Delmar Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Delmar Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF806Jul 17, 2026

  Based on observation, interview and record review it was determined that for one (R1) out of three residents reviewed for allergies, the facility failed to ensure a resident with severe food allergy was not served food containing an allergen. The facility's failure placed the residents at risk for a serious adverse outcome including respiratory depression, anaphylaxis or even death from consuming food with a severe allergy. Due to this failure an Immediate Jeopardy (IJ) was called on 7/15/26 at 3:00 PM. The IJ was abated on 7/16/26 at 12:00 AM. Findings include: Cross refer F656;Review of R1's clinical record revealed:2/12/26 - R1 was admitted to the facility with a diagnosis of Cerebral Palsy. […]

• Actual harm, isolatedF686Oct 6, 2023

  Based on observation, interview and record review it was determined that for two (R58 and R14) out of two residents reviewed for pressure ulcers, the facility failed to provide care and services to promote healing and prevent pressure ulcers. For R58 the facility failed to prevent an avoidable deep tissue injury from developing to the left heel and a stage 4 pressure ulcer to the right ankle causing harm. For R14 the facility failed to ensure that the resident was turned and repositioned to prevent pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF801Sep 26, 2024

  Based on personnel file review and interview, the facility failed to ensure a qualified Dietary Manager (DM) was in place with appropriate competencies and skills to carryout the functions of the food and nutrition service with the potential to affect all 82 census residents. Findings include: Review of the personnel file on 09/23/24 at 1:00 PM revealed the DM hired in the past five weeks lacked management training for the food service director position. He had [AGE] years of management experience in food service. The DM had a Serve Safe certificate but lacked management training. During an interview on 09/25/24 at 12:45 PM, the DM revealed he had an associate degree in design and technology with no reference to food service management. […]

• No harm, potential for more than minimal, widespreadF812Sep 26, 2024

  Based on observation, interviews, and policy review, the facility failed to ensure the three-pan sink had adequate plumbing, the insulated plate dome covers were in good condition, the kitchen was maintained in a clean manner, and the sanitizer bucket and three-pan sink had adequate sanitizer levels in accordance with professional standards for food safety. The failure has the potential to contribute to food-borne illness and cross contamination for 82 census residents. Findings include: Review of the facility's undated policy titled, Dietary Department Sanitizer Guidelines revealed the three-compartment sink, and other solutions shall be sanitized at 200-400 PPM (parts per million). 1. […]

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

  Based on observation and interview, it was determined that the facility failed to maintain the correct concentration of sanitizing solution required to ensure proper sanitization of food preparation surfaces. Findings include: 9/29/23 10:47 AM- During a tour of the kitchen, E18 (Director of Food Services) tested the sanitizer level of the solution in a red sanitizing bucket. When E18 tested the sanitizing solution, the test strip indicated that the level of chemical concentration in the bucket was not sufficient to provide proper sanitization. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.