Delmar Gardens of Chesterfield

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 6, 2022

  Based on observation, interview and record review, the facility failed to ensure staff followed physician orders and facility policies while transferring two residents, each of whom sustained a laceration during their transfer (Residents #3 and #8). Resident #3 had a transfer order for a two person transfer using a gait belt (a belt applied snuggly around the waist and used by staff to provide stability during a transfer) and dermasavers (cushioned sleeves worn to reduce the risk of skin tears) to be worn at all times to the upper/lower extremities. On 8/14/22, the resident sustained a left calf laceration when one agency certified nursing assistant (CNA) J transferred the resident without assistance, without using a gait belt, and without applying the dermasavers. […]

• Actual harm, isolatedF760Jun 30, 2023

  Based on interview and record review, the facility failed to ensure residents received their medications as ordered by failing to ensure admission medications were verified and ordered promptly, medications were reordered prior to running out, staff checked the facility starter kit (an in-facility supply of commonly used medications for immediate use) and/or the medication supply room when a new medication was ordered or a current medication was unavailable. Additionally, staff failed to notify physicians, and/or the resident, and/or the resident's representative when medications were not administered as ordered. Resident #2 had a diagnosis of thyroid cancer and an order for Nexavar (used to prevent the growth and spread of cancer) and cephalexin (antibiotic). […]

• No harm, potential for more than minimal, widespreadF865Feb 15, 2024

  Based on observations, resident and staff interviews, record reviews, and review of the Administrator's Job Description, the facility failed to ensure good faith attempts were made to correct quality deficiencies through their Quality Assurance and Performance Improvement (QAPI) process. The Administration had not implemented any QAPI programs to address the ongoing COVID-19 and respiratory syncytial virus (RSV) outbreaks. Additionally, the administration failed to identify sufficient staffing as a possible quality deficiency. […]

• No harm, potential for more than minimal, widespreadF880Feb 15, 2024

  26006 Based on observations, interviews, record reviews, review of the Centers for Disease Control (CDC) guidelines, and facility policy review, the facility failed to: 1. Wear appropriate personal protective equipment (PPE) when providing care to residents on transmission-based precautions. 2. Doff (take off) soiled PPE prior to exiting the resident's room. 3. Complete resident testing upon new positive cases of COVID-19 in the building. 4. Complete contact tracing for staff that were in close contact with COVID-19 positive residents or exposed to Respiratory Syncytial Virus (RSV) positive residents 5. Provide evidence of staff testing done during an outbreak of COVID-19. 6. Ensure appropriate cohorting of residents within close contact to other COVID-19 and RSV positive residents. […]

• No harm, potential for more than minimal, patternF759Aug 6, 2025

  Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities, two errors occurred, resulting in an 8% medication error rate (Residents #45, and #145). The census was 171 with 166 with certified bed.Review of the facility's Medication Administration-General Guidelines Policy, revised 1/2021, showed: Policy: Only a Registered Nurse (RN), License Practical Nurse (LPN), Certified Medication Aide, or Certified Medication Technician (CMT) are assigned responsibility for preparing, administering and/or record the administration of medications. […]