CMS Inspection Results for DELMAR NURSING & REHABILITATION CENTER

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 01/21/2009 Fire Safety Survey for DELMAR NURSING & REHABILITATION CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Widespread	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Potential for minimal harm

 

• 01/20/2009 Health Survey for DELMAR NURSING & REHABILITATION CENTER

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
Keep safe, clean and homelike surroundings.	Widespread	Potential for minimal harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Potential for minimal harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a plan with the resident and family for the resident's care after leaving the nursing home.	Isolated	Minimal harm or potential for actual harm

 

• 08/12/2008 Fire Safety Survey for DELMAR NURSING & REHABILITATION CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
Vertical Openings
Deficiency	Scope	Level of Harm
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Widespread	Potential for minimal harm

 

• 08/06/2008 Health Survey for DELMAR NURSING & REHABILITATION CENTER

Administration
Deficiency	Scope	Level of Harm
Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
post nurse staffing information.	Pattern	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
Try to resolve each resident's complaints quickly.	Pattern	Potential for minimal harm

 

• 09/10/2007 Fire Safety Survey for DELMAR NURSING & REHABILITATION CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Potential for minimal harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Widespread	Potential for minimal harm

 

• 09/05/2007 Health Survey for DELMAR NURSING & REHABILITATION CENTER

Administration
Deficiency	Scope	Level of Harm
Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Minimal harm or potential for actual harm
Hire a qualified activities director.	Pattern	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
Make sure that staff members wash their hands when needed.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Pattern	Minimal harm or potential for actual harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm