Delmar Gardens North

In the surveyor’s words

From the most serious findings on record at Delmar Gardens North, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 10, 2025

  Based on observation, interview and record review, the facility failed to maintain an environment as free of accident hazards as possible and to provide supervision and assistance to prevent falls for five of seven sampled residents (Residents #1, #3, #4, #5 and #6) by not implementing care planned fall interventions. On 12/31/24 Certified Nurse Aide (CNA) A failed to place Resident #1's bed in a low position. Resident #1 was found screaming and hanging off the bed holding onto the grab rail. A nurse assisted the resident to the floor. The resident sustained bilateral (both sides) fractured femurs (thighbones). […]

• Actual harm, isolatedF610Nov 2, 2023

  Based on interview and record review, the facility failed to ensure staff followed their Abuse, Neglect and Exploitation, Freedom From policy by failing to immediately notify the Administrator/Designee or Director of Nurses (DON)/Designee and promptly begin an investigation regarding one resident's allegation on 10/24/23 around 4:30 P.M. to 5:00 P.M., of being slapped or hit in the face/mouth by Certified Nursing Assistant (CNA) A. In addition, the facility failed to ensure CNA A was immediately suspended from work pending the results of an investigation. CNA A continued to work on 10/24/23 until 10:38 P.M., returned to the facility on [DATE], and worked from 6:34 A.M. until 3:27 P.M., before being suspended from work. […]

• Actual harm, isolatedF684Nov 2, 2023

  Based on interview and record review, the facility failed to ensure staff followed their Condition Change, of the Resident policy. On the morning of 10/9/23, Nurse O (the day shift nurse) documented the night shift nurse reported at shift change one resident had a low blood pressure (BP), the physician was notified and gave orders to encourage fluids. The night shift nurse failed to document in the progress notes and/or on an SBAR (Situation, Background, Assessment, and Recommendation, assessment tool) communication form, the date or time the resident's BP was low, what the BP was, or the physician's order. In addition, Nurse O failed to document on-going assessments/monitoring of the resident throughout the day. […]

• No harm, potential for more than minimal, widespreadF812Oct 6, 2023

  Based on observations, interviews, record review, and policy review, the facility failed to ensure: 1. the high temperature dish machine met proper temperatures and 2. the staff maintained a clean kitchen including items in the storage areas for all 133 residents who received meals from the kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: 1.Observations during the initial tour of the kitchen on 10/02/23 beginning at 9:31 AM with the Food Service Director (FSD) revealed: The hot water dishwasher temperatures of Wash was 152 Fahrenheit (F), the Rinse was 154 F, and the Final Rinse was 190F. […]

• No harm, potential for more than minimal, patternF550Nov 17, 2025

  Based on observation, interview and record review, the facility failed to ensure all residents were treated with dignity and respect, ensuring their comfort, privacy, and personal rights are always upheld, when staff did not knock or announce their presence before entering the rooms of Residents #36, #50, #72, and #84, violating their right to privacy, when Residents #1, #2 and #28 were not provided with call lights within reach, limiting their ability to communicate their needs promptly and when staff failed to adjust the dining room temperature to a comfortable level, compromising their comfort for Residents #26, #72, #145, and #164. This affected the dignity standards to guarantee residents' physical comfort, autonomy, and respect in daily care for nine of 36 sampled residents. […]