | 2023-06-15 | 2023-07-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-18 | 2022-04-08 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Establish methods for sharing information. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-07 | 2022-03-07 | 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 | 2022-01-07 | 2022-03-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-07 | 2022-03-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-07 | 2022-03-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-07 | 2022-03-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-07 | 2022-03-07 | 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 | 2022-01-07 | 2022-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-07 | 2022-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-03-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-11-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-03 | 2019-06-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-05-03 | 2019-06-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-05-03 | 2019-06-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-05-03 | 2019-06-21 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-05-03 | 2019-06-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-03 | 2019-06-21 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-03 | 2019-06-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-03 | 2019-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-03 | 2019-06-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-03 | 2019-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-03 | 2019-06-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-03 | 2019-06-21 | 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 | 2019-05-03 | 2019-06-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-03 | 2019-06-21 | 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 | 2019-05-03 | 2019-06-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-03 | 2019-06-21 | N |
| Dispose of garbage and refuse properly. | Health | 2019-05-03 | 2019-06-21 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-05-03 | 2019-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-02 | 2019-06-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-02 | 2019-06-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-02 | 2019-06-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-02 | 2019-06-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-02 | 2019-06-21 | N |
