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Deficiency Records for Delmar Gardens of Green Valley
A list of the most recent deficiencies for Delmar Gardens of Green Valley. 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 Green Valley. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-16 | 2023-07-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-16 | 2023-07-18 | N |
| 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. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-16 | 2023-07-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-16 | 2023-07-18 | 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 | 2023-06-16 | 2023-07-18 | N |
| 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. | Health | 2023-06-16 | 2023-07-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Develop a communication plan. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-06-15 | 2023-07-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-18 | 2022-04-08 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Establish methods for sharing information. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-06 | 2022-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-07 | 2022-03-07 | 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 | 2022-01-07 | 2022-03-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-07 | 2022-03-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-07 | 2022-03-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-07 | 2022-03-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-07 | 2022-03-07 | 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 | 2022-01-07 | 2022-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-07 | 2022-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-03-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-09-27 | Not Fixed | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-09-27 | Not Fixed | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-27 | Not Fixed | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-27 | Not Fixed | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-27 | Not Fixed | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-09-27 | Not Fixed | N |
| 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. | Health | 2024-09-27 | Not Fixed | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-09-27 | Not Fixed | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-09-27 | Not Fixed | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-09-27 | Not Fixed | N |
| 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 | 2024-09-27 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-27 | Not Fixed | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-09-26 | Not Fixed | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-26 | Not Fixed | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-09-26 | Not Fixed | N |
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