Deficiency Records for Darby Glenn Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Darby Glenn Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-25 | 2023-10-06 | Y |
| 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 | 2023-09-25 | 2023-10-06 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-22 | 2023-05-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-22 | 2023-05-27 | 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 | 2022-12-13 | 2023-01-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-13 | 2023-01-04 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-13 | 2023-01-04 | Y |
| 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 | 2022-12-13 | 2023-01-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-13 | 2023-01-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-13 | 2023-01-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-12-13 | 2023-01-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-09 | 2023-01-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-09 | 2023-01-04 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-02-11 | 2022-03-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-11 | 2022-03-04 | 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 | 2022-02-11 | 2022-03-04 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-11 | 2022-03-04 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-11 | 2022-03-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-11 | 2022-03-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-11 | 2022-03-04 | 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 | 2022-02-11 | 2022-03-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-11 | 2022-03-04 | 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 | 2022-02-11 | 2022-03-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-11 | 2022-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-04 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-02-02 | 2022-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-02 | 2022-03-04 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-02-02 | 2022-03-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-08 | 2021-12-31 | Y |
| 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 | 2021-12-08 | 2021-12-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-20 | 2021-10-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-18 | 2021-10-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-14 | 2021-06-19 | Y |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-03-07 | 2019-04-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-07 | 2019-04-04 | 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 | 2019-03-07 | 2019-04-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-07 | 2019-04-04 | 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 | 2019-03-07 | 2019-04-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-03-08 | 2019-04-04 | 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 | 2019-03-08 | 2019-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-08 | 2019-04-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-08 | 2019-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-08 | 2019-04-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-08 | 2018-04-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-08 | 2018-04-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-02-08 | 2018-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-08 | 2018-04-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-08 | 2018-04-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-02-08 | 2018-04-24 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-02-08 | 2018-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-08 | 2018-04-24 | 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 | 2018-02-05 | 2018-04-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-05 | 2018-04-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-05 | 2018-04-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-02-05 | 2018-04-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-05 | 2018-04-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-05 | 2018-04-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-02-05 | 2018-04-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-02-08 | 2018-02-02 | N |
