Inspection Reports for
Delmar Center for Rehabilitation and Nursing

Standard Health Citations — activities meet interest/needs, administration, care plan timing and revision, competent nursing staff, comprehensive care plan, garbage disposal, drug regimen, food procurement sanitary, free from abuse and neglect, accident hazards, medication error rates, grievances, infection prevention and control, infection preventionist qualifications, investigation of alleged violations, bed hold policy, nutrition/hydration, PASARR screening, personal food policy, QAA committee, quality of care, reporting of alleged violations, resident records, resident rights, resident self-admin meds, med errors, respiratory/tracheostomy care, provider responsibilities, survey results rights, RN coverage, safe/clean environment, sufficient nursing staff, transfer and discharge requirements

Standard Life Safety Code Citations — corridor doors, discharge from exits, doors with self-closing devices, electrical equipment and systems, EP testing and training, fire alarm system, horizontal exits, illumination of means of egress, maintenance/testing of doors, means of egress general, organization and administration, hazard risk assessment plan, sprinkler system installation and maintenance

F0584: The facility failed to maintain a safe, clean, and homelike environment with effective housekeeping and maintenance services across all resident units. Issues included scuffed handrails, insufficient hot water, unclean bathrooms, and non-functioning lights.

F0600: A Certified Nurse Aide did not follow Resident #40's care plan during personal care, resulting in a fall and broken leg. The facility failed to ensure residents were free from abuse and neglect.

F0610: The facility did not thoroughly investigate an alleged injury to Resident #365's hand sustained on 3/25/2025, lacking evidence of investigation to prevent recurrence.

F0656: The facility failed to develop and implement comprehensive care plans with measurable objectives and timeframes for 7 residents, including care plans for specific diagnoses and treatments.

F0684: Resident #34 did not receive daily dressing changes as ordered, and Resident #211's self-performed oral suctioning lacked proper policy, monitoring, and documentation of vital signs.

F0689: Resident #13's medications were not stored securely, with inhalers accessible in a shared room, posing an accident hazard.

F0725: The facility failed to provide sufficient nursing staff and certified nurse aides to meet minimum staffing requirements from 1/12/2025 to 1/17/2025, impacting resident care and safety.

F0760: Resident #62 was administered Alprazolam at incorrect times, with doses given late or early, and no documented physician notification or monitoring for side effects.

F550: The facility failed to ensure residents were treated with dignity and respect, including accommodating resident needs and privacy.

F554: The facility did not assess residents for ability to safely self-administer medications and lacked physician orders for self-administration.

F577: Survey results were not posted in a location accessible to residents, visitors, or staff, limiting transparency.

F584: The facility environment was not maintained in a safe, clean, and homelike manner, with issues in housekeeping and maintenance.

F585: Residents were not provided with adequate means to file grievances anonymously and without fear of reprisal.

F600: The facility failed to protect residents from abuse and neglect, including a fall resulting in a broken leg due to care plan violation.

F609: The facility failed to timely report incidents of abuse and neglect to the State Survey Agency as required.

F622: The facility did not ensure residents had safe and appropriate discharge planning and education, including appeal rights.

F625: The facility failed to provide written notice of bed-hold policy to residents and representatives upon hospital transfer.

F645: The facility did not complete required preadmission screening and resident review (PASARR) for mental illness or intellectual disabilities for multiple residents.

F656: The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for multiple residents' diagnoses and needs.

F657: The facility failed to review and revise comprehensive care plans based on changing resident needs and conditions.

F679: The facility failed to provide activities that met residents' interests and supported their physical, mental, and psychosocial well-being.

F684: The facility failed to provide services consistent with professional standards of practice, including medication administration and care.

F689: The facility failed to maintain a safe environment free from accident hazards and provide adequate supervision to prevent accidents.

F692: The facility failed to maintain acceptable nutritional status and hydration for residents, including monitoring weights and providing ordered fluids.

F695: The facility failed to provide respiratory care consistent with physician orders and professional standards, including oxygen therapy monitoring.

F725: The facility failed to provide sufficient nursing staff to meet resident care needs and comply with minimum staffing requirements.

F726: The facility failed to ensure nursing staff were competent and oriented to provide safe care.

F727: The facility failed to provide a registered nurse on duty for at least 8 consecutive hours per day, 7 days a week.

F757: The facility failed to ensure residents' drug regimens were free from unnecessary medications and included indications for use.

F759: The facility's medication error rate exceeded 5%, including crushing medications not ordered to be crushed.

F760: The facility failed to ensure residents were free from significant medication errors, including improper medication timing.

F761: The facility failed to store drugs and biologicals properly, including unlabeled opened medications and unsecured narcotics.

F812: The facility failed to maintain food service areas in a clean and sanitary condition, including kitchen equipment and nutrition rooms.

F813: The facility failed to ensure safe storage and handling of foods brought in by families and visitors, including unlabeled and unmonitored food.

F814: The facility failed to properly dispose of garbage and refuse, including unsecured dumpsters and litter around the area.

F842: The facility failed to maintain complete, accurate, and accessible medical records, including incomplete treatment documentation.

F868: The facility failed to maintain a quality assurance program with required members and regular meetings.

F880: The facility failed to implement infection prevention and control practices consistent with professional standards, including PPE use and catheter care.

F882: The facility failed to designate a qualified Infection Preventionist responsible for infection control program oversight.

F0550: The facility failed to ensure Resident #1 was treated with respect and dignity during a verbal altercation with staff on 1/12/2024, including use of racial slurs by Certified Nurse Aide #1.

F0609: The facility failed to timely report allegations of abuse involving Residents #1 and #3 to the Administrator and State Agency, and did not thoroughly investigate these allegations promptly.

F0684: The facility failed to provide appropriate treatment and care for Resident #3 by not documenting or monitoring a scratch injury from 1/10/2024 through 1/24/2024, and delayed identification of the injury until survey time.

F0689: The facility failed to ensure Resident #3's medications were stored securely when a bottle of aspirin was found unsecured on the resident's nightstand.

F0760: The facility failed to ensure Resident #1 received prescribed Oxycodone on 1/21/2024 as ordered, administering doses too close together and late.

F0761: The facility failed to ensure all drugs were stored in locked compartments as a bottle of aspirin was found unsecured in Resident #3's room.

F0770: The facility failed to provide timely laboratory services for Resident #2, with a CBC test ordered for 12/25/2023 not completed until 12/29/2023, and failure to notify the provider of abnormal results promptly.

F0773: The facility failed to promptly notify the ordering practitioner of abnormal laboratory results for Resident #2 on 12/29/2023, with notification delayed until 1/2/2024.

F0842: The facility failed to maintain complete, accurate, and timely medical records for Resident #2, lacking documentation of assessments, physician notifications, orders, and resident responses related to a change in condition from 12/31/2023 to 1/1/2024.

Standard Health Citations — accident hazards, investigation/prevention of violations, lab services physician order and notification, drug labeling/storage, laboratory services, quality of care, reporting of alleged violations, resident records, resident rights, med errors

Standard Health Citations — ADL care, comprehensive care plan, facility assessment, food procurement sanitary, infection prevention and control, routine/emergency dental services, safe/clean environment, treatment to prevent/heal pressure ulcers

F 0584: The facility did not ensure a safe, clean, and homelike environment; resident rooms and bathrooms were dirty, had holes in walls, and were in disrepair.

F 0656: The facility did not develop and implement a comprehensive, person-centered care plan with measurable objectives for one resident, omitting support for activities of daily living and skin care.

F 0677: The facility failed to provide necessary assistance with activities of daily living for three residents, including improper disposal of soiled briefs, inadequate denture care, and failure to provide scheduled showers due to lack of bariatric equipment.

F 0686: The facility did not provide appropriate pressure ulcer care for one resident who developed a pressure ulcer after admission and failed to conduct weekly wound assessments and documentation.

F 0790: The facility did not ensure replacement of a lost denture for one resident and failed to reimburse the resident for the cost of replacement.

F 0812: The facility did not store, prepare, distribute, or serve food in accordance with professional standards; issues included excessive dishwashing machine water pressure, unclean kitchen areas, peeling walls, and leaking faucet.

F 0838: The facility assessment did not address care and equipment needs for bariatric residents, omitting necessary resources such as bariatric beds and mechanical lifts.

F 0880: The facility failed to maintain an infection prevention and control program; resident dentures and toothbrushes were not stored or discarded properly, and resident bathrooms were not cleaned and sanitized adequately.

Standard Health Citation — right to access/purchase copies of records

F 0584: The facility did not maintain a safe, clean, and homelike environment; multiple units had urine odors, unclean floors, damaged walls, missing tiles, exposed insulation, and unlabeled personal care items in shared bathrooms.

F 0677: The facility failed to provide necessary personal hygiene services including scheduled showers, hair washing, shaving, and nail care for 3 residents, despite care plans requiring these services.

F 0689: Resident room wardrobes were not secured to walls, creating a risk of toppling and accident hazards across multiple units; facility completed securing wardrobes after survey.

F 0756: The facility did not ensure pharmacist-identified medication irregularities were reviewed and acted upon timely for Resident #12, resulting in insulin administration outside ordered parameters on multiple occasions.

F 0760: Resident #12 received insulin outside physician ordered blood sugar parameters on 62 occasions between October 2022 and January 2023, constituting significant medication errors.

F 0806: Resident #12 was not provided Lactaid milk and diet hot chocolate as documented on meal tickets on 1/25/2023 and 1/26/2023, failing to accommodate dietary preferences and restrictions.

F 0812: The facility failed to maintain food service safety standards; the dishwasher final rinse temperature was inadequate, dishware was stored uncovered, and nourishment rooms and kitchen equipment were dirty and in disrepair.

F 0825: Resident #41 did not receive timely physical and occupational therapy screens following a referral made on 1/23/2023, delaying specialized rehabilitative services.

F 0880: The facility failed to ensure proper hand hygiene and clean technique during wound care for Resident #38, and staff did not consistently wear masks properly to prevent infection spread.

F 0925: The facility did not maintain an effective pest control program; flies were observed in multiple locations on Units C and G, with no timely follow-up or documentation of pest control measures.

F 0940: The facility did not ensure all new and existing staff completed general orientation training as required by facility policy; multiple employee files lacked documentation of completed orientation components.

Standard Health Citations — ADL care, drug regimen review, food procurement sanitary, accident hazards, infection prevention and control, pest control, specialized rehab services, resident allergies, med errors, safe/clean environment, training requirements; Standard Life Safety Code Citations — EP testing requirements, EP training program, multiple occupancies

Standard Health Citations — accuracy of assessments, comprehensive care plan, resident records, respiratory/tracheostomy care

Standard Health Citations — comprehensive care plan, resident records

F 0584: The facility did not provide effective maintenance and pest control services; floors were soiled, walls were in disrepair, and fly activity was observed on multiple units.

F 0609: The facility failed to timely report an alleged incident of staff screaming at a resident to the administrator as required by state law.

F 0641: The facility did not ensure accurate resident assessments for 3 residents; MDS data did not reflect true cognitive or functional status or pressure ulcer stage.

F 0655: The facility did not develop and implement baseline care plans within 48 hours of admission for 4 residents and did not provide summaries to residents or representatives.

F 0656: The facility did not develop and implement comprehensive person-centered care plans with measurable objectives for 9 residents, including care for sensitive skin, pressure ulcers, infections, and dementia-related behaviors.

F 0692: The facility did not maintain acceptable nutritional status for 2 residents; significant weight loss was not recognized, evaluated, or addressed appropriately.

F 0698: The facility did not ensure dialysis care was consistent with professional standards; communication with dialysis center was lacking and fluid restriction orders were not transcribed or monitored.

F 0744: The facility did not provide person-centered dementia care plans with individualized interventions for 2 residents with dementia.

F 0758: The facility did not limit PRN psychotropic medication orders to 14 days or document rationale for extension for 1 resident.

F 0759: The facility's medication error rate was 33.33% with late administration, refusal not documented, and medications withheld without physician notification for 4 residents.

F 0761: The facility did not maintain drugs and biologicals properly; expired medications were found in medication rooms and carts on multiple units.

F 0773: The facility did not promptly notify the physician of critical lab results indicating likely congestive heart failure for 1 resident; notification was delayed by 6 days.

F 0791: The facility did not provide routine annual dental services for 1 resident; no documentation of refusal was found.

F 0806: The facility did not ensure residents received food accommodating allergies, intolerances, and preferences; residents were not offered alternative meals or choices.

F 0812: The facility's automatic dishwashing machine was not operating at the required final rinse temperature to sanitize food surfaces.

F 0842: The facility did not maintain complete, accurate, and accessible medical records for 5 residents; documentation was missing, altered, or incomplete for treatments, ADLs, weights, and wound care.

F 0880: The facility failed to maintain infection prevention and control standards; hand hygiene was not performed appropriately, multi-use equipment was not sanitized between residents, and contaminated wound supplies were improperly stored.