Inspection Results » Delmar Nursing & Rehabilitation Center

Health Inspection on December 3, 2018 ^[1]

1. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. (Corrected 2019-01-08)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-01-08)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-01-08)
   • Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. (Corrected 2019-01-08)
   • Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. (Corrected 2019-01-08)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-01-08)
   • Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. (Corrected 2019-01-08)
   • Provide and implement an infection prevention and control program. (Corrected 2019-01-08)
   • Observe each nurse aide's job performance and give regular training. (Corrected 2019-01-08)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2019-01-08)
   • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2019-01-08)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2019-01-08)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-01-08)

2. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2019-01-08)
   • Respond appropriately to all alleged violations. (Corrected 2019-01-08)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-01-08)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-01-08)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-01-08)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2019-01-08)
   • Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. (Corrected 2019-01-08)
   • Provide activities to meet all resident's needs. (Corrected 2019-01-08)
   • Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (Corrected 2019-01-08)
   • Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (Corrected 2019-01-08)
   • Assess the resident when there is a significant change in condition (Corrected 2019-01-08)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2019-01-08)
   • Ensure that residents are free from significant medication errors. (Corrected 2019-01-08)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2019-01-08)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2019-01-08)
   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2019-01-08)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2019-01-08)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-01-08)
   • Keep residents' personal and medical records private and confidential. (Corrected 2019-01-08)

3. Widespread: No actual harm with potential for minimal harm

   • Post nurse staffing information every day. (Corrected 2019-01-08)