Deficiency Records for Delmar Gardens of Green Valley
Updated as of November 01, 2019
This is not the most recent data for Delmar Gardens of Green Valley. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 | 2018-03-09 | 2018-04-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-09 | 2018-04-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-03-09 | 2018-04-16 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-03-09 | 2018-04-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-09 | 2018-04-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-09 | 2018-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-09 | 2018-04-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-09 | 2018-04-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-03-09 | 2018-04-16 | 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 | 2018-03-09 | 2018-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-09 | 2018-04-16 | 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 | 2018-03-09 | 2018-04-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-09 | 2018-04-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-03-09 | 2018-04-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-09 | 2018-04-16 | 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 ne | Health | 2018-03-09 | 2018-04-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-09 | 2018-04-16 | 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 | 2018-03-09 | 2018-04-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-03-09 | 2018-04-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-09 | 2018-04-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-03-09 | 2018-04-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-09 | 2018-04-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-03-09 | 2018-04-16 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-03-17 | 2017-05-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-03-17 | 2017-05-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-03-17 | 2017-05-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-03-17 | 2017-05-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-03-17 | 2017-05-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-03-17 | 2017-05-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-03-17 | 2017-05-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-03-17 | 2017-05-01 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-22 | 2017-04-24 | N |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2017-03-22 | 2017-04-24 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-03-22 | 2017-04-24 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-22 | 2017-04-24 | N |
| Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2017-03-22 | 2017-04-24 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-22 | 2017-04-24 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-22 | 2017-04-24 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-03-22 | 2017-04-24 | Y |
