Inspection Reports for
Delmar Gardens West
13550 SOUTH OUTER 40 RD, TOWN AND COUNTRY, MO, 63017-5812
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
18.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
236% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
56% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 181
Deficiencies: 1
Date: Apr 11, 2025
Visit Reason
The inspection was conducted to investigate a deficiency related to the inappropriate removal of a peripherally inserted central catheter (PICC line) by a Licensed Practical Nurse (LPN), which was outside the LPN's scope of practice.
Findings
The facility failed to ensure IV services were consistent with professional standards when an LPN removed a PICC line for one resident. The LPN was educated on scope of practice after the incident, and no adverse outcomes were reported.
Deficiencies (1)
F 0694: The facility failed to ensure safe administration of IV fluids when an LPN removed a PICC line, which is outside the LPN's scope of practice. The PICC line was removed without an RN present, contrary to regulations.
Report Facts
Census: 181
Sample size: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Z | Licensed Practical Nurse | Removed the PICC line outside scope of practice and was counseled |
| DON | Director of Nursing | Provided education on scope of practice and clarified IV line procedures |
Inspection Report
Plan of Correction
Census: 181
Deficiencies: 8
Date: Apr 11, 2025
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations, identify deficiencies, and review the facility's plan of correction for Delmar Gardens West.
Findings
The facility was found to have multiple deficiencies including issues with maintaining a safe and comfortable environment, accident hazards, medication errors, drug regimen reviews, infection control, food safety, and storage of drugs and biologicals. The plan of correction outlines steps to address these deficiencies by May 13, 2025.
Deficiencies (8)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide a clean, comfortable, home-like environment as shower drainage was not properly maintained causing water pooling.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to maintain an environment free of accident hazards by not following proper body mechanics when transferring a resident.
F694 Parenteral/IV Fluids: The facility failed to ensure intravenous services were consistent with professional standards when a Licensed Practical Nurse improperly removed a PICC line.
F756 Drug Regimen Review, Report Irregular, Act On: The facility failed to timely address pharmacist recommendations from drug regimen reviews for two residents.
F759 Free of Medication Error Rts 5 Prcnt or More: The facility failed to maintain a medication error rate below 5%, with a 13.51% error rate observed.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure drugs and biologicals were stored in locked compartments and double-locked refrigerated medication rooms.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain food safety standards including proper cleaning, labeling, and storage of food items.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program to prevent communicable diseases and ensure proper use of PPE.
Report Facts
Census: 181
Sample size: 35
Medication error rate: 13.51
Medication error opportunities: 37
Medication errors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Z | Licensed Practical Nurse | Named in findings related to PICC line removal and medication administration |
| DON | Director of Nursing | Named in findings related to transfer policy and medication administration |
| RN Educator/Designee | Registered Nurse Educator/Designee | Responsible for infection control education and medication administration policy |
| PTA F | Physical Therapy Assistant | Involved in resident transfer and therapeutic needs |
Inspection Report
Life Safety
Census: 181
Capacity: 321
Deficiencies: 6
Date: Apr 11, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Delmar Gardens West.
Findings
The facility failed to maintain clear means of egress, maintain sprinkler systems free of dust and corrosion, ensure corridor doors positively latch, maintain electrical wiring and equipment, and properly manage smoking areas. Deficiencies had the potential to affect residents, staff, and visitors.
Deficiencies (6)
K211 Means of Egress - General: The facility failed to maintain exits free of obstructions and did not provide adequate training or documentation on unlocking a locked gate during emergencies.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads free of debris and corrosion, with multiple sprinkler heads loaded with dust or showing damage.
K363 Corridor Doors: The facility failed to maintain corridor doors to resist passage of smoke and to positively latch, with several doors propped open or not latching properly.
K511 Utilities - Gas and Electric: The facility failed to maintain electrical wiring and equipment in compliance with the National Electric Code, including unsecured outlet boxes and damaged receptacles.
K711 Evacuation and Relocation Plan: The facility lacked a complete, specific fire safety plan including required elements and documentation for staff roles during evacuation.
K741 Smoking Regulations: The facility failed to properly dispose of ashtray contents and maintain designated smoking areas, resulting in cigarette butts scattered and ashtrays improperly managed.
Report Facts
Facility capacity: 321
Resident census: 181
Number of sprinkler heads affected: 16
Number of smoke compartments affected: 7
Number of smoke compartments affected: 5
Number of sprinkler heads loaded with dust or damaged: 40
Number of cigarette butts observed: 175
Inspection Report
Routine
Census: 181
Deficiencies: 8
Date: Apr 11, 2025
Visit Reason
Routine inspection of Delmar Gardens West nursing home to assess compliance with health and safety regulations including resident care, medication administration, infection control, and food service.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and clean environment, improper body mechanics during resident transfers, unauthorized removal of a PICC line by an LPN, delayed pharmacist recommendations follow-up, medication errors including insulin administration errors, improper medication storage, food safety violations, and lapses in infection prevention and control practices.
Deficiencies (8)
F 0584: The facility failed to maintain a clean, comfortable, home-like environment when shower drainage for Resident #53 was obstructed causing water pooling during use.
F 0689: Staff failed to maintain proper body mechanics during transfer of Resident #67, using a gait belt loosely and improper lifting technique causing unsafe transfer.
F 0694: Licensed Practical Nurse removed a PICC line for Resident #142, which is outside the LPN scope of practice, without RN supervision or proper protocol.
F 0756: Facility failed to timely address pharmacist Drug Regimen Review recommendations for Residents #157 and #16, risking medication management issues.
F 0759: Medication error rate was 13.51% with errors in insulin administration timing, priming, and technique observed in multiple residents.
F 0761: Controlled medications in two medication rooms were not double-locked as required, compromising medication security.
F 0812: Food safety violations included uncovered food, expired products, unclean kitchen equipment, incomplete dishwashing logs, and failure to follow puree recipes.
F 0880: Infection control failures included improper PPE use for Resident #424 with C-diff, sharing insulin pens between residents, failure to wear gowns during enhanced barrier precautions for Resident #22, inadequate cleaning of blood glucose monitors, medication administration with dropped pills, and uncovered laundry transport.
Report Facts
Resident census: 181
Medication error rate: 13.51
Sample size: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Z | Licensed Practical Nurse | Removed PICC line outside scope of practice |
| CMT P | Certified Medication Technician | Observed dropping pill and picking it up with bare hands during medication administration |
| DC BB | Dietary Cook | Observed preparing pureed foods without following recipes |
| LPN D | Licensed Practical Nurse | Observed nearly administering wrong resident's insulin pen |
| CNA V | Certified Nurse Aide | Failed to wear gown during enhanced barrier precaution care for Resident #22 |
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 2
Date: Oct 9, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide services per acceptable standards of practice and failure to ensure a safe environment free from accident hazards.
Complaint Details
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.
Findings
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.
Deficiencies (2)
F 0658: The facility failed to provide services per acceptable standards of practice and the resident's plan of care by not obtaining daily weights and sending them to the cardiologist as ordered for Resident #1.
F 0689: The facility failed to ensure the environment was free from accident hazards and provide adequate supervision when a CNA attempted to transfer a resident using a Hoyer lift without assistance, resulting in the resident falling and being sent to the hospital.
Report Facts
Census: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) B | Named in the finding related to improper transfer causing resident fall |
Inspection Report
Routine
Census: 181
Deficiencies: 6
Date: Aug 21, 2024
Visit Reason
Routine inspection to evaluate the facility's pest control program and compliance with professional standards of care.
Findings
The facility failed to maintain an effective pest control program as evidenced by active roach infestations in the kitchen and other areas. Additionally, the facility failed to provide professional standards of care related to comprehensive care plans and supervision, resulting in a resident injury during transfer.
Deficiencies (6)
F925 Maintain an effective pest control program to prevent pests and rodents. The facility had active cockroach infestations in the kitchen and other areas despite pest control efforts.
F658 Services provided must meet professional standards including comprehensive care plans. The facility failed to obtain daily weights for a resident per physician orders, contributing to inadequate care.
F689 Ensure resident environment is free of accident hazards and provide adequate supervision and assistance devices. A resident was injured during a transfer when staff failed to follow the no-lift policy and assist properly.
A6039 Effective rodent control measures must be utilized to prevent harborage or feeding of insects or rodents. This regulation was not met as evidenced by the pest control deficiencies cited at F925.
A4054 No medication, treatment, or diet shall be given without a written order. This regulation was not met as evidenced by the deficiency cited at F658.
A4074 Each resident shall receive 24-hour protective oversight and supervision. This regulation was not met as evidenced by the deficiency cited at F689.
Report Facts
Census: 181
Census: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide B | CNA | Named in resident transfer injury incident for failing to assist resident properly. |
| Licensed Practical Nurse A | LPN | Responsible for faxing resident weights to cardiologist and involved in care plan compliance. |
| Dietitian | Interviewed regarding pest control and kitchen conditions. | |
| Administrator | Interviewed about pest control company visits and facility conditions. | |
| Pest Control Company Representative | Interviewed about pest control issues and recommendations. | |
| Director of Nursing | DON | Interviewed regarding resident transfer incident and staff education. |
| Cook E | Interviewed about kitchen cleaning and pest control. | |
| Certified Medication Technician H | CMT | Interviewed about resident transfers and staff knowledge. |
Inspection Report
Routine
Census: 180
Deficiencies: 3
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, resident safety, and pest control in the nursing facility.
Findings
The facility failed to follow physician orders for daily resident weights and faxing them to the cardiologist, failed to follow transfer policy resulting in a resident falling from a mechanical lift, and failed to maintain an effective pest control program with evidence of roaches and gnats in the kitchen area.
Deficiencies (3)
F 0658: The facility failed to obtain and fax daily weights for a resident to the cardiologist as ordered, with missed faxing on multiple Mondays.
F 0689: The facility failed to follow its transfer policy requiring two staff for mechanical lifts, resulting in a resident falling from a Hoyer lift and being sent to the hospital.
F 0925: The facility failed to maintain an effective pest control program, with observations of live and dead cockroaches in the kitchen and inadequate pest control documentation.
Report Facts
Resident census: 180
Resident census: 181
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in failure to fax resident weights and transfer incident |
| CNA B | Certified Nurse Aide | Named in mechanical lift transfer incident resulting in resident fall |
| Director of Nursing | Director of Nursing | Provided statements on nursing expectations and transfer policy |
| CMT H | Certified Medication Technician | Provided statements on mechanical lift transfer practices |
| CNA I | Certified Nurse Aide | Provided statements on mechanical lift transfer practices |
| CNA E | Certified Nurse Aide | Provided statements on mechanical lift transfer practices |
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 2
Date: Apr 29, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide sufficient hot water and to ensure access to behavioral health services for a resident who was homeless and discharged.
Complaint Details
The complaint investigation substantiated issues with hot water availability and behavioral health service access for a resident discharged and homeless.
Findings
The facility failed to provide a homelike environment by not ensuring adequate hot water for residents on the 100 unit, affecting 17 residents. Additionally, the facility did not ensure access to behavioral health services for a resident with a diagnosis of major depression who was discharged and homeless.
Deficiencies (2)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide sufficient hot water for three sampled residents on the 100 unit for at least three months, affecting 17 residents. Water temperatures were consistently below the required standard of 105 to 120 degrees Fahrenheit.
F740 Behavioral Health Services: The facility failed to ensure a resident with a diagnosis of major depression and known to be homeless received access to behavioral health services as an option to process emotional stressors. The resident was discharged without such access.
Report Facts
Census: 185
Number of residents affected: 17
Inspection Report
Routine
Census: 185
Deficiencies: 2
Date: Apr 29, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care and facility environment, including water temperature standards and behavioral health services.
Findings
The facility failed to provide sufficient hot water on the 100 unit for at least three months, affecting multiple residents. Additionally, the facility did not ensure a resident discharged with behavioral health needs received access to appropriate behavioral health services.
Deficiencies (2)
F 0584: The facility failed to provide a homelike environment by not ensuring sufficient hot water on the 100 unit for at least three months, with water temperatures frequently below the standard 105-120 degrees Fahrenheit.
F 0740: The facility failed to ensure a resident discharged with a diagnosis of major depression received access to behavioral health services as an option to process emotional stressors.
Report Facts
Census: 185
Water temperature readings below standard: 17
Severity score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding water temperature issues and repairs | |
| Compliance Officer | Interviewed regarding resident behavioral health and discharge | |
| Social Worker | Interviewed regarding resident behavioral health and care | |
| Admissions Staff | Interviewed regarding resident admission and interactions |
Inspection Report
Plan of Correction
Census: 191
Deficiencies: 1
Date: Apr 2, 2024
Visit Reason
The document is a plan of correction submitted in response to a deficiency related to failure to provide timely basic life support including CPR to a resident with physician orders for CPR.
Findings
The facility failed to provide timely basic life support, including CPR, to a resident who had physician orders for CPR and was found without a pulse, resulting in the resident's death. The deficiency was based on interviews, record reviews, and investigative summaries showing staff did not administer CPR when obvious signs of death were present.
Deficiencies (1)
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to provide timely basic life support, including CPR, to a resident with physician orders for CPR who was found without a pulse and expired.
Report Facts
Resident census: 191
Date of incident: Mar 23, 2024
Inspection Report
Census: 191
Deficiencies: 1
Date: Apr 2, 2024
Visit Reason
The inspection was conducted due to a failure to provide timely basic life support, including CPR, for a resident with physician orders for CPR who was found without a pulse and subsequently expired.
Findings
The facility failed to provide timely CPR to Resident #1 who had physician orders for CPR and was found without a pulse. Staff identified obvious signs of death and did not administer CPR, but the facility was found to have immediate jeopardy past non-compliance which was later corrected with staff training.
Deficiencies (1)
F 0678: The facility failed to provide basic life support, including CPR, prior to the arrival of emergency medical personnel for one resident with physician orders for CPR who was found without a pulse and expired.
Report Facts
Residents Affected: 4
Census: 191
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Conducted rounds, found resident without signs of life, did not administer CPR |
| LPN B | Licensed Practical Nurse | Assisted LPN A in death assessment, did not administer CPR |
| CNA C | Certified Nurse's Assistant | Completed rounds on resident prior to death |
| Physician D | Physician | Provided opinion on CPR administration expectations |
| Administrator | Administrator | Reviewed staff statements and noted terminology issues regarding dependent lividity |
Inspection Report
Life Safety
Census: 183
Capacity: 321
Deficiencies: 11
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code survey to assess compliance with federal, state, and local emergency preparedness and fire safety regulations.
Findings
The facility was found deficient in maintaining an updated emergency preparedness plan and communication plan, proper signage and exit access in multiple dining rooms, sprinkler system maintenance, electrical equipment safety, and smoking regulations. Several fire safety code violations were cited, including blocked exits, missing signage, and inadequate sprinkler coverage.
Deficiencies (11)
E004 Emergency Plan. The facility failed to ensure all copies of the Emergency Preparedness plan were updated annually and included all necessary information.
E030 Names and Contact Information. The facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for all staff.
K211 Means of Egress - General. The facility failed to maintain proper signage on doors leading to smoking patios and ensure clear exit paths in multiple dining rooms.
K222 Egress Doors. The facility failed to maintain clear signage on delayed egress doors in multiple dining halls.
K321 Hazardous Areas - Enclosure. The facility failed to maintain fire and smoke resistance rating of the laundry sorting room wall due to unsealed holes.
K351 Sprinkler System - Installation. The facility failed to provide adequate sprinkler coverage in the laundry sorting room and HVAC closet.
K353 Sprinkler System - Maintenance and Testing. The facility failed to maintain sprinkler heads free of debris and corrosion in multiple areas.
K363 Corridor - Doors. The facility failed to ensure doors positively latched within doorframes in multiple smoke compartments.
K511 Utilities - Gas and Electric. The facility failed to maintain electrical wiring and power strips in compliance with NFPA standards.
K741 Smoking Regulations. The facility failed to properly maintain designated smoking areas and dispose of ashtray contents safely.
K920 Electrical Equipment - Power Cords and Extension Cords. The facility failed to ensure power strips and extension cords were used and maintained safely.
Report Facts
Facility capacity: 321
Resident census: 183
Deficiencies cited: 11
Inspection Report
Routine
Census: 183
Deficiencies: 2
Date: Nov 17, 2023
Visit Reason
The inspection was conducted to assess compliance with residents' rights, personal hygiene care, and provision of a homelike environment at the nursing home.
Findings
The facility failed to uphold residents' rights by turning off call lights without providing timely assistance, resulting in residents waiting long periods for help. Additionally, the facility served meals on Styrofoam plates for an extended time, which was not homelike. The facility also failed to provide adequate personal hygiene care, including leaving a resident soiled for an extended period and inadequate grooming of another resident.
Deficiencies (2)
F 0550: The facility failed to uphold residents' rights by turning off call lights without helping residents, causing long wait times, and served meals on Styrofoam plates for an extended period, which was not homelike.
F 0677: The facility failed to provide necessary personal hygiene care, leaving one resident soiled for an extended time and inadequately grooming another resident with food in his/her beard.
Report Facts
Sample size: 35
Census: 183
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse M | Confirmed resident was soiled during perineal care observation | |
| CNA K | Certified Nurse Aide | Turned off call light without assisting resident and stated not assigned to resident |
| CNA L | Certified Nurse Aide | Turned off call light and delayed changing resident until after breakfast delivery |
| Administrator | Stated residents should be treated with dignity and that waiting over an hour to be changed was unacceptable | |
| Director of Nursing | DON | Agreed CNAs should have changed resident promptly and beard should have been cleaned |
| Dietary Manager | Explained use of Styrofoam plates due to broken dishwasher | |
| CNA N | Certified Nurse Aide | Said aides were responsible for beard care when showering residents |
| CNA O | Certified Nurse Aide | Observed resident's beard filled with food crumbs needing cleaning and trimming |
| Nurse A | Observed resident's beard dirty and filled with food crumbs |
Inspection Report
Annual Inspection
Census: 183
Deficiencies: 7
Date: Nov 17, 2023
Visit Reason
The inspection was an annual survey to assess compliance with regulatory standards for nursing home care, including resident rights, quality of care, medication management, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to uphold residents' rights by not responding properly to call lights, inadequate personal hygiene care, incomplete post-fall documentation, improper medication self-administration procedures, failure to notify physicians and pharmacy about medication refusals, improper respiratory device cleaning, medication storage temperature violations, and unsanitary kitchen conditions with staff not following hairnet/beard net policies.
Deficiencies (7)
F 0550: The facility failed to uphold residents' rights by turning off call lights without assisting residents, causing long wait times, and served meals on Styrofoam plates for an extended period, which was not homelike.
F 0658: The facility failed to meet professional standards by not completing post-fall documentation for two residents and not completing self-administration assessments or obtaining physician orders for one resident with bedside medications.
F 0677: The facility failed to provide necessary personal hygiene care for one resident left soiled for an extended time and inadequately groomed another resident with food in his beard.
F 0695: The facility failed to ensure respiratory care met professional standards by not following policy or obtaining physician orders for cleaning a resident's C-PAP machine.
F 0760: The facility failed to ensure one resident was free from significant medication errors by not notifying the physician and pharmacy about refusal of prescribed inhalers and medication substitution issues.
F 0761: The facility failed to store drugs and biologicals at proper temperature controls; medication refrigerator temperatures were consistently out of range without proper investigation or corrective action.
F 0812: The facility failed to maintain sanitary food storage and preparation areas, with trash and spills observed in storage rooms, sticky and dirty kitchen floors, and staff not consistently following hairnet and beard net policies.
Report Facts
Sample size: 35
Census: 183
Medication refrigerator temperature: 56
Medication refrigerator temperature: 52
Medication refrigerator temperature log out-of-range dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA K | Certified Nurse Aide | Named in failure to assist resident with call light and personal hygiene |
| CNA L | Certified Nurse Aide | Named in failure to timely assist resident and perform perineal care |
| Nurse M | Nurse | Performed perineal care and confirmed resident was soiled |
| Administrator | Provided statements on residents' rights and facility expectations | |
| Director of Nursing (DON) | Director of Nursing | Provided statements on care expectations and policy compliance |
| CMT R | Certified Medication Technician | Commented on resident self-administration of medications |
| RN A | Registered Nurse | Interviewed regarding medication administration and resident refusals |
| LPN C | Licensed Practical Nurse | Verified medication refrigerator temperatures and logging |
| Pharmacist J | Pharmacist | Commented on medication refusal communication expectations |
| Dietary Manager | Provided statements on kitchen cleanliness and hairnet/beard net policy | |
| Dietary Staff F | Observed not wearing beard net in kitchen | |
| Dietary Staff G | Commented on hair and beard net policy compliance | |
| [NAME] E | Dietary Staff | Observed not wearing beard net and responsible for cleaning kitchen floors |
Inspection Report
Plan of Correction
Census: 183
Deficiencies: 14
Date: Nov 17, 2023
Visit Reason
The inspection was conducted to investigate and document deficiencies related to resident rights, professional standards, respiratory care, medication errors, and other regulatory compliance issues at Delmar Gardens West nursing facility.
Findings
The facility was found deficient in multiple areas including failure to uphold residents' rights, inadequate professional standards in care plans, improper respiratory care, medication errors, and failure to maintain cleanliness and safety in food service areas. Several residents were observed to have unmet care needs and the facility failed to follow policies and procedures in multiple domains.
Deficiencies (14)
F550 Resident Rights: The facility failed to uphold residents' rights by turning off call lights, resulting in residents waiting long periods for help and serving meals on Styrofoam plates for an extended time.
F658 Services Provided Meet Professional Standards: The facility failed to meet professional standards by not completing post-fall documentation and self-administration assessments for residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure residents received necessary personal hygiene care, leaving residents soiled and inadequately groomed.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure respiratory services were consistent with professional standards, including cleaning of CPAP devices and obtaining physician orders.
F760 Residents are Free of Significant Med Errors: The facility failed to ensure one resident was free from significant medication errors by not notifying the physician and pharmacy about medication refusals.
F761 Label/Store Drugs and Biologicals: The facility failed to store all drugs and biologicals at proper temperatures and maintain medication room temperature logs.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain sanitary conditions in the kitchen, including dirty floors, sticky surfaces, and improper food storage.
A4060 Medication Errors/Adverse Reaction Reported: The facility failed to report medication errors and adverse reactions as required.
A4064 Medication Storage: The facility failed to store medications securely and separately from discontinued medications.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions.
A4077 Residents Groomed/Dressed Appropriately: The facility failed to ensure residents were well-groomed and dressed appropriately.
A6012 Floor Surfaces: The facility failed to maintain clean and good repair floors in food preparation and other areas.
A7003 Clean Clothing, Hair Restraints: The facility failed to ensure employees wore effective hair restraints to prevent contamination of food.
A8030 Dignity/Privacy: The facility failed to treat residents with full recognition of dignity and privacy in care and treatment.
Report Facts
Sample size: 35
Census: 183
Residents audited weekly: 25
Residents audited monthly: 5
Inspection Report
Complaint Investigation
Census: 194
Deficiencies: 1
Date: Jul 21, 2023
Visit Reason
The inspection was conducted due to a complaint alleging physical abuse of a resident by a Certified Nurse Aide (CNA G) at the facility.
Complaint Details
The complaint involved Resident #2 who reported being punched in the face by CNA G on 7/10/23, resulting in bruising and swelling. Multiple staff statements and medical notes confirmed the injury and fear experienced by the resident. The CNA was terminated. The resident was cognitively intact and had no history of aggression or bruising. The investigation included interviews with staff, the resident, social workers, and hospital personnel.
Findings
The facility failed to ensure one resident was free from physical abuse when staff inflicted injury causing bruising and fear. The facility investigated, suspended the CNA involved, and implemented corrective measures promptly.
Deficiencies (1)
F 0600: The facility failed to protect a resident from physical abuse by staff, resulting in bruising and fear in the resident. The abuse was confirmed and corrective actions were taken including staff suspension.
Report Facts
Census: 194
Date of alleged incident: Jul 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nurse Aide | Named as the staff member who allegedly punched the resident causing injury |
| CNA F | Certified Nurse Aide | Reported the resident's injury and abuse allegation to nursing staff |
| Nurse I | Nurse | Received report of abuse and investigated the resident's injury |
| Nurse D | Nurse | Notified of resident injury and provided care including ice pack |
| Nurse H | Night Nurse | Interviewed resident and conducted skin assessment after abuse report |
| Nurse S | Nurse | Responded to resident's claim of abuse and conducted skin assessment |
| Social Worker B | Social Worker | Interviewed resident and provided assessment of resident's cognitive and behavioral status |
| Social Worker P | Social Worker | Provided assessment of resident's behavior and history |
| Director of Nursing | Director of Nursing | Provided information on resident's history and facility records |
| Hospital Nurse C | Hospital Nurse | Interviewed resident and documented resident's report of abuse |
Inspection Report
Plan of Correction
Census: 194
Deficiencies: 1
Date: Jul 21, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a regulatory inspection of Delmar Gardens West nursing facility, addressing a past noncompliance regarding abuse and neglect of a resident.
Findings
The facility failed to ensure one resident was free from physical abuse by a Certified Nurse Aide (CNA), resulting in bruising and fear. The facility conducted an investigation, took corrective measures including suspension of the CNA, and corrected the violation.
Deficiencies (1)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent physical abuse of a resident by staff, causing bruising and fear. The resident was assaulted by a CNA, and the facility took corrective action including suspension of the CNA.
Report Facts
Resident census: 194
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide G | Named as staff involved in resident abuse | |
| Nurse I | Reported abuse incident and interviewed staff | |
| Nurse D | Investigated resident injury and provided care | |
| Nurse H | Conducted skin assessment and interviewed resident | |
| CNA F | Witnessed and reported abuse incident | |
| CNA E | Witnessed resident condition and staff interactions | |
| CNA M | Interviewed regarding resident bruising and behavior | |
| Social Worker P | Interviewed about resident behavior and history | |
| Director of Nursing | Director of Nursing | Interviewed about resident history and bruising |
Inspection Report
Plan of Correction
Census: 180
Deficiencies: 2
Date: May 5, 2022
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident records and clinical documentation, specifically focusing on safeguarding resident-identifiable information and maintaining accurate medical records.
Findings
The facility failed to ensure care and services were provided according to accepted clinical standards, including incomplete documentation of weights, physician orders, and medication administration records for multiple residents. The deficiencies were related to resident records and clinical documentation accuracy and accessibility.
Deficiencies (2)
F842 Resident Records - The facility failed to safeguard medical record information and maintain complete, accurate, and accessible clinical records for residents, including missing physician orders and incomplete documentation of weights and medication administration.
A4116 Clinical Records Accurate/Accessible - The facility did not maintain clinical records that were complete, accurately documented, readily accessible, and systematically organized on each nursing unit, as evidenced by the deficiencies cited at F842.
Report Facts
Census: 180
Sample size: 6
Missed weight documentation: 5
Missed weight documentation: 5
Missed TED hose documentation: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nurses (ADON) | Interviewed regarding resident weight and documentation practices |
Inspection Report
Plan of Correction
Census: 184
Deficiencies: 5
Date: Nov 5, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, including bathing preferences, perineal care, pressure ulcer prevention and treatment, accident hazards, and dietary support.
Findings
The facility was found deficient in accommodating resident bathing preferences, providing thorough perineal care, preventing and treating pressure ulcers, ensuring a safe environment free of accident hazards, and maintaining sufficient dietary support personnel. Several residents experienced inadequate care related to these areas.
Deficiencies (5)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to accommodate resident bathing preferences, including providing transfer assistance and appropriate equipment such as Hoyer pads, resulting in residents receiving bed baths instead of showers.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide thorough perineal care and routine weekly showers for sampled residents, leading to inadequate hygiene and potential infection risk.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to prevent pressure ulcers for one resident, ensure weekly skin assessments, implement physician-ordered treatments timely, and notify the wound physician of changes.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure staff followed the mechanical lift policy safely, including video surveillance showing unsafe transfers by one staff member.
F802 Sufficient Dietary Support Personnel: The facility failed to provide sufficient dietary staff to serve meals timely and according to resident preferences, resulting in late and cold meals and inadequate meal service.
Report Facts
Resident census: 184
Sample size: 27
Sample size: 4
Pressure ulcer residents reviewed: 2
Number of showers per week: 3
Braden scale score: 16
Inspection Report
Complaint Investigation
Census: 213
Deficiencies: 4
Date: Nov 25, 2020
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted from 11/16/2020 through 11/25/2020. The investigation included a complaint regarding failure to notify a resident's responsible party after the resident developed pressure ulcers.
Complaint Details
Complaint investigation related to failure to notify a resident's responsible party after the resident developed pressure ulcers. The complaint was substantiated.
Findings
The facility was found to be in compliance with COVID-19 emergency preparedness requirements but failed to notify one resident's responsible party after the resident developed two pressure ulcers. Additionally, the facility failed to ensure licensed staff completed daily pressure ulcer treatments and weekly skin assessments as ordered, and failed to maintain an effective infection prevention and control program.
Deficiencies (4)
F580 Notification of Changes: The facility failed to notify one resident's responsible party after the resident developed two pressure ulcers. The sample size was 13 and the census was 213.
F658 Services Provided Meet Professional Standards: The facility failed to ensure staff notified the charge nurse of a change in condition for one of 13 sampled residents. The census was 213.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to ensure licensed staff completed daily pressure ulcer treatments and weekly skin assessments as ordered for 16 residents with pressure ulcers. The census was 213.
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program, including failure to ensure staff wore correct PPE and follow infection control policies during the COVID-19 pandemic. The census was 213.
Report Facts
Sample size: 13
Census: 213
Residents with pressure ulcers: 16
Residents sampled for notification failure: 1
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 3
Date: Oct 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from 10/27/2020 through 10/30/2020. The facility was found to be in compliance with emergency preparedness regulations, but complaint-related deficiencies were identified regarding care for dependent residents.
Complaint Details
The investigation was complaint-related, focusing on failure to provide adequate grooming, personal hygiene, and safe environment for residents. The complaint was substantiated as deficiencies were found.
Findings
The facility failed to provide necessary grooming and personal hygiene services for dependent residents, resulting in residents with long fingernails and unclean conditions. Additional deficiencies included failure to provide treatment and care in accordance with professional standards, and failure to ensure a safe environment free of accident hazards.
Deficiencies (3)
F677: The facility failed to provide necessary grooming and personal hygiene services for dependent residents, evidenced by residents with long fingernails and unclean conditions.
F684: The facility failed to ensure residents received treatment and care in accordance with professional standards, including proper perineal care and skin assessments.
F689: The facility failed to ensure the resident environment was free of accident hazards and that residents received adequate supervision and assistance to prevent accidents.
Report Facts
Sampled residents: 21
Resident census: 212
Residents affected: 4
Residents affected: 2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 10/07/2020 through 10/09/2020 to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 08/27/20 through 09/01/20 to assess compliance with CMS and CDC COVID-19 related regulations and recommendations.
Complaint Details
The complaint investigation related to COVID-19 infection control found no deficiencies and was substantiated by compliance with CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 07/27/2020 through 08/07/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted from 06/18/2020 through 06/24/2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Life Safety
Census: 235
Capacity: 321
Deficiencies: 5
Date: Jan 15, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations, including fire safety, smoke barriers, smoking regulations, electrical systems, and oxygen storage.
Findings
The facility failed to maintain smoke doors properly, failed to dispose of ashtray contents according to NFPA regulations, did not maintain documentation of repairs for electrical receptacles, failed to provide a remote manual stop for the emergency generator, and failed to maintain oxygen cylinder storage according to NFPA code. These deficiencies affected multiple smoke compartments and had the potential to impact all occupants.
Deficiencies (5)
K374: The facility failed to maintain smoke doors so they closed securely and prevented gaps exceeding 1/8 inch, affecting four of 23 smoke compartments.
K741: The facility failed to dispose of ashtray contents in accordance with NFPA regulations, affecting all staff, visitors, and residents using two designated smoking areas.
K914: The facility failed to maintain documentation of repairs for annual receptacle testing, including 95 receptacles documented as failed and no repair records.
K918: The facility failed to provide a remote manual stop for the emergency generator, which could affect all occupants in an emergency.
K923: The facility failed to maintain oxygen cylinder storage according to NFPA code, including combustible materials stored less than three feet from oxygen tanks.
Report Facts
Facility capacity: 321
Resident census: 235
Smoke compartments affected: 4
Receptacles tested: 95
Designated smoking areas: 2
Oxygen storage closet shelves: 3
Inspection Report
Routine
Census: 235
Deficiencies: 6
Date: Jan 15, 2020
Visit Reason
Routine inspection of nursing home facility to assess compliance with regulatory standards including resident care, safety, medication management, infection control, and food service.
Findings
The facility failed to post survey results and plan of correction accessibly, did not consistently follow professional standards in resident care including documentation and physician communication, failed to follow proper transfer procedures with Hoyer lifts, did not ensure timely physician response to pharmacist recommendations, improperly stored food items, and failed to follow infection control practices including hand hygiene and catheter care.
Deficiencies (6)
F 0577: Facility failed to post the most recent survey results and plan of correction in a place readily accessible to residents, family members, and the public.
F 0658: Facility failed to document communication of registered dietician recommendations to physicians, obtain physician orders for care changes, complete resident assessments and vital signs upon readmission, and properly document urinary output and blood pressure monitoring for multiple residents.
F 0689: Facility failed to ensure proper use of Hoyer lifts by staff, including not widening the legs of the lift during transfers for three residents.
F 0756: Facility failed to ensure physicians addressed pharmacist recommendations within an acceptable time frame for seven residents, including medication adjustments and lab monitoring.
F 0812: Facility failed to discard expired milk and ensure thickening products were used or discarded by recommended dates.
F 0880: Facility staff failed to follow infection control practices including hand hygiene and glove changes during perineal care and improperly placed urinary catheter tubing and drainage bags for five residents.
Report Facts
Census: 235
Expired milk date: 2020
Thickening product expiration: 2019
Pharmacist recommendations: 7
Hoyer lift transfers observed: 5
Residents affected by Hoyer lift deficiency: 3
Residents sampled: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) A | Named in infection control hand hygiene deficiency during perineal care | |
| Certified Nurse Aide (CNA) B | Named in improper Hoyer lift use and catheter care deficiencies | |
| Certified Nurse Aide (CNA) C | Named in improper Hoyer lift use and catheter care deficiencies | |
| Director of Nursing (DON) | Interviewed regarding deficiencies in dietician communication, Hoyer lift use, infection control, and catheter care | |
| Food Services Manager | Interviewed regarding expired food items | |
| Corporate Registered Dietician | Interviewed regarding dietician recommendation documentation |
Inspection Report
Annual Inspection
Census: 235
Deficiencies: 12
Date: Jan 15, 2020
Visit Reason
The inspection was the annual state survey of Delmar Gardens West nursing facility conducted to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including failure to post survey results and plan of correction, failure to meet professional standards for comprehensive care plans, failure to protect residents from accidents, inadequate drug regimen review, infection control deficiencies, and food safety violations. The facility submitted a plan of correction with a completion date of February 21, 2020.
Deficiencies (12)
F577 Right to Survey Results/Advocate Agency Info: The facility failed to post the most recent survey results and plan of correction in a place accessible to residents and the public.
F658 Services Provided Meet Professional Standards: The facility failed to document physician orders for care and failed to complete assessments and vital signs for sampled residents.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to protect three residents from potential harm by not following policy for transferring with a Hoyer lift.
F756 Drug Regimen Review: The facility failed to ensure pharmacist recommendations were acted upon and documented in residents' medical records.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store food properly, discard expired milk, and ensure food safety practices, including labeling and dating.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection control program and failed to follow hand hygiene and glove use policies.
A4060 Drug Regimen Review-Monthly: At least monthly pharmacist review of each resident's drug regimen was not documented or acted upon.
A4073 Protective Oversight, Voluntary Leave: The facility failed to have procedures for residents on voluntary leave.
A4074 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions.
A4085 Infection Control/Communicable Disease: The facility failed to make reports to the health department for communicable diseases.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to protect food from contamination and maintain proper temperatures.
A8002 Noncompliance/Inspection Reports Posted: The facility failed to post notice of noncompliance in a conspicuous location.
Report Facts
Census: 235
Sample size: 35
Deficiencies cited: 12
Inspection Report
Plan of Correction
Census: 243
Deficiencies: 1
Date: Aug 23, 2019
Visit Reason
This visit was a plan of correction review following a past non-compliance related to freedom from abuse and neglect involving a resident fall and injury.
Findings
The facility failed to ensure a resident's right to be free from neglect when a resident who required two staff for personal care fell and sustained serious injuries. The facility submitted a plan of correction and removed the noncompliance by 07/10/19.
Deficiencies (1)
F 600: The facility failed to prevent neglect of a resident requiring two staff assistance, resulting in a fall causing subarachnoid hemorrhage, scalp hematoma, and fractured clavicle. The noncompliance was corrected by 07/10/19.
Report Facts
Resident census: 243
Inspection Report
Plan of Correction
Census: 263
Deficiencies: 1
Date: Dec 13, 2018
Visit Reason
The visit was conducted to address an Immediate Jeopardy (IJ) related to failure to provide basic life support including CPR to a resident, as documented in the facility's Statement of Deficiencies and Plan of Correction.
Findings
The facility failed to provide basic life support including cardiopulmonary resuscitation (CPR) to a resident whose breathing and heartbeat had stopped. The failure was linked to staff not following CPR policies and procedures, resulting in an Immediate Jeopardy that was later removed after corrective actions.
Deficiencies (1)
F 678: Personnel failed to provide basic life support, including CPR, to a resident whose heartbeat and breathing had stopped. Staff did not follow the facility's CPR policy and procedures.
Report Facts
Resident census: 263
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Nurse | Named in the finding for failing to initiate CPR and making a poor decision during the resident's emergency |
| Nurse J | Certified Nursing Assistant (CNA) | Interviewed regarding last seeing the resident and care provided |
| Director of Nursing | Director of Nursing (DON) | Mentioned in relation to CPR status sheet and staff instructions |
Inspection Report
Annual Inspection
Census: 255
Deficiencies: 8
Date: Dec 5, 2018
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations for Delmar Gardens West nursing facility.
Findings
The facility was found deficient in multiple areas including advance directives documentation, notice requirements before transfer/discharge, pressure ulcer prevention and treatment, mobility and restorative therapy services, infection control, food safety, and catheter care. Several residents' records and care practices did not meet regulatory standards.
Deficiencies (8)
F578 Advance Directives: Facility failed to ensure physicians signed Do Not Resuscitate (DNR) orders for sampled residents. Documentation lacked physician signatures on DNR forms.
F623 Notice Before Transfer/Discharge: Facility failed to issue written transfer notices to residents or their representatives upon discharge to hospital. Several residents discharged without proper notice.
F686 Pressure Ulcers: Facility failed to provide appropriate care and services to prevent and heal pressure ulcers. One resident developed a pressure ulcer on the left heel.
F688 Mobility: Facility failed to ensure residents with limited mobility received restorative therapy services as ordered. Two residents did not receive ordered therapy.
F690 Bowel/Bladder Incontinence and Catheter Care: Facility failed to maintain proper placement and care of indwelling urinary catheters. Sampled residents had issues with catheter care and documentation.
F880 Infection Control: Facility failed to ensure staff used proper infection control procedures during blood glucose testing and incontinence care. Multiple observations showed lapses in hand hygiene and equipment cleaning.
F812 Food Safety: Facility failed to maintain food safety standards including cleanliness of kitchen equipment and proper storage of food items. Observed grease, dust, and expired milk in kitchen areas.
A4010 License/Exceptions Posted: Facility failed to post current license and exceptions in a public area visible to residents and visitors.
Report Facts
Resident census: 255
Residents with indwelling urinary catheters: 22
Sample size for catheter care review: 35
Residents sampled for DNR order review: 7
Residents discharged without transfer notice: 5
Blood glucose testing observations with problems: 4
Inspection Report
Life Safety
Census: 255
Deficiencies: 7
Date: Dec 5, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including means of egress, exit signage, cooking facility maintenance, portable fire extinguisher placarding, smoking regulations, prohibition of portable space heaters, and electrical panel clearance. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (7)
K211 Means of Egress - General: The facility failed to maintain exit pathways to a public way, including an all-weather path to safety and proper exit discharge surfaces.
K293 Exit Signage: The facility failed to maintain and test exit signage, including lack of exit signs in hallways.
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood to NFPA standards, including grease accumulation and lack of monthly inspections.
K355 Portable Fire Extinguishers: The facility failed to maintain K-class fire extinguishers with required placards stating activation instructions.
K741 Smoking Regulations: The facility failed to maintain smoking areas according to NFPA regulations, including presence of cigarette butts and improper ashtray contents.
K781 Portable Space Heaters: The facility failed to prohibit the use of portable space heaters in the facility, including a space heater found under a desk.
K911 Electrical Systems - Other: The facility failed to maintain clear work space around electrical panels, with items stored within three feet of panels.
Report Facts
Facility census: 255
Inspection Report
Annual Inspection
Census: 258
Deficiencies: 14
Date: Jan 19, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and to evaluate the quality of care and resident rights at Delmar Gardens West nursing facility.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate abuse/neglect policies and training, failure to provide meaningful activities, quality of care issues including pressure ulcer prevention and treatment, and unsafe environment concerns such as inadequate supervision and fall prevention.
Deficiencies (14)
F550 Resident Rights: Facility staff failed to treat residents in a dignified and respectful manner, including rude behavior, failure to assist, and not wearing name badges.
F607 Abuse/Neglect Policies: Facility failed to develop and implement adequate policies and training to prevent abuse and neglect, including failure to check CNA registry for some staff.
F679 Activities: Facility failed to provide meaningful activities to residents, resulting in lack of engagement for some residents.
F684 Quality of Care: Facility failed to provide treatments as ordered by physicians, including inadequate care for residents receiving enteral feeding and medication administration.
F686 Skin Integrity: Facility failed to prevent and treat pressure ulcers appropriately, including inadequate assessments and documentation.
F689 Accident Hazards: Facility failed to ensure a safe environment, resulting in falls and injuries to residents due to inadequate supervision and unsafe equipment.
F690 Bowel/Bladder Incontinence: Facility failed to ensure proper catheter care and continence management, increasing risk of infection and discomfort.
A4053 Written Orders; Restraints: No medication, treatment, or diet shall be given without a written order from a lawful person; facility failed to comply.
A4054 Safe/Effective Medication System: Facility failed to maintain a safe and effective medication system as required.
A4074 Nursing Care per Resident Condition: Facility failed to provide personal attention and nursing care consistent with resident needs and nursing standards.
A4082 Pressure Sore Prevention/Treatment: Facility failed to keep residents free from avoidable pressure sores and provide adequate treatment.
A4085 Infection Control/Communicable Disease: Facility failed to use acceptable infection control procedures to prevent spread of infection.
A4100 Activity Program: Facility failed to designate an employee responsible for activity program and failed to provide adequate activities.
A8030 Dignity/Privacy: Facility failed to treat residents with full recognition of dignity and privacy in treatment and care.
Report Facts
Facility census: 258
Number of sampled residents: 35
Number of deficient staff: 3
Plan of correction completion date: Global completion date February 20, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse E | Named in plan of correction for CNA registry check | |
| Licensed Practical Nurse F | Named in plan of correction for CNA registry check | |
| Licensed Practical Nurse G | Named in plan of correction for CNA registry check |
Inspection Report
Life Safety
Census: 251
Capacity: 321
Deficiencies: 4
Date: Jan 9, 2018
Visit Reason
The inspection was a life safety code survey to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations.
Findings
The facility failed to maintain walls free of penetrations to resist smoke passage, did not provide proper signage for delayed egress doors, had smoke detectors improperly installed near ventilation systems, and failed to ensure corridor doors resisted smoke passage. These deficiencies affected multiple areas of the building and posed potential risks to residents and staff.
Deficiencies (4)
K161: The facility failed to maintain walls free of penetrations to resist the passage of smoke, evidenced by a 12 inch by 6 inch hole in the storage closet wall. This affects all residents, staff, and occupants in the event of a fire.
K222: The facility failed to provide a durable sign with instructions on how to operate the delayed egress locking mechanism on the exit door, as required by NFPA 101.
K341: The fire alarm system was not installed in accordance with NFPA 72, 2010 edition, as smoke detectors were located too close to ventilation systems, compromising their effectiveness.
K363: Corridor doors did not shut tight to create a smoke seal, with an observed inch gap in one door, affecting smoke compartment integrity.
Report Facts
Facility capacity: 321
Resident census: 251
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