Delmar Gardens on the Green

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 16, 2022

  Based on interview and record review, the facility failed to keep one resident (Resident #1) free from physical abuse. On 2/23/22, at approximately 9:00 P.M., two agency staff members, Certified Medication Technician (CMT) I and Nurse F held the resident's upper extremities and attempted to pry the resident's hand open, in an effort to take back an antibiotic medication. The resident was upset, yelled out, and sustained bruises. The census was 93. The administrator was notified on 3/10/22 at 4:00 P.M. of an immediate jeopardy (IJ) which began on 2/23/22. […]

• Immediate jeopardy, isolatedF609Mar 16, 2022

  Based on interview and record review, the facility failed to ensure all staff, including agency staff, were aware of procedures on how to report abuse when one resident (Resident #1) was physically abused. On 2/23/22 at approximately 9:00 P.M., two agency staff members, Certified Medication Technician (CMT) I and Nurse F, held the resident's upper extremities and attempted to pry the resident's hand open, in an effort to take back an antibiotic medication. The resident was upset, yelled out and sustained bruises. Two additional, certified nurse's aides, employed by the facility, heard the resident yelling but did not immediately intervene. […]

• Immediate jeopardy, isolatedF689Apr 23, 2021

  Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #6), admitted on [DATE], for a respite stay (a planned short term stay). On 6/1/21 at 6:40 P.M., the resident was observed pushing on, opening and sounding an alarm on a delayed egress emergency exit door (to open the door, 15 seconds of pressure is required on the door handle/bar. Once opened, an alarm sounds alerting staff). After the resident was redirected away from the delayed egress emergency exit door, facility staff failed to follow their Elopement, Residents at Risk policy by failing to apply a department alert bracelet on the resident (an electronic device most often worn on the wrist or ankle that sets off an alarm on two of the 12 facility exit doors equipped only with the… […]

• Actual harm, isolatedF684Oct 4, 2024

  Based on interview and record review, the facility failed to ensure professional standards of practice where met, when staff failed to transcribe one resident's new treatment order onto the electronic treatment administration record (eTAR), resulting in the new treatment order not being administered from 7/24/24 to 8/2/24 as ordered by the physician for one resident (Resident #8) resulting in the wound showing signs and symptoms of infection. The sample was 18. The census was 96 with 83 residents in certified beds. […]

• Actual harm, isolatedF600Oct 11, 2023

  Based on interview and record review, the facility failed to ensure one resident was free from verbal abuse and intimidation (Resident #1). On 8/19/23 between 3:30 P.M. and 4:30 P.M., during medication pass, Certified Medication Technician (CMT B) was observed by Certified Nurse Aide (CNA) C and Nurse A standing chest to chest with the resident, yelling/cursing at the resident, and/or throwing a towel at the resident. CMT B initially refused to leave the resident's room when Nurse A instructed him/her to do so and continued to yell and curse at the resident who was visibly upset. […]