Deficiency Records for Delmar Center For Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Delmar Center For Rehabilitation and Nursing. 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? |
|---|---|---|---|---|
| Establish staff and initial training requirements. | Fire Safety | 2023-01-31 | 2023-03-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-31 | 2023-03-28 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-01-31 | 2023-03-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-03-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-03 | 2023-03-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-03 | 2023-03-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-03 | 2023-03-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-03 | 2023-03-21 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-02-03 | 2023-03-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-03 | 2023-03-21 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-02-03 | 2023-03-21 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-02-03 | 2023-03-21 | 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 | 2023-02-03 | 2023-03-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-03 | 2023-03-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-10 | 2022-10-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-18 | 2021-10-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-18 | 2021-10-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-11 | 2021-05-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-11 | 2021-05-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-11 | 2021-05-11 | Y |
| 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 | 2020-09-16 | 2020-10-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-09-16 | 2020-10-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-09-16 | 2020-10-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-09-16 | 2020-10-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-16 | 2020-10-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-09-16 | 2020-10-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-09-16 | 2020-10-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-09-16 | 2020-10-29 | 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 | 2020-09-16 | 2020-10-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-09-16 | 2020-10-29 | 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 | 2020-09-16 | 2020-10-29 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-09-16 | 2020-10-29 | N |
| Provide or obtain dental services for each resident. | Health | 2020-09-16 | 2020-10-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-09-16 | 2020-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-16 | 2020-10-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-09-16 | 2020-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-16 | 2020-10-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-09-16 | 2020-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-16 | 2020-10-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-09-16 | 2020-10-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-16 | 2020-10-28 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-09-16 | 2020-10-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-01-24 | 2019-04-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-01-24 | 2019-04-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-01-24 | 2019-04-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-24 | 2019-04-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-24 | 2019-04-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-24 | 2019-04-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-24 | 2019-04-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-01-24 | 2019-04-19 | 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 | 2019-01-24 | 2019-03-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-24 | 2019-03-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-01-24 | 2019-03-25 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-01-24 | 2019-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-24 | 2019-03-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-01-24 | 2019-03-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-01-24 | 2019-03-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-24 | 2019-03-25 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-01-24 | 2019-03-25 | N |
| Dispose of garbage and refuse properly. | Health | 2019-01-24 | 2019-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-24 | 2019-03-25 | N |
| Keep all essential equipment working safely. | Health | 2019-01-24 | 2019-03-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-01-24 | 2019-03-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-01-24 | 2019-03-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-01-24 | 2019-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-24 | 2019-01-24 | N |
