The Estates at Delano LLC

In the surveyor’s words

From the most serious findings on record at The Estates at Delano LLC, in the surveyor’s own words.

• Actual harm, isolatedF697Jan 4, 2024

  Based on interview and document review, the facility failed to ensure pain management was provided consistent with professional standards of practice and the residents' goals and preferences for 2 of 2 residents (R131 and R14) reviewed for pain managment. This deficient practice caused actual harm for R131, who experienced unmanaged pain, disturbed sleep patterns and who had reports of pain. Findings include: R131's discharge Minimum Data Set (MDS) dated , 9/23/23, identified resident admitted to the facility 9/22/23 from an acute care hospital for aftercare following surgery on the nervous system and diagnoses of spondylolisthesis lumbar region (a spinal disorder in which a vertebra slips forward onto the bone below it), radiculopathy lumbar region (a pinched nerve), spinal stenosis (a… […]

• Actual harm, isolatedF686Jan 15, 2021

  Based on interview and document review, the facility failed to ensure assistance was provided with repositioning and applied medical devices were removed timely to prevent pressure ulcer formation and associated complications for 1 of 3 residents (R13) reviewed for pressure ulcer care. This resulted in actual harm for R13 when they developed multiple unstageable pressure injuries to their buttocks and sacrum after they were left on a bedpan for an extended period of time. Findings include: A State agency (SA) submitted Incident Report Summary, dated [DATE], identified the nursing home reported an allegation of potential neglect when R13 was found to have a bed pan underneath of her which caused redness. […]

• No harm, potential for more than minimal, widespreadF851Oct 16, 2024

  F851 Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information at least quarterly based on payroll and other verifiable and auditable data during (2024) 1 of 1 quarter reviewed (Quarter three) in Federal Fiscal Year (2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This has the potential to affect all 33 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review: 4/6/24, 4/20/24, 4/21/24, 5/19/24 and 6/15/24 for failure to have registered nurse (RN) coverage eight hours per day. […]

• No harm, potential for more than minimal, widespreadF812Jan 4, 2024

  Based on observation, interview and document review, the facility failed to store and distribute food in accordance with professional standards for food safety. This had the potential to affect all 32 resident currently residing in the facility. Findings include: During observations and interview in the facility dining room on 1/2/24 at 11:15 a.m., in the resident dining room were two refrigerators side by side. One refrigerator referred to as the nurse refrigerator by the culinary services director (CSD), had latches on the bottom refrigerator door and on the upper freezer door but was not locked. There was a thermometer inside and temperature logs were kept. Inside the freezer were mighty shake supplements the CSD stated were used by nursing for the residents. […]

• No harm, potential for more than minimal, widespreadF851Jan 4, 2024

  Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Payroll Based Journal (PBJ) [NAME] Report 1705 identified the following dates triggered: 7/1/23, 8/26/23, 8/27/23, 9/30/23 for failure to have licensed nurse coverage 24 hours per day and 8/5/23, 8/6/23, 8/19/23, 8/20/23, 9/2/23, 9/3/23, 9/30/23 for no registered nurse (RN) hours. […]