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Deficiency Records for Delmar Gardens of Chesterfield
A list of the most recent deficiencies for Delmar Gardens of Chesterfield. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Delmar Gardens of Chesterfield. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-08 | 2024-06-01 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-02-15 | 2024-03-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-02-15 | 2024-03-26 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-02-15 | 2024-03-26 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-02-15 | 2024-03-26 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-15 | 2024-03-26 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-15 | 2024-03-26 | Y |
| 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 necessary and PRN use is limited. | Health | 2024-02-15 | 2024-03-26 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-15 | 2024-03-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-15 | 2024-03-26 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-02-15 | 2024-03-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-15 | 2024-03-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-15 | 2024-03-26 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-08 | 2024-03-26 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-02-08 | 2024-03-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-08 | 2024-03-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-03-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-08 | 2024-03-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-08 | 2024-03-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-30 | 2023-07-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-30 | 2023-07-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-30 | 2023-07-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-06 | 2022-09-17 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-22 | 2022-02-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-22 | 2022-01-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-22 | 2022-01-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-11-22 | 2022-01-05 | N |
| 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. | Health | 2021-11-22 | 2022-01-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-11-22 | 2022-01-05 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-11-22 | 2022-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-22 | 2022-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-22 | 2022-01-05 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-11-22 | 2022-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-22 | 2022-01-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-22 | 2022-01-05 | Y |
| 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. | Health | 2021-11-22 | 2022-01-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-22 | 2022-01-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-22 | 2022-01-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-22 | 2022-01-05 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-22 | 2022-01-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-07 | 2019-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-07 | 2019-03-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-07 | 2019-03-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-02-07 | 2019-03-14 | N |
| 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. | Health | 2019-02-07 | 2019-03-14 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2019-02-07 | 2019-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-02-07 | 2019-03-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-07 | 2019-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-07 | 2019-03-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-02-07 | 2019-03-14 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-07 | 2019-03-14 | N |
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