Inspection Reports for
Delmar Gardens West

Ten deficiencies were cited: six federal Life Safety (K) deficiencies addressing means of egress, sprinkler system maintenance, corridor doors, electrical wiring/equipment, evacuation/relocation planning, and smoking/ashtray practices; and four Missouri state citations corresponding to sprinkler system testing/maintenance, ashtray disposal, substantial construction/maintenance, and electrical wiring/equipment.

MO00250188; substantiation status not stated in the file.

Twenty-one deficiencies were cited (8 federal CMS deficiencies and 13 Missouri State Form deficiencies) covering medication management and medication errors, drug regimen review and storage, infection prevention and control, food safety and kitchen sanitation (including puree preparation), plumbing/drainage issues in a resident shower, transfer techniques/accident hazards, and IV/PICC management.

MO00240710, MO00240668; substantiation not stated in the document.

Six deficiencies were cited across federal and state forms. Main issues were ineffective pest/rodent control in the kitchen and failures in resident care including missing physician-ordered weights, unsafe transfer practices/accident hazards, and related written orders/restraint and protective oversight deficiencies.

MO00234143; substantiation not stated in the record.

There are 4 deficiencies: 2 federal deficiencies addressing insufficient hot water/comfortable environment and lack of access to behavioral health services, and 2 Missouri state deficiencies citing hot water temperature requirements and nursing care per resident condition.

The file contains 7 federal health deficiencies addressing resident rights, professional standards of care/post-fall documentation, ADL/personal hygiene care, respiratory/C-PAP care, medication error follow-up, medication storage/temperature control, and food procurement/food safety; and 7 Missouri state deficiencies citing medication errors and storage, nursing care, grooming/dressing, floor surfaces, clean clothing/hair restraints, and dignity/privacy.

Seventeen deficiencies were cited: 11 federal deficiencies (2 Emergency Preparedness and 9 Life Safety Code) and 6 Missouri State deficiencies. Main topics include Emergency Preparedness plan and staff contact information, means of egress and signage, sprinkler installation and maintenance, hazardous area enclosures, electrical/power strip use and damaged outlet covers, and smoking area/ashtray disposal.

Two deficiencies were cited: one federal health deficiency concerning resident records/identifiable information and failures to follow physician orders and document weights, TED hose use, and turning/repositioning; and one Missouri state citation regarding clinical records accuracy and accessibility referencing the federal finding.

Complaint numbers: MO00187829, MO00188664, MO00192730, MO00192914, MO00189880, MO00188010, MO00188098, MO00189990, MO00190223, MO00190536; outcome/substantiation not stated in the report.

Ten deficiencies were cited (five federal and five state) addressing failure to accommodate resident bathing/transfer needs, inadequate ADL/perineal care and missed showers, deficient pressure ulcer prevention and treatment, unsafe use of mechanical lifts, and insufficient dietary staffing causing delayed/cold meal service.

There are 4 federal deficiencies involving failure to notify responsible parties of changes, failures in communication of condition changes, inadequate pressure ulcer prevention/treatment, and failures in infection prevention and control; there are 4 Missouri State Form Class II deficiencies that reference those federal findings.

Eight deficiencies were extracted (four federal CMS-2567 items and four Missouri State Form items). The federal findings address failures in provision of personal care/grooming, quality of care for ostomy/g-tube/oxygen/orders, and accident/fall supervision and transfer practices; the state items (Class II) reference those federal deficiencies.

Six federal health survey deficiencies were cited addressing posting of survey results/resident rights, professional standards of services/clinical documentation, accident hazards/transfer devices, drug regimen review, food safety, and infection prevention and control. Six Missouri state deficiencies were cited under 19 CSR addressing drug regimen review, protective oversight/voluntary leave, nursing care per resident condition, infection control, food protection/temperature, and posting of inspection reports.

Nine deficiencies were cited: five Life Safety Code deficiencies involving smoke door clearances, smoking/ashtray disposal, electrical receptacle testing and documentation, missing generator remote manual stop, and oxygen/gas cylinder storage; and four Missouri state citations referencing oxygen storage, smoke section walls/doors, ashtray disposal, and facility construction/maintenance.

Fourteen deficiencies were cited: seven Life Safety (K-) deficiencies addressing means of egress, exit signage, kitchen range hood and suppression, portable fire extinguishers, smoking area/ashtray management, portable space heaters, and electrical panel clearance; and seven Missouri State Form deficiencies that reference and mirror these same topics.

Eighteen deficiencies were cited (7 federal CMS-2567 items and 11 Missouri State Form items). Federal findings cover resident advance directives/physician signatures, transfer/discharge notice procedures, pressure ulcer prevention and treatment, restorative/physical therapy provision, indwelling catheter care and continence/UTI management, kitchen/food safety, and infection prevention practices; state licensure deficiencies mirror many of these topics (license posting, nursing care, pressure sore prevention/treatment, infection control, sanitary food handling and related rules).

Fourteen deficiencies were cited: seven federal health tags addressing resident rights, abuse/neglect policies, activities, quality of care, pressure ulcer treatment, accident hazards/supervision and bowel/bladder/catheter care; and seven Missouri state citations referencing written orders/medication systems, pressure sore prevention, infection control, activity program and dignity/privacy that cross-reference the federal findings.

There are 4 federal Life Safety deficiencies involving building construction/wall penetrations, egress/locking arrangements/signage, fire alarm installation/smoke detector placement, and corridor doors not forming smoke seals. There are 7 Missouri state licensure deficiencies, several of which refer to the federal Life Safety findings and address LSC edition requirements, fire alarm testing/maintenance, and physical plant construction/maintenance.

Ten deficiencies were cited: six federal Life Safety (K) deficiencies addressing means of egress, sprinkler system maintenance, corridor doors, electrical wiring/equipment, evacuation/relocation planning, and smoking/ashtray practices; and four Missouri state citations corresponding to sprinkler system testing/maintenance, ashtray disposal, substantial construction/maintenance, and electrical wiring/equipment.

MO00250188; substantiation status not stated in the file.

Twenty-one deficiencies were cited (8 federal CMS deficiencies and 13 Missouri State Form deficiencies) covering medication management and medication errors, drug regimen review and storage, infection prevention and control, food safety and kitchen sanitation (including puree preparation), plumbing/drainage issues in a resident shower, transfer techniques/accident hazards, and IV/PICC management.

The investigation was complaint-related, focusing on failure to meet professional standards of care and failure to prevent accidents. The deficiencies were substantiated with minimal harm or potential for actual harm noted.

The facility failed to obtain daily weights and send them to the resident's cardiologist as ordered, and failed to follow transfer policy resulting in a resident falling from a Hoyer lift and requiring hospital evaluation.

MO00240710, MO00240668; substantiation not stated in the document.

Six deficiencies were cited across federal and state forms. Main issues were ineffective pest/rodent control in the kitchen and failures in resident care including missing physician-ordered weights, unsafe transfer practices/accident hazards, and related written orders/restraint and protective oversight deficiencies.

MO00234143; substantiation not stated in the record.

There are 4 deficiencies: 2 federal deficiencies addressing insufficient hot water/comfortable environment and lack of access to behavioral health services, and 2 Missouri state deficiencies citing hot water temperature requirements and nursing care per resident condition.

Complaint MO00229571; substantiation not stated in the document.

One federal deficiency for failure to provide timely cardiopulmonary resuscitation/basic life support.

The file contains 7 federal health deficiencies addressing resident rights, professional standards of care/post-fall documentation, ADL/personal hygiene care, respiratory/C-PAP care, medication error follow-up, medication storage/temperature control, and food procurement/food safety; and 7 Missouri state deficiencies citing medication errors and storage, nursing care, grooming/dressing, floor surfaces, clean clothing/hair restraints, and dignity/privacy.

Seventeen deficiencies were cited: 11 federal deficiencies (2 Emergency Preparedness and 9 Life Safety Code) and 6 Missouri State deficiencies. Main topics include Emergency Preparedness plan and staff contact information, means of egress and signage, sprinkler installation and maintenance, hazardous area enclosures, electrical/power strip use and damaged outlet covers, and smoking area/ashtray disposal.

Complaint numbers MO00221193, MO00221315, MO00221766; substantiation not stated.

One federal health deficiency for abuse and neglect related to a resident who sustained facial bruising and alleged staff assault; past noncompliance was noted.

Two deficiencies were cited: one federal health deficiency concerning resident records/identifiable information and failures to follow physician orders and document weights, TED hose use, and turning/repositioning; and one Missouri state citation regarding clinical records accuracy and accessibility referencing the federal finding.

Complaint numbers: MO00187829, MO00188664, MO00192730, MO00192914, MO00189880, MO00188010, MO00188098, MO00189990, MO00190223, MO00190536; outcome/substantiation not stated in the report.

Ten deficiencies were cited (five federal and five state) addressing failure to accommodate resident bathing/transfer needs, inadequate ADL/perineal care and missed showers, deficient pressure ulcer prevention and treatment, unsafe use of mechanical lifts, and insufficient dietary staffing causing delayed/cold meal service.

There are 4 federal deficiencies involving failure to notify responsible parties of changes, failures in communication of condition changes, inadequate pressure ulcer prevention/treatment, and failures in infection prevention and control; there are 4 Missouri State Form Class II deficiencies that reference those federal findings.

Eight deficiencies were extracted (four federal CMS-2567 items and four Missouri State Form items). The federal findings address failures in provision of personal care/grooming, quality of care for ostomy/g-tube/oxygen/orders, and accident/fall supervision and transfer practices; the state items (Class II) reference those federal deficiencies.

No deficiencies were cited on the F (Infection Control) or E (Emergency Preparedness) CMS-2567 forms; the facility was found to be in compliance as stated in the Initial Comments.

No deficiencies were cited. The Emergency Preparedness survey found the facility in compliance with applicable emergency preparedness requirements and the Infection Control survey found the facility in compliance with CDC-recommended COVID-19 infection control practices.

No deficiencies were cited. The E section notes the facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6); the F section notes the facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

No federal health (F) or emergency preparedness (E) deficiencies were cited; both forms contain only Initial Comments stating the facility was found to be in compliance with applicable COVID-19 preparedness and infection control practices.

Six federal health survey deficiencies were cited addressing posting of survey results/resident rights, professional standards of services/clinical documentation, accident hazards/transfer devices, drug regimen review, food safety, and infection prevention and control. Six Missouri state deficiencies were cited under 19 CSR addressing drug regimen review, protective oversight/voluntary leave, nursing care per resident condition, infection control, food protection/temperature, and posting of inspection reports.

Nine deficiencies were cited: five Life Safety Code deficiencies involving smoke door clearances, smoking/ashtray disposal, electrical receptacle testing and documentation, missing generator remote manual stop, and oxygen/gas cylinder storage; and four Missouri state citations referencing oxygen storage, smoke section walls/doors, ashtray disposal, and facility construction/maintenance.

Complaint numbers MO00158108, MO00158147, MO00158168 are listed; the survey does not state whether the complaints were substantiated.

One federal health deficiency was cited for failure to protect residents from abuse and neglect related to staff providing care alone when two-staff assistance was required, resulting in a resident fall with serious injury. Past noncompliance was noted.

One federal health deficiency was cited regarding failure to provide basic life support/CPR and inadequate staff response and code status management; past noncompliance and immediate jeopardy were noted.

Fourteen deficiencies were cited: seven Life Safety (K-) deficiencies addressing means of egress, exit signage, kitchen range hood and suppression, portable fire extinguishers, smoking area/ashtray management, portable space heaters, and electrical panel clearance; and seven Missouri State Form deficiencies that reference and mirror these same topics.

Eighteen deficiencies were cited (7 federal CMS-2567 items and 11 Missouri State Form items). Federal findings cover resident advance directives/physician signatures, transfer/discharge notice procedures, pressure ulcer prevention and treatment, restorative/physical therapy provision, indwelling catheter care and continence/UTI management, kitchen/food safety, and infection prevention practices; state licensure deficiencies mirror many of these topics (license posting, nursing care, pressure sore prevention/treatment, infection control, sanitary food handling and related rules).

Fourteen deficiencies were cited: seven federal health tags addressing resident rights, abuse/neglect policies, activities, quality of care, pressure ulcer treatment, accident hazards/supervision and bowel/bladder/catheter care; and seven Missouri state citations referencing written orders/medication systems, pressure sore prevention, infection control, activity program and dignity/privacy that cross-reference the federal findings.

There are 4 federal Life Safety deficiencies involving building construction/wall penetrations, egress/locking arrangements/signage, fire alarm installation/smoke detector placement, and corridor doors not forming smoke seals. There are 7 Missouri state licensure deficiencies, several of which refer to the federal Life Safety findings and address LSC edition requirements, fire alarm testing/maintenance, and physical plant construction/maintenance.