Delmar Gardens West

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Apr 2, 2024

  Based on interview and record review, the facility failed to provide timely basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped) for one of four sampled residents, who had physician orders for CPR and was found by staff without a pulse (Resident #1). The resident expired. The census was 191. The Administrator was notified on [DATE], of the Immediate Jeopardy (IJ) past non-compliance, which occurred on [DATE]. The facility provided training and in-servicing for all staff regarding the facility's CPR policy and using proper definitions/verbiage when reporting on CPR/Death Reporting Form. […]

• Actual harm, isolatedF600Jul 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure one resident was free from physical abuse (Resident #2), when staff inflicted injury to a resident, bruising underneath the eye, and also caused the resident to be fearful. The sample was three residents. The census was 194. The Administrator was notified on 7/21/23 of the past-noncompliance which began on 7/10/23. The facility conducted an investigation and immediately in-serviced staff on 7/10/23 regarding combative residents, abuse/neglect/exploitation and body mechanics. The facility instituted corrective measures on 7/10/23, including suspension of Certified Nurse Aide (CNA) G. The violation was corrected on 7/10/23. […]

• Actual harm, isolatedF686Nov 5, 2021

  Based on interview and record review, the facility failed to prevent the development of pressure ulcers to one resident (Resident #1). The resident admitted to the facility from the hospital with intact skin. The facility failed to ensure documentation of weekly skin assessments after the resident admitted to the facility on [DATE] until the discovery of the wound on 6/30/21. In addition, the facility failed to implement a physician-ordered specialized mattress until after the wound developed and failed to notify the wound physician when the resident refused a recommended supplement. At the time of the initial discovery of the wound, staff documented the sacral wound as a stage III pressure ulcer (full thickness tissue loss. […]

• No harm, potential for more than minimal, widespreadF812Apr 11, 2025

  Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to cover food and failed to ensure that expired thickened dairy products were discarded. The facility also failed to ensure kitchen equipment was kept clean during three of five days of observation. In addition, the facility failed to maintain records of dish washing temperature logs as well as chloride testing logs. Furthermore, the facility failed to follow the puree recipes for six of the seven purees observed and failed to ensure dishes were properly washed in between use. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 181. 1. […]

• No harm, potential for more than minimal, widespreadF925Aug 21, 2024

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent roaches and gnats in the kitchen, where residents' food was prepared and served. The census was 181. Review of the facility's Pest Control Policy, revised 08/2024, showed: -Purpose: To ensure that the facility is free to exposure to pests to include, but not limited to insects, cockroaches, rats, mice, bed bugs, etc; -Procedure: -The Director of Environmental Services is the designated coordinator for this facility. This person acts as a liaison between the building occupants and the pest management provider; -Regular inspections will be performed by both the Director of Environment Service/designee and the contracted pest management professional. […]