Inspection Results » Delmar Gardens of Green Valley

Health Inspection on March 9, 2018 ^[1]

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

   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-04-16)
   • Provide and implement an infection prevention and control program. (Corrected 2018-04-16)
   • Implement a program that monitors antibiotic use. (Corrected 2018-04-16)

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

   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-04-16)
   • Provide for the safe, appropriate administration of IV fluids for a resident when needed. (Corrected 2018-04-16)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-04-16)
   • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2018-04-16)
   • Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Corrected 2018-04-16)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2018-04-23)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-04-16)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-04-16)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-04-16)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-04-16)
   • Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (Corrected 2018-04-16)
   • 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 2018-04-16)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-04-16)
   • Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (Corrected 2018-04-16)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-04-16)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-04-16)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-04-16)
   • Assess the resident when there is a significant change in condition (Corrected 2018-04-16)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-04-16)