Delmar Gardens South

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 11, 2026

  Based on interview and record review, the facility failed to ensure one resident (Resident #1) received adequate assistance to prevent accidents when staff performed a Hoyer (mechanical lift) transfer with a torn Hoyer sling on 05/06/26 after staff observed a tear in one of the straps of the Hoyer sling. All four Hoyer straps ripped during the transfer and the resident fell to the floor which resulted in fractures to both of the resident's femurs (the upper leg bone, that is the longest and strongest bone in the human body and is the structural link between the hip and knee) that required surgery. The sample was 6. […]

• Actual harm, isolatedF689Feb 13, 2024

  Based on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1) who required staff assistance with transfers and mobility when toileting. On 1/15/24, after the resident asked for privacy in the bathroom, staff did not ensure the resident was in a safe position. The resident fell and sustained an L2 (second lumbar spinal vertebrae in the human body) compression fracture (the fracture occurs when the bone collapses, and the front (anterior) part of the vertebral body forms a wedge shape). The sample size was 3. […]

• No harm, potential for more than minimal, patternF761Sep 17, 2024

  Based on observation, interview and record review, the facility failed to label and store medications according to acceptable standards of practice, for two of seven medication carts reviewed. The facility failed to date insulin pens when removed from the refrigerator and placed in the medication cart. In addition, the facility failed to ensure narcotic medications were always maintained under double lock when not under direct supervision. The facility identified 14 medication/treatment carts. The census was 240 with 184 in certified beds. […]

• No harm, potential for more than minimal, isolatedF689Sep 17, 2024

  Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents when a Certified Nursing Assistant (CNA) failed to ensure two staff were present before providing care, which resulted in a fall where the resident suffered a skin tear to the left upper extremity (LUE), a purple bruise purple above his/her left eye with a laceration on top of the bruise (Resident #33). The census was 240 residents, with 184 in certified beds. […]

• No harm, potential for more than minimal, isolatedF919Dec 28, 2023

  Based on observation and interview, the facility failed to follow their policy when staff failed to acknowledge audible and visual call light signals located above the resident's door or answer call lights promptly for three residents (#1, #4 and #7). The census was 224. Review of the facility's Call Lights Answering policy, reviewed 6/2021, showed: -Purpose: To get to the resident when he/she calls for assistance; -To assist the nurse in meeting the resident's request; -Procedure: 1. Go to the resident as soon as he/she calls. Answer within 5-15 minutes. Emergency lights should be responded to immediately to prevent injury; 2. Ask the resident, in friendly manner, what he/she needs; 3. Turn off the call light so that others will know that it has been answered; 4. […]