Delmar Center for Rehabilitation and Nursing

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Have exits that are accessible at all times.

Egress Deficiencies

Install proper backup exit lighting.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Gas, Vacuum, and Electrical Systems Deficiencies

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Rights Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Egress Deficiencies

Have horizontal exits used in accordance with safety requirements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Resident Rights Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

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.

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Construction Deficiencies

Meet requirements for sections of health care facilities separated by fire resistive construction.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.