Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
treat each resident with respect and dignity and provide care in a manner and in an
environment that promotes maintenance or enhancement of his or her quality of life by
failing to ensure a sufficient amount of food was available during meal service, failing
to provide adequate number of tableware and clothing protectors for resident use and
failing to provide meals and meal assistance to residents in a timely manner. This
affected eight out of 35 sampled residents and had the potential to affect other residents
requiring staff assistance (Residents #13, #79, #333, #22, #104, #135, #181 and #120). The
census was 223 with 193 residents in certified beds.
1. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/28/18, showed the following:
-Brief interview of mental status (BIMS) score of 3 out of 15;
-A BIMS score of 0-7, showed the resident had severe cognitive impairment;
-Required extensive assistance of two for transfers;
-Supervision, oversight, cueing, set up only for meals;
-Wheelchair for mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 7/31/18 and in use during the survey, showed the
following:
-Problem: Received a pureed no concentrated sweets (NCS) diet. Trial with mechanical
soft/regular food;
-Goal: Will maintain current nutritional status and stable weight;
-Approach: Allow extra time to eat, assist at mealtimes to ensure adequate meal intake,
dietitian to evaluate and follow as needed, encourage to eat and drink at meals.
Observation on 2/13/19 at 10:55 A.M., showed the resident sat in his/her room in a Broda
chair (medical reclining chair), his/her spouse sat in a chair beside him/her. The
resident’s spouse said he/she visited daily and assisted with meals when he/she was
present, but was worried his/her spouse did not get enough assistance to eat when he/she
was not visiting.
Observation of the dining room on 2/14/19, showed the following:
-At 11:45 A.M., the resident sat in a Broda chair at a dining room table;
-At 12:04 P.M., staff placed the resident’s pureed meal in front of the resident, on the
table;
-At 12:21 P.M., dietary staff continued to plate food while staff served other resident’s
their meals. The resident sat in his/her chair without meal assistance, and he/she did not
attempt to eat;
-At 12:50 P.M., certified nursing assistant (CNA) P sat down next to the resident and
assisted the resident with his/her meal that had sat in front of him/her since 12:04 P.M.
During an interview on 2/19/19 at 4:00 P.M., the Administrator said staff should not make
residents who need assistance with meals, wait until everyone is served before they
provide assistance with their meals.
2. Review of Resident #79’s quarterly MDS, dated [DATE], showed:
-BIMS score of 7 out of a possible score of 15;
-Extensive assistance required for dressing;
-Supervision required for eating;
-[DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-Received a mechanically altered diet.
Review of Resident #333’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Independent with dressing and eating;
-[DIAGNOSES REDACTED].>-Received a therapeutic diet.
Observation and interview on 2/13/19 at 12:11 P.M., showed approximately 32 residents in
the division 100 dining room. Staff provided residents with clothing protectors prior to
being served their meal. Staff had not offered all residents a clothing protector. CNA J
said there were no more clothing protectors and sat down at a table with several
residents. CNA J did not ask the remaining residents if they wanted a clothing protector
or call laundry to request more clothing protectors sent to the division. Staff did not
offer the last two tables of residents and they did not receive a clothing protector.
Resident #79 and Resident #333 did not receive a clothing protector during meal service.
After the meal, Resident #79 had crumbs on his/her black shirt and black pants. When
Resident #79 was asked why he/she did not have a clothing protector, Licensed Practical
Nurse (LPN) K immediately said Resident #79 did not want one and brushed the crumbs from
the resident’s shirt and pants. LPN K said some residents do not want to use a clothing
protector. LPN K transported Resident #79 out of the dining room to the nurse’s station.
LPN K continued to wipe the crumbs from the resident’s pants and shirt. Resident #333 used
his/her napkin to wipe his/her hands off during the meal. He/she had food crumbs on
his/her pants after the meal.
During an interview on 2/20/19 at 3:31 P.M., the Administrator said she would expect the
residents to be offered a clothing protector. She would expect staff to call laundry if
they run out of clothing protectors. Maintenance staff is able to get the residents
clothing protectors as well.
3. Observation and interview on the 100 division, showed:
-On 2/13/19 at 12:40 P.M., the dietary aide said they ran out of onion rings. There were
several residents that had not been served. The dietary aide stopped serving the residents
in the 100 division to wait for the onion rings. Eight residents waited for their meal. At
12:50 P.M., division 100 dining room received their onion rings, and the dietary aide
resumed serving the residents;
-On 2/14/19 at 12:27 P.M., staff served residents their meal in the Division 100 dining
room. Dietary staff ran out of carrots and bowls. He/she called the kitchen and requested
more food and bowls. The dietary aide stopped serving the residents. There were several
residents that did not receive their meal. At 12:31 P.M., the division 100 dining room
received the carrots and bowls. The dietary aide resumed serving the residents;
-On 2/19/19 at 12:42 P.M., staff served the residents their meal in the division 100
dining room. Dietary Aide L said he/she needed more mechanical soft food and ambrosia
salad. A CNA in the dining room yelled out, again, I’m getting tired of this. The dietary
aide stopped serving the residents in the dining room. Dietary Aide L called the kitchen
and asked for more food. During an interview at this time, Dietary Aide L said he/she was
waiting for three more regular diets and one more mechanical soft diet to be served.
Dietary Aide L said there was not enough food sent to division 100. It happens a lot.
During an interview on 2/20/19 at 2:03 P.M., Resident #22 said he/she has to wait if they
run out of food, which is all the time. It is horrible. He/she did not like to wait.
He/she waited an hour to receive his/her dinner yesterday, 2/19/19.
During an interview on 2/20/19 at 2:09 P.M., the dietary manager said the dietary staff
have a count list of the number of regular, mechanical, and puree diets for each division.
Staff are expected to know the number of plates and bowls to send. Staff should wait until
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
the food arrived, so a partial plate is not served; however, there should be enough food
for the residents in case they wanted seconds. Staff are expected to be prepared during
meal service so it is not interrupted.
4. Review of Resident #104’s medical record, showed:
-An annual MDS, dated [DATE], showed:
-BIMS score of 4;
-Required assist of one for eating;
-Care Area triggered for dementia and nutritional status;
-[DIAGNOSES REDACTED].
-A care plan, dated 12/26/18 and in use at the time of the survey, showed:
-Problem: Received a regular diet;
-Goal: Will maintain current nutritional status and stable weight;
-Interventions: Allow extra time to eat; Assist at mealtimes to ensure adequate meal
intake; Encourage resident to eat and drink at meals.
Review of Resident #135’s medical record, showed:
-A quarterly MDS, dated [DATE], showed the following:
-BIMS score of 14;
-A BIMS score of 13-15, showed cognitively intact;
-Set up help for eating;
-[DIAGNOSES REDACTED].
-A care plan dated 1/9/19, and in use at the time of the survey, showed:
-Problem: Required a regular, no added salt diet;
-Goal: Will verbalize understanding of dietary regimen and restrictions;
-Intervention: Provide as much control as possible in routines, food preferences, etc.
Review of Resident #181’s medical record, showed:
-A quarterly MDS, dated [DATE], showed the following:
-BIMS score of 13 out of 15;
-Required one person physical assist for eating;
-Impairment on one side of upper body;
-A care plan, dated 1/30/19 and in use at the time of the survey, showed:
-Problem: Resident has a deficit in activities of daily living (ADL) functioning related
to weakness;
-Goal: Resident will participate in ADL activities, as tolerated;
-Intervention-Set up supplies. Cueing if needed.
Review of Resident #120’s quarterly MDS, dated [DATE], showed the following:
-BIMS score of 9;
-A BIMS score of 8-12, showed moderate cognitive impairment;
-Required one person physical assist for eating;
-[DIAGNOSES REDACTED].
-A care plan, dated 1/2/19 and in use at the time of the survey, showed:
-Problem: On a regular diet;
-Intervention: Provide eating assistance.
Observations on 2/14/19, showed:
-At 12:09 P.M., dietary staff began serving plates of food to the residents seated in the
dining room;
-At 12:21 P.M., CNA V placed a plate of soup, corn bread and carrots in front of Resident
#104. The resident said he/she wanted to eat something else and CNA V called back I’ll
order you something, as the CNA walked away from the table;
-At 12:33 P.M., as residents in the dining room ate their meals, Resident #104, #135,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
#181, and #120 still did not have food;
-At 12:35 P.M., Resident #135 called out to staff in the dining room, Where is my food
at?;
-At 12:37 P.M., Resident #181 sat at a table by his/herself without a plate of food.
He/she looked back over his/her shoulder to the dining room, turned back to his/her table,
reached for a packet of sugar and licked the outside of the package;
-At 12:41 P.M., the Assistant Director of Nursing (ADON) told Resident #120 his/her food
was on the way, everyone is very busy today;
-At 12:45 P.M., Dietary Aide (DA) W entered the dining room from the kitchen and said to
CNA V and the ADON that the kitchen did not have additional food orders prepared because
the cook did not know what the residents wanted to eat;
-At 12:47 P.M., CNA V said Residents #181 and #120 order the same food items every day and
it is pre-arranged with the kitchen so their meals come out at the same time as the rest
of the meal service. Resident #135 often orders a baloney sandwich;
-At 12:53 P.M., the dessert of ice cream and coffee served to the remaining residents in
the dining room;
-At 12:54 P.M., Residents #135, #181 and #120 received their meals and began to eat.
Resident #104 propelled him/herself away from the dining room table, into the nursing
station without eating any food;
-At 12:57 P.M., during an interview, Resident #104 said he/she did not eat anything during
the meal. Staff does not always tell him/her what there is to eat and sometimes he/she
does not understand things. He/she was hungry;
-At 1:00 P.M., the ADON asked Resident #104 if he/she had eaten his/her sandwich. The
resident replied he/she never had a sandwich. He/she lowered his/her head and mumbled
he/she was hungry and hoped to get a sandwich as the ADON walked away;
-At 1:03 P.M., CNA V propelled Resident #104 from the nurse’s station back to the
resident’s dining table. CNA V set a plate full of chips and a sandwich in front of the
Resident. The resident ate both the sandwich and the chips with coffee.
During an interview on 2/20/19 at 4:05 P.M., the Director of Nursing (DON) and the ADON
said it is not acceptable to make residents wait for a long period of time for their
meals.

F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to honor resident
rights to make choices about aspects of his or her life in the facility that are
significant to the resident for two residents (#37 and #13) by not getting one resident up
at the time they wanted and not providing coffee to one resident when requested. The
sample size was 35. The census was 223 with 193 in certified beds.
1. Review of the Resident #37’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/11/18, showed:
-[DIAGNOSES REDACTED].
-Cognitively intact;
-Limited assistance required for transfer and locomotion on and off the unit;
-Special treatments indicated for [MEDICAL TREATMENT] (the process of filtering toxins

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
from the blood in individuals with kidney failure).
Observation and interview on 2/14/19 at 7:48 A.M., showed the resident sat on his/her bed.
The resident said that he/she is on [MEDICAL TREATMENT] and has been on [MEDICAL
TREATMENT] for about nine years. He/she attends [MEDICAL TREATMENT] on Mondays, Wednesdays
and Fridays. Sometimes his/her choices are not honored. Sometimes he/she wants to get up
earlier on [MEDICAL TREATMENT] days (around 6:00 A.M.) so he/she could be ready. The night
staff do not get him/her up and say he/she does not have to leave until 10 A.M. or 10:30
A.M. The resident did not feel he/she had enough time on [MEDICAL TREATMENT] days to get
ready if staff waited until the dayshift to get him/her up.
During an interview on 2/20/19 at 9:42 A.M., Certified Nursing Assistant (CNA) Y said if a
resident wanted to get up at a certain time, staff would try to get them up. Sometimes it
is impossible to get them up at a certain time. Staff try to get the resident up close to
the time he/she wishes.
During an interview on 2/20/19 at 2:30 P.M., the Assistant Director of Nursing (ADON) and
the Director of Nursing (DON) said staff is expected to get residents up when they want to
get up. Staff should be getting residents up when they want, even if its 3:00 A.M. They
were not aware the resident wanted to get up early. This probably started happening once
the resident moved to the 200 hall. When he/she was on 300 hall, the staff knew his/her
routine.
2. Review of Resident #13’s quarterly MDS, dated [DATE], showed the following:
-Brief Interview of Metal Status (BIMS) score of 3 out of 15;
-A BIMS score of 0-7, showed severe cognitive impairment;
-Supervision, oversight, cueing, set up only for meals;
-Wheelchair for mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 7/31/18 and in use at the time of the survey,
showed the following:
-Problem: Received a pureed no concentrated sweets (NCS) diet. Trial with mechanical
soft/regular food;
-Goal: Will maintain current nutritional status and stable weight;
-Approach: Allow extra time to eat, assist at mealtimes to ensure adequate meal intake,
Dietitian to evaluate and follow as needed, encourage to eat and drink at meals.
Observation and interview on 2/13/19 at 10:55 A.M., showed the resident sat in his/her
room in a Broda chair (medical reclining chair), his/her spouse sat in a chair beside
him/her. The resident’s spouse said the only concern he/she had with the facility was in
regard to feeding assistance while he/she was not present.
Observation of the dining room on 2/13/19, showed the following:
-At 12:17 P.M., the resident sat in a Broda chair at the dining room table. As staff
walked past the resident, he/she requested a glass of milk. Staff did not provide milk or
lactose free milk;
-At 12:31 P.M., as staff walked by the resident and served other resident’s their lunch,
the resident repeatedly asked for a cup of coffee. Staff did not address the resident’s
requests and did not provide coffee;
-At 12:32 P.M., as staff walk past the resident, the resident asked for a cup of coffee,
he/she sighed and said, that is all I ever ask for. No coffee offered or provided.
Observation of the dining room on 2/14/19, showed the following:
-At 8:16 A.M., the resident sat in a Broda chair at a table in the dining room. As staff
walked past the resident, he/she requested a cup of coffee, none provided;
-At 12:04 P.M., an empty and unused coffee cup with a straw placed in the cup, sat in
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
front of the resident;
-At 12:47 P.M., as staff walked past the resident, and refilled other resident’s coffee
cups, the resident asked for a cup of coffee, none provided;
-At 12:50 P.M., CNA Q sat next to the resident and assisted him/her with his/her meal. CNA
Q said the resident cannot have coffee because he/she heard it caused him/her diarrhea.
Further review of the resident’s medical record, showed no documentation of allergies
[REDACTED].
Observation of the dining room on 2/15/19, showed the following:
-At 7:16 A.M., the resident sat in the dining room. Staff did not offer coffee to the
resident. The resident requested coffee, none provided;
-At 10:36 A.M., the surveyor asked CNA R if the resident could have coffee, CNA R said
he/she would have to ask the nurse because neither milk nor coffee was listed on the
resident’s care card;
-At 10:40 A.M., Nurse S said the resident may have coffee and there is no reason he/she
could not have coffee.
During an interview on 2/19/19 at 3:23 P.M., the DON said staff should honor meal choices.

F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Keep residents’ personal and medical records private and confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a
resident with personal privacy during personal care when a staff person entered the bath
room without knocking while a resident sat on the toilet, for one of four residents
observed during personal care (Resident #13), the facility failed to provide privacy of
resident records when staff hung information to include resident’s first and last names,
dietary orders, allergies and other resident specific information in dining rooms,
uncovered and visible to residents and visitors. In addition, staff failed to provide
privacy when they failed to knock on resident doors before entering. The census was 223
with 193 residents in certified beds.
1. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/28/19, showed:
-Brief interview of Mental Status (BIMS) score of 3 out of 15;
-A BIMS score of 0-7, showed the resident had severe cognitive impairment;
-Total dependence for transfer, toilet use and personal hygiene.
Review of the resident’s care plan, in use at the time of the survey, showed:
-[DIAGNOSES REDACTED].
-Problem: Cognitive loss/dementia: Loss of short/long term memory with difficulty in
making decisions regarding daily tasks of life;
-Approach: Give positive feedback and praise for accomplishments.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 8/30/17, for transfer needs: One person assist;
-An order dated 11/21/18, may be up in Broda chair (medical reclining chair) with assist
for positioning.
Observation on 2/13/19 at 11:37 A.M., showed Certified Nursing Assistant (CNA) A
transferred the resident to the toilet. As the resident sat on the toilet, with his/her
pants down, a staff person swung the door open, without first knocking and/or announcing
him/herself, and told CNA A that he/she left his/her cell phone in the bathroom. He/she

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
opened the privacy curtain approximately 4 inches. The resident visible to the hall. CNA A
handed the staff person his/her cell phone and the staff person left the bathroom and
closed the door.
During an interview on 2/20/19 at 2:40 P.M., with the Director of Nursing (DON), Assistant
DON, Administrator, Assistant Administrator and corporate nurse, they said they would you
expect staff to knock and announce themselves before walking into the bathroom. If staff
needed something from the bathroom as the resident sat on the toilet, they should provide
privacy.
2. Observation of the facility’s unit dining rooms, showed a list of residents who reside
on the individual units with their first and last name, room number, diet order, thickened
liquid order as applicable, allergies as applicable and a section for other, which
included preferences as applicable, that hung on the outside of the steam table and faced
residents in the dining room:
-On the 300 hall on 2/13/19 at 8:54 A.M. and 12:32 P.M., on 2/14/19 at 12:09 P.M., on
2/15/19 at 8:46 A.M., on 2/19/19 at 9:05 A.M., and on 2/20/19 at 9:11 A.M.;
-On the 100 hall on 2/14/19 at 12:10 P.M., on 2/15/19 at 8:48 A.M., and on 2/19/19 at 9:16
A.M.;
-On the 500 hall on 2/14/19 at 12:04 P.M., on 2/15/19 at 8:44 A.M., and on 2/19/19 at 8:24
A.M.;
-On the 200 hall on 2/19/19 at 9:11 A.M.
During an interview on 2/20/19 at 2:40 P.M., with the DON, Assistant DON, Administrator,
Assistant Administrator and corporate nurse, they said they would consider a resident’s
first and last name in combination with diet orders and allergies to be protected health
information. There is a privacy flap that should cover the information that hangs in the
dining rooms and staff should lift the flap if they need to review the information.
3. Observation on the 200 hall, showed:
-On 2/15/19 at 10:10 A.M., a CNA entered room [ROOM NUMBER] without knocking;
-On 2/15/19 at 10:14 A.M., a CNA entered room [ROOM NUMBER] without knocking. He/she had a
mobile ice cooler and took the resident some ice;
-On 2/15/19 at 10:15 A.M., a CNA entered room [ROOM NUMBER] without knocking. He/she asked
the resident if he/she wanted some ice;
-On 2/15/19 at 10:17 A.M., a nurse entered room [ROOM NUMBER] without knocking;
-On 2/15/19 at 10:18 A.M., a male staff member entered room [ROOM NUMBER] without
knocking;
-On 2/15/19 at 10:19 A.M., a CNA entered room [ROOM NUMBER] without knocking and took ice
into the room;
-On 2/15/19 at 10:20 A.M., a nurse entered room [ROOM NUMBER] without knocking.
During an interview on 2/20/19 at 2:40 P.M., with the DON, Assistant DON, Administrator,
Assistant Administrator and corporate nurse, they said they would expect staff to knock
before entering the resident’s room, as this is a privacy issue.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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.

Based on observation and interview, the facility failed to maintain a comfortable sound
level during night time and early morning hours and vacuumed hallways outside of resident

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
rooms for one of one day of observation during the night shift. The census was 223 with
193 in certified beds.
During an observation and interview on 2/15/19 at 6:20 A.M., Maintenance Worker F vacuumed
the hallway and around the nurses’ station on the 200 Hall. The vacuum, a large industrial
vacuum and was loud, and made it difficult to hear someone right next to you speak. Both
the Director of Nurses (DON) and the Education Coordinator were on the hallway. When
questioned about the vacuuming, the DON said they should not be vacuuming at that time of
the morning and told Maintenance Worker F to stop.
During an interview on 2/15/19 at 6:25 A.M., Maintenance Worker F said the vacuuming is
usually done by the night shift, they start vacuuming around 2:00 A.M., and they vacuum
all of the resident hallways and nurses’ stations. The night shift person called off, so
he/she started vacuuming that morning.
During a group interview on 2/15/19 at 9:45 A.M., with nine resident, they said staff
vacuum late at night, usually around 1:30 A.M. One resident said just the other day it
woke him/her up.
During an interview on 2/20/19 at 2:40 P.M., the Administrator said they had been
vacuuming the hallways during the night for some time and she was not aware the vacuuming
was disturbing the residents.

F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to electronically transmit
encoded, accurate, and complete Minimum Data Set (MDS, a federally mandated resident
assessment completed by facility staff) data to the Centers for Medicare and Medicaid
(CMS) System within 14 days after a facility completes a resident’s assessment. In
addition, the facility failed to complete and transmit an annual MDS for one of one
resident triggered and investigated for timely submission of MDS (Resident #4). The sample
was 35. The census was 223 with 193 residents in certified beds.
1. Review of Resident #4’s MDS record, showed:
-A quarterly MDS, dated [DATE], accepted;
-An annual MDS, dated [DATE], validated.
During an interview on 2/14/19 at 2:53 P.M., MDS Coordinator C said when the MDS records
indicate an MDS is validated, it means it is not finalized and has not been transmitted.
The timeframe to transmit an MDS is 14 days after the sign off of the care plan. The
resident’s annual MDS should have already been submitted.
2. Review of the facility’s CMS Submission Reports, showed:
-On 1/16/19, 37 records submitted, of those, two submitted late;
-On 1/18/19, 32 records submitted, of those, 11 submitted late;
-On 1/28/19, 33 records submitted, of those, six submitted late;
-On 2/1/19, 51 records submitted, of those, eight submitted late;
-On 2/5/19, 19 records submitted, of those, two submitted late.
During an interview on 2/14/19 at 2:53 P.M., MDS Coordinator C said he/she would expect
MDS be submitted and transmitted timely.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure the
resident’s Minimum Data Set (MDS), a federally required assessment instrument completed by
facility staff, accurately reflect the resident’s status for two of 35 sampled residents
(Resident #13 and #183). The census was 223 with 193 residents in certified beds.
1. Review of Resident #13’s quarterly MDS, dated [DATE], showed:
-Total assist of two staff required for transfers;
-No diagnoses listed for diabetes mellitus, [MEDICAL CONDITION] (high fat levels in the
blood), [MEDICAL CONDITION], gastro-[MEDICAL CONDITION] reflux disease (GERD, heart burn),
[MEDICAL CONDITION] (loss of bone strength and density), and other fractures not indicated
as diagnoses;
-Additional Diagnoses: [REDACTED].
Review of the resident’s medical records, showed diagnoses included diabetes mellitus,
[MEDICAL CONDITIONS], GERD, [MEDICAL CONDITION], current pathological fracture, vitamin D
deficiency, [MEDICAL CONDITION], constipation, falls and pain.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Diagnoses included: [MEDICAL CONDITION] and [MEDICAL CONDITION] (loss of bone strength
and density);
-Problem: Falls;
-Goal: Prevent/manage future likelihood of falls;
-Approach: Transfer with assist of one and gait belt.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 8/30/17, for transfer needs: One person assist;
-An order dated 11/21/18, may be up in Broda chair (medical reclining chair) with assist
for positioning.
Observation on 2/13/19 at 11:37 A.M., showed Certified Nursing Assistant (CNA) A
transferred the resident to and from the toilet. Prior to the transfer the resident sat in
a Broda chair. CNA A placed a gait belt around the resident, directed the resident to grab
onto the grab bar and without locking the wheels to the Broda chair, assisted the resident
to stand and pivot to the toilet. After assisting the resident with care, CNA A locked the
left side of the Broda chair, instructed the resident to grab the grab bar, assisted the
resident to stand, pulled up the resident’s pants and assisted the resident to transfer to
the Broda chair with the use of the gait belt.
During an interview on 2/20/19 at 2:40 P.M., with the Director of Nursing (DON), assistant
DON, Administrator, Assistant Administrator and corporate nurse, they said if a resident
is assist of one person with the use of the gait belt to transfer, this should this be
accurately reflected on the MDS. The resident’s diagnoses should be accurately reflected
on the MDS.
2. Review of Resident #183’s medical record, showed:
-An order dated 9/26/18, admit to hospice with [DIAGNOSES REDACTED].
-Hospice initial certification, dated 9/28/18, showed based on the patient’s [DIAGNOSES
REDACTED]. Signed by the certifying physician.
Review of the resident’s significant change MDS, dated [DATE], showed prognosis: Does the
resident have a condition or chronic disease that may result in a life expectancy of less
than 6 months: No.
During an interview on 2/14/19 at 2:53 P.M., MDS Coordinator C said she would expect an
accurate MDS. If a resident has documentation of certification of a terminal illness, she

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
would expect the MDS to reflect a life expectancy of less than 6 months.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a baseline care plan for each resident that included the instructions needed to
provide effective and person-centered care of the resident that meet professional
standards of quality care, for six of six newly admitted residents sampled who had not had
a comprehensive assessment completed (Residents #235, #236, #241, #242, #244 and #245).
The census was 223 with 193 in certified beds.
1. Review of Resident #235’s face sheet, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s admission assessment, showed:
-admitted with 23 staples to the right hip;
-admitted with a Stage II (partial thickness loss of dermis presenting as a shallow open
ulcer with a red-pink wound bed without slough (dead tissue). (MONTH) also present as an
intact or open/ruptured blister) pressure ulcer to the coccyx (buttocks) that measured 1
centimeter (cm) long by 0.4 cm wide and no depth. A superficial Stage II pressure ulcer to
the right of the coccyx that measured 1.5 cm long by 1 cm wide and no depth.
Review of the resident’s baseline care plan, dated 2/7/19, showed:
-Problem: Skin – Allergy to [MEDICATION NAME] sulfate, opioid [MEDICATION NAME] with
possible reaction;
-Goal: Will not be exposed to [MEDICATION NAME] sulfate, opioid [MEDICATION NAME] causing
allergic reaction;
-Interventions included: Add allergy to banner, educate staff regarding allergies and
potential reactions, monitor for exposure to substances, foods, medications, tape, etc.,
notify dietary personnel of any food allergies and notify physician/pharmacy of any
allergies;
-The care plan failed to identify the resident as being post hip surgery with goals and/or
interventions;
-The care plan failed to identify the presence of a surgical incision site with goal
and/or interventions;
-The care plan failed to identify the use of staples and/or steri-strips for incisional
wound treatment;
-The care plan failed to identify the presence of pressure ulcers with goal and/or
interventions;
-The care plan failed to identify the presence of [MEDICAL CONDITION] with goal and/or
interventions.
During an interview on 2/15/19 at 10:08 A.M., Minimum Data Set (MDS) coordinator G
verified the resident’s care plan only addressed his/her narcotic allergy.
2. Review of Resident #236’s face sheet, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s admission nurse’s note, dated 2/7/19 at 1:53 P.M., showed;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
-Left hip surgical wound 14.5 cm long with 17 staples;
-Left buttock, Stage II pressure ulcer that measured 4 cm long by 6.5 cm wide with no
depth;
-Pureed diet.
Review of the resident’s baseline care plan, dated 2/7/19, showed:
-Problem: Nutritional status. Received a pureed diet at meals;
-Goal: Resident will maintain current nutritional status and stable weight;
-Interventions included: Allow extra time to eat, assist at mealtimes to ensure adequate
meal intake, dietary manager and/or dietician to evaluate and follow as needed, dietary
supplements as ordered, encourage to eat and drink at meals, monitor food intake and
document, monitor weights as ordered, provide diet as ordered;
-The care plan failed to identify the resident as post hip surgery with goals and/or
interventions;
-The care plan failed to identify the presence of a surgical incision site with goal
and/or interventions;
-The care plan failed to identify the use of staples and/or steri-strips for incisional
wound treatment;
-The care plan failed to identify the presence of pressure ulcers with goal and/or
interventions;
-The care plan failed to identify the history of falls with goal and/or interventions;
-The care plan failed to identify the resident had diabetes with goals and/or
interventions.
During an interview on 2/15/19 at 10:08 A.M., MDS coordinator G verified the resident’s
care plan only addressed his/her nutritional status.
3. Review of Resident #241’s face sheet, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s baseline care plan, dated 2/9/19, showed:
-Problem: Skin – Allergy to ACE inhibitors, [MEDICATION NAME]-[MEDICATION
NAME]-[MEDICATION NAME] with possible reaction;
-Goal: Will not be exposed to ACE inhibitors, [MEDICATION NAME]-[MEDICATION
NAME]-[MEDICATION NAME] causing allergic reaction;
-Interventions: Add allergy to banner, educate staff regarding allergies and potential
reactions, monitor for exposure to substances, foods, medications, tape, etc., notify
dietary personnel of any food allergies, notify physician/pharmacy of any allergies;
-The care plan failed to identify the resident as post hip surgery with goals and/or
interventions;
-The care plan failed to identify the presence of a surgical incision site with goal
and/or interventions;
-The care plan failed to identify the use of staples and/or steri-strips for incisional
wound treatment;
-The care plan failed to identify the presence of [MEDICAL CONDITION] with goal and/or
interventions.
During an interview on 2/15/19 at 10:08 A.M., MDS coordinator G verified the resident’s
care plan only addressed his/her drug allergy.
4. Review of Resident #242’s face sheet, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s baseline care plan, showed the care plan blank as late as
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
2/15/19.
During an interview on 2/15/19 at 10:08 A.M., MDS coordinator G verified the resident’s
care plan had not been done as required.
5. Review of Resident #244’s face sheet, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s baseline care plan, dated 1/31/19, and updated on 2/7/19, showed:
-Problem: Nutritional status. Received a regular no added salt diet at meals;
-Goal: Will maintain current nutritional status and stable weight.
-2/7/19 – Problem: Wandering/Elopement risk. Resident has the potential for elopement from
the facility;
-Goal: Will remain indoors unless accompanied by staff, volunteer or family member;
-The care plan failed to identify the presence of pressure ulcers with goal and/or
interventions;
-The care plan failed to identify the history of falls with goal and/or interventions;
-The care plan failed to identify the resident of had [MEDICAL CONDITION] with goals
and/or interventions.
6. Review of Resident #245’s face sheet, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Observation on 2/13/19 at 12:53 P.M., on 2/14/19 at 7:02 A.M., and on 2/15/19 at 8:27
A.M., showed the resident sat in his/her wheelchair with oxygen on at 2 to 3 liters a
minute by nasal cannula.
Review of the resident’s baseline care plan, dated 2/7/19, showed:
-Problem: Skin: Allergy to sulfa with possible reaction;
-Goal: Resident will not be exposed to sulfa causing allergic reaction;
-The care plan failed to identify oxygen usage with goal and/or interventions;
-The care plan failed to identify the resident had major [MEDICAL CONDITION] with goal
and/or interventions;
-The care plan failed to identify the history of falls with goal and/or interventions.
7. During an interview on 2/15/19 at 10:08 A.M., MDS coordinator G said the facility has
two MDS coordinators, they are responsible for completing the baseline care plans as well
as the comprehensive care plans. The baseline care plans are required to be completed
within 48 hours of admission to the facility and should include specific information
regarding the resident’s diagnoses, diet, skin condition, code status, transfer status,
ambulation status and any pertinent information. He/she verified the residents’ baseline
care plan had not been done as required.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a comprehensive person-centered care plan for each resident to address the use
of a [DEVICE] ([DEVICE], a small tube surgically inserted through the abdomen in to the
stomach to administer nutrition, fluids and medications), allergies to medications, and
preference of activities, for three of 35 sampled residents (Residents #126, #68 and #10).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
The census was 223 with 193 residents in certified beds.
1. Review of Resident #126’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/2/19, showed the following:
-Brief interview of mental status (BIMS) score of 3 out of 15;
-A BIMS score of 0-7, showed severe cognitive impairment;
-Total dependence for dressing, eating, and transfers;
-Has a feeding tube ([DEVICE]).
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
-An order, dated 12/27/18, for enteral feeding (tube feeding) and elevate head of bed to
30 degrees;
-An order, dated 12/27/18, formula intake (document) per shift every shift;
-An order, dated 1/19/19, to flush [DEVICE] with 250 milliliters (ml) of water every six
hours and at least 30 ml of water before and after each medication every six hours at
12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.;
-An order, dated 1/19/19 for formula, [MEDICATION NAME] (liquid nutrition) strength 1.2,
flow rate at 60 ml every shift;
-An order, dated 1/19/19 for enteral feeding: reason for pump (continuous feeding).
Review of the resident’s care plan, dated 1/11/19, showed:
-Problem: Regular diet. Over ideal body weight. Would like to lose weight;
-Approach: Assess for dehydration (dizziness on sitting/standing, change in mental status,
decreased urine output, concentrate urine, poor skin turgor, dry, cracked lips, dry mucus
membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance);
-Diet: Regular monitor and record intake of food. Monitor/record weight. Notify physician
and family of significant weight change. Encourage oral intake of food and fluids. Provide
assistance for meals. Offer available substitutes if he/she has problems with the food
being served. Monitor need to advance diet consistency. Obtain dietary or speech therapy
consult for need;
-Further review of the resident’s care plan, showed staff did not document the resident’s
use of [DEVICE] or what services or care staff were to provide for the [DEVICE].
Observation of the resident on 2/13/19 at 1:35 P.M., 2/14/19 at 12:07 P.M. and 2:48 P.M.,
12/15/19 at 5:58 A.M., and 2/19/19 at 9:17 A.M., showed the resident’s [DEVICE] feeding
infused continuously at 60 ml/hr.
2. Review of Resident #68’s annual MDS, dated [DATE], showed the following:
-BIMS score of 9 out of 15;
-A BIMS score of 8-12, showed moderate cognitive impairment;
-Limited assistance of one staff person for activities of daily living;
-[DIAGNOSES REDACTED].
Review of the resident’s current electronic POS, showed and order, dated 6/11/2018 for
[MEDICATION NAME] (levetiracetam, used to treat [MEDICAL CONDITION]) 500 milligrams (mg),
twice daily.
Review of the resident’s care plan, reviewed/revised on 6/27/18, showed the following:
-Problem: Allergy to [MEDICATION NAME], and sleeping pills with possible reaction;
-Goal: Will not be exposed to these substances causing allergic reaction;
-Approach: Educate staff regarding my allergies and potential reactions. Flag chart/POS
with allergy. Monitor for exposure to these substances. Notify physician/pharmacy of any
allergies. Notify dietary personnel of any food allergies.
During an interview 2/14/19 at 1:15 P.M., the nurse practitioner said she was not aware a
[MEDICATION NAME] allergy was listed on the resident’s care plan. The resident was
admitted on [MEDICATION NAME] and the [MEDICATION NAME] allergy should not be on the care
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
plan.
3. Review of Resident #10’s annual MDS, dated [DATE], showed the following:
-Severely impaired vision – no vision or sees only light, colors or shapes; eyes do not
appear to follow objects;
-BIMS score of 13 out of 15;
-A BIMS score of 13-15, showed resident cognitively intact;
-Feeling down, depressed, or hopeless 7-11 days (half or more of the days);
-[DIAGNOSES REDACTED].>-Care plan triggered for activities.
Review of Resident’s care plan dated 1/23/19, showed activities not care planned.
Observations on 2/13/19, showed:
-At 10:36 A.M., the resident alone in his/her room, sat in his/her recliner and faced the
open door with a nasal cannula inserted in his/her nostrils, with the bedside table in
front of him/her;
-At 12:31 P.M., the resident sat alone in his/her room, in his/her recliner and faced the
open door and ate his/her lunch from the bedside table located in front of him/her;
-At 2:09 P.M., the resident sat alone in his/her room, in his/her recliner and faced the
open door with a nasal cannula inserted in his/her nostrils, with the bedside table
cleared of lunch, in front of him/her.
Observations on 2/14/19, showed:
-At 7:18 A.M., Resident alone in his/her room, sat in a recliner facing an open door, with
the bedside table placed in front of him/her and wore a nasal cannula for oxygen therapy;
-At 11:21 A.M., Resident remained in the same place alone in his/her room with his/her
head bowed to his/her chest;
-At 1:10 P.M., Resident sat in his/her recliner, and ate his/her lunch off of the bedside
table.
During an interview on 2/13/19 at 10:37 A.M., the resident said he/she is blind and likes
to listen to the stories on the television. He/she does not leave the room unless the
restorative nurse comes for his/her exercises. Staff bring him/her meals and take him/her
to the bathroom and that’s it.
During an interview on 2/14/19 at 1:45 P.M., the resident stated he/she gets lonely
sometimes and does not always like to listen to the television. He/she enjoys talking to
his/her family on the phone and mentioned they cannot visit due to transportation issues.
He/she looks forward to visits from a volunteer on Sundays because they come from the same
home state.
4. During an interview on 2/19/19 at 2:40 P.M., the Director of Nursing (DON) said care
plans are very individualized. The MDS coordinator reviews the care plans quarterly, and
anytime there is a change. Initially when someone comes in with an allergy, staff must
confirm with the physician if it is an actual allergy. The [MEDICATION NAME] allergy must
have been an error, the MDS coordinator or someone must have made an error.

F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure residents do not lose the ability to perform activities of daily living unless
there is a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
are given the appropriate treatment and services to maintain or improve his or her ability

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
to carry out the activities of daily living (ADL) by failing to provide restorative
therapy to help residents maintain or improve their mobility, for three of six residents
investigated for rehab and restorative services who had physician orders [REDACTED].#68,
#11, and #134). The census was 223 with 193 in certified beds.
1. Review of Resident #68’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/4/18, showed the following:
-Brief interview for mental status (BIMS) score of 9 out of 15;
-A BIMS score of 8-12, showed moderately impaired cognitive skills for daily decision
making;
-Limited assistance of one staff person for activities of daily living;
-[DIAGNOSES REDACTED].
Review of the resident’s current electronic physician order [REDACTED]. Resting hand
splint offered prior to session and donned at end of session.
Review of restorative therapy notes, showed the following:
-The week of 11/7/18, one day of therapy documented as provided;
-The week of 12/9/18, no therapy documented as provided;
-The week of 12/19/18, one day of therapy documented as provided;
-The week of 12/28/18, one day of therapy documented as provided;
-The week of 1/11/19, one day of therapy documented as provided;
-The week of 2/11/19, one day of therapy documented as provided.
2. Review of the Resident #11’s (MONTH) 2019 POS, showed an order dated 12/19/18 for
restorative therapy twice a week to include: bilateral (both sides) upper extremity
exercise with 0-3 pounds all planes, lower extremity exercise with 2-3 pounds right, and
ambulation up to 35 feet with wheeled walker and contact guard assistance, to prevent
functional decline with physical therapy re-evaluated as needed. Special instructions;
change flow sheet to restorative therapy.
Review of the resident’s care plan, dated 2/18/19 and in use at the time of the survey,
showed:
-Problem: Mobility; Deficit in mobility related to weakness:
-Approach: Assess current level of function and document;
-Do range of motion to reduce potential range of motion loss unless contraindicated;
-Place items within reach for the resident.
Review of restorative therapy notes, showed restorative therapy provided:
-The week of 1/6/19, no documentation therapy provided;
-The week of 1/20/19, one day of therapy documented as provided;
-The week of 1/27/19, one day of therapy documented as provided;
-The week of 2/10/19, one day of therapy documented as provided.
3. Review of the Resident #134’s (MONTH) 2019 POS, showed an order, dated 11/27/18, for
restorative therapy twice a week to include: bilateral lower extremity (BLE) and bilateral
upper extremity (BUE) and passive range of motion (PROM) to maintain function and prevent
contractures. Special Instructions: Change flow sheet to restorative therapy.
Review of the resident’s care plan, dated 1/16/19, showed:
-Problem: Required total assistance with bed mobility, transfers, dressing, toilet use,
hygiene, and dressing. He/she is a Hoyer lift for transfers. He/she has [MEDICAL
CONDITION] and has a contracture to his/her left arm. He/she can feed herself in the
division dining room;
-Approach: Do ROM to reduce potential ROM loss unless contraindicated;
-Document amount of assistance needed with ADLs;
-Have the resident assist with dressing;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-Mobility: Manual wheelchair;
-Place items within reach for him/her;
-Provide clean, appropriate clothing daily and as needed (PRN);
-Report mental and functional changes;
-Supervise/assist him/her with bathing per facility protocol;
-Use a Hoyer lift for transfers.
Review of restorative therapy notes, showed the following:
-The week of 1/6/19, one day of therapy documented as provided;
-The week of 1/13/19, one day of therapy documented as provided;
-The week of 1/20/19, no documentation therapy provided;
-The week of 1/27/19, one day of therapy documented as provided;
-The week of 2/3/19, one day of therapy documented as provided;
-The week of 2/10/19, one day of therapy documented as provided.
During an interview on 2/19/19 at 9:32 A.M., the resident said he/she was not sure if
he/she received restorative therapy. Someone comes in to stretch his/her legs, but that
was it.
4. During an interview on 2/19/19 at 12:30 P.M., Restorative Therapy Aide (RTA) H said the
facility has two RTAs for the entire building. They are both pulled to work the floor 2 to
4 times a week and no one does any restorative therapy on those days. The other RTA took a
day off, he/she had been pulled to work the floor and none of the residents are receiving
any restorative therapy as ordered.
5. During an interview on 2/20/19 at 2:58 P.M., the Director of Nursing (DON) said there
is a quarterly review to ensure therapy orders are still appropriate and to determine if
the resident should continue with restorative therapy. Restorative therapy aides are
pulled to the floor to work, but not two to three times a week.
6. During an interview on 2/20/19 at 2:59 P.M., the administrator said, if therapy aides
are pulled to the floor to work, staff are pulled from the therapy department to take care
of some of the therapy treatments.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident who is unable to carry out activities of daily living receives the necessary
services to maintain good grooming and personal hygiene for one of 35 sampled residents
(Residents #26). The census was 223 with 193 residents in certified beds.
Review of Resident #26 care plan, dated 2/6/19 and in use at the time of the survey,
showed [DIAGNOSES REDACTED].
-Problem: Activities of daily living (ADL) Functional/Rehabilitation Potential: Deficit in
ADL functioning related to [MEDICAL CONDITION];
-Goal: Will participate in ADL activities, as tolerated;
-Approaches: Supervise/assist with bathing. Required total care with dressing. Provide
clean, appropriate clothing daily and as needed.
Review of the resident’s medical record, showed:
-A quarterly Minimum Data Set (MDS), federally mandated assessment instrument completed by
facility staff, dated 11/7/18, showed extensive assistance required for personal hygiene;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-The resident scheduled to receive his/her showers on Tuesdays, Thursdays, and Saturdays;
-A physician order [REDACTED].
During an interview on 2/13/19 at 11:13 A.M., the resident said he/she has issues
concerning his/her showers. He/she is dependent on certified nursing assistants (CNAs) for
showers. Some CNAs try to get out of giving showers by saying they are out of hot water or
cannot find the shower chair at the time.
During an interview on 2/19/19 at 12:02 P.M., the resident said he/she did not get a
shower this past Saturday. He/she asked a CNA BB about his/her shower and CNA BB said
he/she did not have time. His/her last shower was last Tuesday (2/12/19). He/she did not
do bed baths because he/she not like them. How often his/her showers happens depends on
the CNA.
Review of the resident’s shower sheets, for (MONTH) 2019 through current and provided by
the facility on 2/20/19, showed two showers documented (2/6/19 and 2/12/19). No
documentation of refused showers.
During an interview on 2/21/19 at 9:45 A.M., with the Director of Nursing (DON), Assistant
DON, Administrator, Assistant Administrator and corporate nurse, they said they are very
aware of the residents’ concerns with showers. They would expect for the staff to give the
residents their showers three times a week unless they refuse. Part of the issue is that
the resident demands a shower when he/she wants it. If staff leave to find the shower
chair, he/she interprets it as them refusing to shower him/her. When they return, he/she
refuses. This is something we are working on with him/her. There should be something
documented to show when he/she refuses.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
meaningful activities, for two of four residents investigated for activities (Residents
#434 and #54). The sample size was 35. The census was 223 with 193 in certified beds.
1. Review of Resident #434’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/16/18, showed:
-Rarely/never understood;
-Staff assessment of daily activity preferences: None;
-Care Area Assessment Summary (CAAS) triggered for activities and the facility indicated
activities will be care planned.
Review of the resident’s care plan, dated 12/26/18 and used during the survey, showed:
-Call button: Keep call light button within reach. Advise resident to use it and wait for
staff when in need of assistance;
-Transfer: Mechanical full body lift, number of staff, two;
-Diagnoses: [REDACTED]. These non-bony tissues include muscles, ligaments and tendons) of
muscle, right lower leg, contracture of muscle, left lower leg, and muscle weakness;
-Activities not care planned with goals and/or interventions.
Review of the resident’s activity participation sheets, showed the resident had not
received any one to one (1:1) visits in (MONTH) (YEAR), received 1:1 visits one time in
(MONTH) (YEAR), one time in (MONTH) 2019, and no 1:1 visits in (MONTH) 2019. No
documentation the resident was offered or participated in any group activities or other
meaningful activities.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
2. Review of Resident #54’s admission MDS, dated [DATE], showed:
-Cognitively intact;
-Limited assistance required for locomotion on the unit;
-Locomotion off the unit: Activity did not occur;
-Interview for activities preferences:
-How important is it to you to be around animals such as pets: Very important;
-How important is it to you to do things with groups of people: Very important;
-How important is it to you to participate in religious services or practices: Very
important.
Review of the resident’s care plan, dated 12/18/18 and used during the survey, showed:
-Dressing: Limited assistance with dressing;
-Bathing: Supervise/assist with bathing;
-Transfer: One staff member with gait belt. At times two staff members with assistance;
-Diagnoses: [REDACTED].
Review of the resident’s activity participation sheets, reviewed on 2/20/19, showed the
resident participated in activities two times in (MONTH) (YEAR), two times in (MONTH)
2019, none in (MONTH) 2019, and received 1:1 visits one time in (MONTH) (YEAR). No other
documentation the resident was offered and/or refused activities.
During an interview on 2/13/19 at 9:14 A.M., the resident said he/she would like to be
involved in activities, but staff to not offer to take him/her to any. He/she likes arts
and crafts. On 2/15/19 at 6:47 A.M., the resident said staff will take him/her to BINGO.
3. During an interview on 2/20/19 at 2:30 P.M., the Director of Nursing (DON) and
Assistant DON said they expect staff to provide 1:1 activities and document 1:1 activities
with residents. They have lost three activities staff. Now the Activity Director is
juggling responsibility of the activities.
4. During an interview on 2/21/19 at 9:25 A.M., the Activity Director said every month he
looks at who is in the building and always evaluates and reviews who is coming to
activities and who is in the bed. He has a volunteer who will visit with residents. We
make sure all residents are checked on one way or another.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
with pressure ulcers received necessary treatment and services, consistent with
professional standards of practice to promote healing, prevent infection and prevent new
ulcers from developing, for one resident (Resident #117). The facility identified eight
residents as having pressure ulcers. The sample was 35 residents. The census was 223 with
193 in certified beds.
Review of Resident #117’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/24/18, showed the following:
-Brief Interview of Mental Status (BIMS) score of 13 out of 15, showed the resident
cognitively intact;
-Total dependence of two person physical assist for transfers;
-Total dependence of two person physical assist for toileting;
-Impairment on both sides of lower extremities;
-[DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
-Risk of pressure ulcers;
-One stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow
open ulcer with a red-pink wound bed without slough, may also present as an intact or
open/ruptured blister).
Review of the resident’s care plan, dated 12/26/18 and in use at the time of the survey,
showed:
-Problem: Required extensive assistance with activities of daily living (ADLs) related to
[MEDICAL CONDITION];
-Goal-Will be well groomed at all times;
-Intervention- Apply creams and ointments as ordered;
-The presence of pressure ulcers not care planned.
Review of the resident’s electronic health record on 2/14/19 at 10:57 A.M., showed:
-A physician order [REDACTED]. 100,000 unit/gram, cleanse with soap and water, pat dry and
apply nickel thick to redness on buttocks, twice a day and as needed;
-A physician order [REDACTED]. Cleanse with normal saline, then apply nickel thick Santyl
and apply dry Teille pad dressing (absorbent dressing) once every other day.
Observation on 2/14/19 at 1:58 P.M., showed the resident lay in his/her bed and waited for
nursing staff to complete the treatment to his/her stage III pressure ulcer (Full
thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not
exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH)
include undermining or tunneling) located on his/her left ischium (lower portion of the
hip bone.) The Assistant Director of Nursing (ADON) stated the resident had previously had
a bowel movement and nursing staff had removed the old bandage in order to perform
perineal care (peri-care, washing the front and back of the hips, genitals, anal area and
buttocks). The resident lay on a nonsterile absorbent pad without a brief or bandage
covering the stage III pressure ulcer or reddened areas on the buttocks. The ADON and
Licensed Practical Nurse (LPN) W washed their hands, donned gloves and gathered supplies
for the treatment. LPN W asked the resident to roll over to his/her right side. The
resident rolled over and exposed the pressure ulcer on the resident’s left ischium. The
ADON and LPN W began wound care:
-LPN W picked up a bottle of normal saline, labeled with another resident’s name, and wet
a piece of gauze;
-LPN W took the normal saline wet gauze and wiped the resident’s stage III pressure ulcer
in circular motions, wiping both the skin around the wound and the wound base with the
same area of the gauze;
-Without changing gloves, LPN W took a dry piece of gauze, handed from the ADON, and used
it to blot and wipe the normal saline from the wound base. LPN W used the same area of the
gauze to wipe the skin surrounding the stage III pressure ulcer and the wound base;
-LPN W took off his/her gloves, did not sanitize his/her hands, placed two gloves on each
hand, and measured the stage III pressure ulcer. Both LPN W and the ADON confirmed a
measurement of 2.1 centimeter (cm) length and 1.7 cm width, with moderate slough (moist
dead tissue) at the center of the wound;
-The ADON prepped the bandage at the treatment cart by uncapping the tube of Santyl,
squeezed a small amount on a 2×2 piece of gauze. The ADON then removed the glove from her
hand, opened the sterile wrapper of a bandage, took the bandage out with her bare hand and
labeled it.
-The ADON removed the protective film from the bandage and placed the 2×2 gauze on top of
it, with the Santyl facing out, and passed it over to LPN W;
-LPN W and the ADON both pressed the bandage against the resident’s wound;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
-The ADON went back to the treatment cart, without changing gloves, and took the cap of
the [MEDICATION NAME] cream off and brought it over to LPN W;
-LPN W took off one glove, stretched his/her hand out, and the ADON squeezed a small
amount into the his/her hand;
-LPN W rubbed the [MEDICATION NAME] cream onto the resident’s buttocks. LPN W did not
wash the area with soap and water and pat dry before application.
During an interview on 2/20/19 at 1:32 P.M., the Director of Nursing (DON) said;
-When cleansing a wound, the nurse should wash his/her hands and put on clean gloves
before removing a dressing. And again before cleansing the wound, change gloves and
sanitize hands before applying the new dressing;
-It is not appropriate to clean a wound using a circular motion or to cleanse the
peri-wound (the skin around the wound) and wound bed with the same piece of gauze. The
appropriate technique is to wipe from clean to dirty;
-A nurse should not use normal saline that belongs to another resident to cleanse a
residents wound due to possible cross contamination of infections. Products are used for
the assigned resident only due to infection control issues;
-Normal saline is an activator for Santyl, she expected a little bit of normal saline be
left in the wound base to activate the Santyl. She did not expect nurses to completely pat
the normal saline out of a wound base;
-Santyl is applied to a pressure ulcer with slough, nickel thick, to the wound base with
a tongue depressor or cotton tipped applicator, not directly to the dressing.
During an interview on 2/21/19 at 9:25 A.M., the ADON stated she expects nurses to follow
the physician orders [REDACTED].

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
resident environment remains as free of accident hazards as is possible and each resident
receives adequate supervision and assistance devices to prevent accidents when the
facility staff failed to lock a medical reclining chair during a transfer, resulting in
the chair rolling away from the resident as the resident attempted to sit in the chair,
for one of five residents observed during a gait belt transfer (Resident #13). In
addition, the facility failed provide supervision for one resident observed smoking
without staff supervision (Resident #64). The census was 223 with 193 residents in
certified beds.
Review of the facility’s Gait Belt Use policy, dated 7/1/15, showed:
-Purpose: To provide control and balance of residents that requires physical assistance
for transfers and gait;
-Gait belts should be used with all residents that require physical lifting assistance for
transfers and/or ambulation;
-Wrap the gait belt around resident’s waste and pull the strap through the buckle and
tighten;
-Gait belt should be snug but not comfortable. Make sure you can slide your open (flat)
hand between the belt and resident;
-Verify that the belt is secured before assisting residents with mobility by pulling on

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
belt;
-Face resident when assisting to a standing position and place both hands on belt;
-Once standing, assistant should position dominate hand on gait belt at center of
resident’s back to assist with mobility;
-Follow proper body mechanics when using gait belt.
1. Review Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/28/19, showed total assist of two staff
required for transfers.
Review of the resident’s care plan, in use at the time of the survey, showed:
-[DIAGNOSES REDACTED].
-Problem: Falls;
-Goal: Prevent/manage future likelihood of falls;
-Approach: Transfer with assist of one and gait belt.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 8/30/17, for transfer needs: One person assist;
-An order dated 9/13/17, fall risk red;
-An order dated 11/21/18, may be up in Broda chair (medical reclining chair) with assist
for positioning.
During an interview on 2/20/19 at 2:11 P.M., the Director of Nursing (DON) said fall risk
red means the resident is a high fall risk.
Observation on 2/13/19 at 11:37 A.M., showed Certified Nursing Assistant (CNA) A
transferred the resident to and from the toilet. Prior to the transfer the resident sat in
a Broda chair. CNA A placed a gait belt around the resident, directed the resident to grab
onto the grab bar and without locking the wheels to the Broda chair, assisted the resident
to stand and pivot to the toilet. After assisting the resident with care, CNA A locked the
left side of the Broda chair, instructed the resident to grab the grab bar, assisted the
resident to stand, pulled up the resident’s pants and assisted the resident to transfer to
the Broda chair with the use of the gait belt. As the resident started to sit, the right
side of the Broda chair rolled back and to the left rapidly, approximately 12 inches, and
came to rest against the sink. CNA A caught the resident with the use of the gait belt.
Only the edge, approximate 1 inch of the resident’s buttocks touched the seat of the Broda
chair. CNA A said whoa, I should have locked both sides. CNA A lifted the resident and
repositioned him/her into the Broda chair by lifting the resident with use of the gait
belt and said thank goodness you are small.
During an interview on 2/20/19 at 2:40 P.M., with the DON, Assistant DON, Administrator,
Assistant Administrator and corporate nurse, they said the gait belt transfer policy
should be followed. If a resident is being transferred to and from a Broda chair and
toilet, the Broda chair should be locked before transferring the resident.
2. Review of Resident #64’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Cognitively intact with no memory problems;
-No behaviors;
-A smoker;
-Received antipsychotic and antianxiety medications 7 out of 7 days;
-Required maximum assistance from staff for transfers, hygiene and bathing.
Review of the resident’s smoking assessment, dated 1/24/19, showed supervised smoking by
staff in designated area.
Review of the resident’s care plan, dated 3/22/17, updated on 12/18/18, and in use during
the survey, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
-Problem: Enjoyed smoking vapor/electronic cigarette or cigarettes;
-Goal: Will maintain safety when smoking;
-Interventions: Staff to offer smoking every shift and as needed. Continue quarterly
smoking assessments. Give frequent reminders not to smoke in the room, even if it is a
vapor/electronic cigarette. Smokes several times throughout the day and is made aware and
reminded of policies regarding smoking. Resident will smoke in designated area per
facility protocol.
During an observation on 2/15/19 at 6:50 A.M., showed the resident sat in his/her electric
wheelchair outside on the smoking patio by him/herself, and smoked a cigarette. He/she had
on a black nylon puffy coat, fully zipped up. The resident said he/she comes outside by
him/herself to smoke every morning and usually it is earlier in the morning when he/she
comes outside. None of the staff are with him/her to smoke. He/she finished the cigarette,
placed a second cigarette in his/her mouth, raised a lighter to the cigarette and tried to
light the cigarette. His/her hands shook and the flame from the lighter blew dangerously
close toward the collar of the nylon coat before he/she could get the cigarette lit.
During an interview on 2/19/19 at 10:30 A.M., the Administrator said they do have a
smoking apron in the facility, it is kept at the receptionist desk; however, no one would
be at the receptionist desk at that time of the morning to give the smoking apron to the
resident. The resident is able to smoke unsupervised, but if wearing a nylon puffy jacket
and shaking while lighting the cigarette, it could be a safety problem.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide oxygen
therapy consistent with professional standards of practice for two of four residents
investigated for respiratory care who received oxygen therapy (Residents #159 and #245).
The sample size was 35. The census was 223 with 193 in certified beds.
1. Review of Resident #159’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/19/19, showed:
-Brief Interview of Mental Status (BIMS) score of 13 out of 15;
-A BIMS score of 13-15, showed the resident cognitively intact;
-[DIAGNOSES REDACTED].
Review of the resident’s electronic physician order [REDACTED].
Observation on 2/13/19 at 9:00 A.M., showed the resident sat in his/her wheelchair and
watched television. The resident did not have any oxygen on. The oxygen concentrator sat
on the floor beside the resident’s bed. The oxygen concentrator on and the tubing and
nasal prongs lay directly on the resident’s bed.
Observation on 2/19/19 at 2:47 P.M., showed the resident lay in the bed. The oxygen
concentrator on. The nasal prongs located under the resident’s nose, not inside the
resident’s nostrils. The resident said he/she does not have to wear the oxygen all the
time, just at night.
Observation on 2/20/19 at 8:12 A.M., showed the resident sat in his/her wheelchair. The
resident did not have any oxygen in place. The oxygen concentrator sat on the floor beside
the resident’s bed, turned off. The tubing and nasal prongs were wrapped around the handle
of the oxygen concentrator. The resident said he/she would turn the oxygen contractor back
on and put the nasal prongs back on sometime today.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
Review of the resident’s medical record, showed no documentation of the resident’s refusal
to wear oxygen on the days of observation.
During an interview on 2/21/19 at 9:30 A.M., the Assistant Director of Nurses (ADON) and
the Director of Nursing (DON) said if the residents have orders for oxygen, it is expected
for the that order to be followed. The DON said the resident is independent. If the
resident is not wearing his/her oxygen tubing and not receiving oxygen, she would expect
this to be documented. In addition, if the resident was taking off his/her tubing, she
would expect this to be documented as well.
2. Review of Resident #245’s face sheet, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s electronic POS, in use during the survey, showed:
-No orders for oxygen usage as late as 2/19/19 at 9:30 A.M.;
-An order dated 2/17/19, for staff to titrate the oxygen to keep the oxygen saturations
(amount of oxygen in the blood) greater than 91%;
-No order found for how many liters of oxygen to be used or how to be administered.
Observation on 2/13/19 at 12:53 P.M., on 2/14/19 at 7:02 A.M., on 2/15/19 at 8:27 A.M.,
showed the resident sat in his/her wheelchair with oxygen on at 2 to 3 liters a minute by
nasal prongs.
Observation on 2/20/19 at 9:05 A.M., showed the resident sat in his/her wheelchair in
his/her room and fed him/herself breakfast. The resident did not have any oxygen in place.
The oxygen concentrator sat on the other side of the resident’s bed, with the tubing and
nasal prongs directly on the floor. The oxygen concentrator had been turned on and the
oxygen flow set to 1 liter a minute. The resident said he/she was short of breath and
needed the oxygen.
During an interview on 2/20/19 at 9:10 A.M., the ADON verified the oxygen tubing lay on
the floor, said it would never be appropriate for the tubing to be on the floor due to
infection control issues and it should be in a protective bag when not in use. The ADON
verified there were no orders for the oxygen usage until 2/17/19, when staff obtained the
order to titrate the oxygen and there should have been an order for [REDACTED].
3. During an interview on 2/21/19 at 9:30 A.M., the ADON and the DON said if the residents
have orders for oxygen, it is expected for oxygen orders to be followed.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure correct
installation, use, and maintenance of bed rails, including assessing the resident for risk
of entrapment from bed rails prior to installation, reviewing the risks and benefits of
bed rails with the resident or resident representative and obtaining informed consent
prior to installation, for three out of the 35 sampled residents (Resident #90, #65, and
#117.) The census was 223 with 193 in certified beds.
1. Review of Resident #90’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/20/18, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-Brief interview for mental status (BIMS) score of 6 out of 15;
-A BIMS score of 0-7, showed severe cognitive impairment;
-Required extensive assistance for bed mobility and transfers;
-Upper and lower body impairment on one side;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 12/26/18 and in use at the time of the survey,
showed:
-Problem: Risk for falls related to history of stroke, falls, poor muscle control,
decreased mobility, unassisted attempts to stand/transfer/ambulate, poor safety awareness
and a history of falling;
-Goal: To manage/prevent future falls and the potentials for injury;
-Interventions: Low bed, floor mat at bedside and bed against wall.
Review of the resident’s electronic health record on 2/14/19 at 11:12 A.M., showed:
-An Admission Bed Assist Devices Evaluation, dated 1/15/19 at 7:15 P.M., marked invalid
for incorrect data;
-No documentation staff verified correct installation, use, and maintenance of bed rails;
-No documentation of assessed resident risk of entrapment from bed rails prior to
installation;
-No documentation staff reviewed the risks and benefits of bed rails with the resident or
resident representative and/or obtained informed consent prior to installation.
Observations, showed:
-On 2/13/19 at 10:57 A.M. and 2/14/19 at 11:13 A.M., the resident’s bed against the wall
with a bed rail on the opposite side. The loose bed rail rattled back and forth when
moved, creating a 4-5 inch gap in between the mattress and bed rail;
-On 2/15/19 at 5:30 A.M., the resident sat on the side of his/her bed as Certified Nursing
Assistant (CNA) X prompted him/her to stand up. The loose bed rail in an upright position
rattled back and forth when moved, creating a 4-5 inch gap in between the mattress and bed
rail.
2. Review of Resident #65’s annual MDS, dated [DATE], showed the following:
-Extensive assistance required for bed mobility, dressing, toilet use, and transfers;
-Moving from a seated to standing position: Not steady, only able to stabilize with human
assistance;
-Upper and lower body impairment on one side;
-[DIAGNOSES REDACTED].
-Care Area Assessment Summary (CAAS) triggers for activities of daily living (ADL)
functional/rehabilitation potential.
Review of the resident’s care plan, dated 12/5/18 and in use at the time of the survey,
showed:
-Problem: At risk for falls related to multiple [MEDICAL CONDITION] with left sided
weakness;
-Goal: Will be free of falling and will remain free from injury thru the next review;
-Intervention: Call light within reach. Assess for ability to understand use of call light
and ability to utilize.
Review of the resident’s medical record, showed:
-No documentation staff verified correct installation, use, and maintenance of bed rails;
-No documentation of assessed resident risk of entrapment from bed rails prior to
installation;
-No documentation staff reviewed the risks and benefits of bed rails with the resident or
resident representative and/or obtained informed consent prior to installation.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
Observation of the resident’s room, showed on 2/13/19 at 2:46 P.M., on 2/14/19 at 7:51
A.M., and on 2/19/19 at 10:42 A.M., the resident’s bed located near the wall with a bed
rail up on the right side. The loose bed rail rattled back and forth when moved, creating
a 4-5 inch gap in between the mattress and bed rail.
3. Review of Resident #117’s quarterly MDS, dated [DATE], showed the following:
-BIMS score of 13 out of 15, showed the resident cognitively intact;
-Total dependence of two person physical assist for transfers and toileting;
-Impairment on both sides of lower extremities;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 12/26/18 and in use at the time of the survey,
showed:
-Problem: High risk for falls related to decreased mobility and use of [MEDICAL CONDITION]
drugs;
-Goal: Resident will not have any future falls;
-Intervention: Give verbal reminders not to transfer without assistance.
Review of the resident’s medical record, showed:
-No documentation staff verified correct installation, use, and maintenance of bed rails;
-No documentation of assessed resident risk of entrapment from bed rails prior to
installation;
-No documentation staff reviewed the risks and benefits of bed rails with the resident or
resident representative and/or obtained informed consent prior to installation.
Observation of the resident’s room, showed on 2/13/19 at 1:20 P.M., on 2/14/19 at 1:58
P.M., and on 2/19/19 at 11:33 A.M., bilateral (both sides) side rails attached to the
resident’s bed, in the upright position. Both the left and the right side rails loose,
shook back and forth and up and down when moved creating a 4-5 inch gap in between the
mattress and bed rails.
4. During an interview on 2/19/19 at 9:37 A.M., the Director of Nursing (DON) said she is
aware there is an issue with the bedrail use in the community; there are too many in use
and the residents need reevaluated for appropriateness for use. Nursing staff is expected
to complete quarterly bed rail assessments. The facility does not have bed mobility assist
device informed consent and release forms signed by residents or their representatives. On
2/21/19 at 9:05 A.M., the DON said all beds in the facility are Invacare beds.
5. Review of the Invacare user manual, dated 2012, showed:
-Inspect the wheel locks for correct locking action before actual use;
-After any adjustments, repair or service and before use, make sure all attaching hardware
is tightened securely.
6. Review of the facility’s bed mobility assist devices policy, dated (MONTH) (YEAR),
showed:
-Purpose: To ensure that the use of bed mobility assist devices are utilized when
appropriate and alternatives to their use have been attempted, documented and communicated
to the resident and/or their representative. A consent form must be obtained prior to the
utilization of the assist device;
-A bed mobility device evaluation should be completed by the nurse upon the assessed need,
quarterly, annually, and with significant change thereafter;
-Bed mobility assist device informed consent and release form should be reviewed and
signed by the resident and/or their representative upon the application of the assist
device and yearly thereafter;
-Environmental staff will install and inspect the assist device for safety prior to use.
Preventative maintenance will continue bi-monthly and as needed to ensure that the assist
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
device remains secure and that no gap exists between the assist device and the mattress.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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.

Based on observation, interview and record review, the facility failed to provide
separately locked storage of controlled drugs listed in Schedule II of the Comprehensive
Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, for one of
six medication carts checked. The census was 223 with 193 residents in certified beds.
Observation on 2/15/19 at 8:10 A.M., of the 300 unit Medicine technician cart, showed
controlled medications in an unlocked box. Certified Medication Technician (CMT) E opened
the drawer and lifted the lids of the two lock boxes with his/her fingers, no key needed.
CMT E said, they should be double locked at all times, it is the responsibility of the
CMT. CMT E locked the medication cart as he/she walked away to administer medications to
the residents, but did not lock the box of the controlled medications.
Review of the facility’s Medications, Controlled Drugs policy, revised 2014, showed:
-Storage of controlled medications: [REDACTED]
-All controlled medications must be stored in a separately locked area that requires a
different key;
-Schedule II (controlled medication) medications will remain in a double locked cabinet
in the med room or in a locked container or the nurses’ treatment cart;
-Schedule III, IV and V (controlled medication) routine medications will be placed in a
locked box on the medication cart.
During an interview on 2/15/19 at 10:34 A.M., the director of nursing said, controlled
medication should be stored in a locked box in a locked medicine cart, it is not ok for
the lock box to be unlocked.

F 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
appealing options of similar nutritive value to residents who choose not to eat food that
is initially served or who request a different meal choice by failing to provide alternate
meals for lunch and dinner and the facility failed to offer alternate choices for
residents with food allergies [REDACTED].#53 and #13). The sample was 35. The facility
census was 223 with 193 in certified beds.
Review of the facility’s undated resident choice or holiday meals policy, showed:
-Procedures: The principals of substitution will be used to insure the components for the
daily menu are met:
-Meat item will be replaced with another meat item;
-Starch will be replaced with another starch item;
-Vegetable and/or salad will be replaced with another vegetable or salad;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
-Fruit will be replaced with another fruit item.
Review of the facility’s menu, showed the following:
-Additional offering for lunch: Peanut butter and jelly, grilled cheese, grilled
hamburger, turkey, ham, braunschweiger or bacon, lettuce and tomato sandwich, fruit plate,
or chef salad;
-Additional offering for dinner: Peanut butter and jelly, grilled cheese, baked chicken,
baked fish, turkey or ham sandwich, fruit plate, or chef salad;
-Further review of the menu did not show any substitute for starch and vegetable sides.
1. Observation and interview, showed:
-On 2/13/19 at 12:11 P.M., residents served cauliflower soup, BBQ hamburger, potato salad,
and onion rings. The residents did not receive alternate options in place of the potato
salad and onion rings;
-On 2/14/19 at 12:30 P.M., residents served chicken and dumplings, cornbread, and baby
carrots. The residents did not receive alternate options in place of the baby carrots.
During an interview at 12:57 A.M., Resident #134 said he/she did not eat the baby carrots.
He/she was not aware of other vegetable options he/she was able to receive;
-On 2/19/19 at 12:30 P.M., residents served deli shaved fried chicken, and fried vegetable
sticks. The residents did not receive alternate options in place of the fried vegetable
sticks. During an interview at 1:06 P.M., Resident #53 said he/she had no idea what the
vegetable stick was. He/she did not eat it. He/she did not have any alternate vegetable
options.
During an interview on 2/15/19 at 9:45 A.M., all nine residents in attendance at the
resident council meeting said there were not enough alternate food options. If a resident
was served a meal they did not like for lunch, their only option is to have a sandwich.
The residents can order baked chicken or fish for dinner, but it has to be ordered ahead
of time and it is often late. There are no alternate options for side dishes. If dietary
is serving mashed potatoes and greens beans for the side dish, there are no other options
they could have for lunch or dinner.
During an interview on 2/19/19 at 12:19 P.M., Dietary Aide I confirmed that the residents
were served fried vegetable sticks for lunch. If a resident did not want the fried
vegetable sticks, they are to offer green beans, corn, peas, and mixed vegetables. The
alternate side dishes are not sent to each of the units. The residents have to ask for it
and it is delivered to them.
2. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/28/18, showed the following:
-Brief interview of mental status (BIMS) score of 3 out of 15;
-A BIMS score of 0-7, showed severe cognitive impairment;
-Required extensive assistance of two for transfers;
-Supervision, oversight, cueing, set up only for meals;
-Wheelchair for mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED]. Medication administration notes: NO
DAIRY PRODUCTS.
Review of the resident’s care plan, dated 7/31/18 and in use at the time of the survey,
showed the following:
-Problem: Received a pureed no concentrated sweets (NCS) diet. Trial with mechanical
soft/regular food;
-Goal: Will maintain current nutritional status and stable weight;
-Approach: Allow extra time to eat, assist at mealtimes to ensure adequate meal intake,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
dietitian to evaluate and follow as needed, encourage to eat and drink at meals.
Observation and interview on 2/14/19, showed the following:
-At 12:30 P.M., the resident sat in the dining room and waited on assistance with his/her
meal;
-At 12:40 P.M., ice cream arrived in individual bowls and served to the other residents;
-At 12:50 P.M., as Certified Nursing Assistant (CNA) P assisted the resident to eat
his/her lunch, other residents at the table received ice cream. Resident #13 did not
receive a bowl of ice cream. CNA P said the resident cannot have ice cream because he/she
is lactose intolerant;
-At 12:51 P.M., no substitution for dessert offered or provided to the resident.
During an interview on 2/20/19 at 4:00 P.M., the Assistant Director of Nursing (ADON) said
staff should offer resident’s choices and alternates are on the menu and the menus are
handed out daily.
During an interview on 2/20/19 at 4:15 P.M., the administrator said she expected
alternates to arrive with the other resident’s food. Staff should have provided an
alternate for residents who cannot have ice cream, dietary should have provided something
for the resident.
3. During an interview on 2/20/19 at 2:29 P.M., the dietary manager said the dietary staff
uses a meal ticket only for alternate meals. There is also a list of likes and dislikes on
the steam table.
The list is completed only on admission. Dietary staff also go over the alternate menu and
residents are told they can call and ask for something else to eat. There are no
alternates for the vegetables, but the residents can ask for them. During the resident
council meetings, the residents are asked what they like. The servers are aware the
residents can ask for an alternate vegetable or starch. The dietary manager confirmed that
an alternate vegetable or starch is not on the menu, so residents may not be aware they
can order something else. The food listed on the menu is the only food on the steam table
and transported to the units. A resident who is lactose intolerant should be offered
sherbet or fruit. It is on the likes and dislikes sheet, so staff should be aware. The
dietary manager would expect staff to honor the resident’s choices and provide alternates
if there is a food allergy.
4. During an interview on 2/20/19 at 3:31 P.M., the Administrator and the Director of
Nursing (DON) said they would expect staff to honor the resident’s meal choices and
provide appropriate alternates for the residents who have food allergies [REDACTED].

F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure therapeutic diets are prescribed by the attending physician and may be delegated
to a registered or licensed dietitian, to the extent allowed by State law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow the
physician ordered diet for one resident when staff transcribed the physician’s orders
[REDACTED]. This affected one of 35 sampled residents (Resident #68). The census was 223
with 193 residents in certified beds.
Review of Resident #68’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/4/18, showed the following:
-Brief interview of mental status (BIMS) score of 9 out of 15, showed moderately impaired
cognition;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
-Limited assistance of one staff person for activities of daily living;
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
Review of the resident’s dietary notes, dated 10/22/18, showed the resident on a regular
diet, no added salt, with clear Ensure twice a day.
Further review of the resident’s medical record, showed no documentation staff provided
the clear Ensure.
Observation of meal service on 2/13/19 at 12:20 P.M., 2/14/19 at 8:16 A.M. and 12:47 P.M.
and on 2/15/19 at 8:21 A.M., showed no clear Ensure provided to the resident.
During an interview on 2/19/19 at 1:56 P.M., Nurse T said the resident did not receive a
supplement or have an order for [REDACTED]. The person who entered the order entered it
incorrectly. The order, under the wrong location, would not show up on the resident’s
Medication Administration Record [REDACTED]. The order had been in the wrong location
since June. Nurses are expected to enter the orders correctly.
During an interview on 2/21/19 at 9:31 A.M., the Assistant Director of Nursing (ADON) said
the order for the supplement was a transcription error. Staff are expected to enter orders
correctly.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to store, prepare,
distribute and serve food in accordance with professional standards for food service
safety. The facility failed to ensure all expired and non-dated food and beverages were
discarded; failed keep the floors around the cooking equipment, inside the walk in cooler,
the double sink, and range hood free of food crumbs, debris, and grease; failed to ensure
staff practiced proper hand washing practice. This resulted in one resident being served
expired lactose free milk (Resident #13). Additionally, the facility failed to have a
system in place to test their dish machine. This deficient practices had the potential to
affect all residents who ate at the facility. The facility census was 223 with 193 in
certified beds.
1. Review of the facility’s 2014 Food Storage policy, showed:
-All food items will be labeled. The label must include the name of the food and the date
by which it should be sold, consumed, or discarded;
-Discard food that has passed the expiration date, and discard food that has been prepared
in the facility after seven days of storing under proper refrigeration;
-Leftover contents of cans and prepared food will be stored in covered, labeled, and dated
containers in the refrigerators and/or freezer.
2. Review of the facility’s 2014 Labeling/Dating Foods policy, showed:
-Prepared food or opened food items should be discarded when:
-The food item does not have a specific manufacturer expiration date and has been
refrigerated for seven days;
-The food item is leftover for more than 72 hours;
-The food item is older than the expiration date.
3. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated [DATE], showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
-Brief interview for mental status (BIMS) score of 3 out of 15;
-A BIMS score of ,[DATE], showed severe cognitive impairment;
-Required extensive assistance of two for transfers;
-Required assistance of one for toilet use and personal hygiene;
-Supervision, oversight, cueing, set up only for meals;
-Wheelchair for mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated [DATE], showed the following:
-Problem: Received a pureed no concentrated sweets (NCS) diet. Trial with mechanical
soft/regular food;
-Goal: Will maintain current nutritional status and stable weight;
-Approach: Allow extra time to eat, assist at mealtimes to ensure adequate meal intake,
dietitian to evaluate and follow as needed, encourage to eat and drink at meals.
Observation and interview on [DATE], showed the following:
-At 8:24 A.M., a glass of milk on the table in front of the resident, a straw in the
glass, with half of the milk finished;
-At 8:48 A.M., Certified Nursing Assistant (CNA) R, opened the small refrigerator located
in the kitchenette on 500 hall, and removed a carton of lactose free milk, the expiration
date printed by the manufacturer on the carton, [DATE], and handwritten on cap, [DATE];
-At 8:50 A.M., CNA R looked at the expiration date on the carton and said uh oh, he/she
gave the resident the lactose free milk earlier.
During an interview on [DATE] at 2:09 P.M., the dietary manager said the dietary aides are
to ensure all food and beverages are dated and labeled inside the division refrigerators
every day when sandwiches and health shakes are delivered. She would expect staff check
the date of all food and beverages before it is served to the residents.
During an interview on [DATE] at 4:00 P.M., the Assistant Director of Nursing (ADON) said
she expected staff to label and date food items daily for expiration and to check
expiration dates prior to service.
4. Observation of the kitchen, showed:
-On [DATE] at 3:35 P.M.:
-Food crumbs on the floor under the table in front of the steam table;
-Grease build up on the range hood;
-Food crumbs and debris on the floor behind and underneath the cooking equipment;
-Staff used a water hose to clean the outside of the soup kettle during meal preparation.
This left soapy water on the floor;
-On [DATE] at 11:39 A.M.:
-A trash can, next to the preparation table, overflowed about 4 inches from the top,
without a lid;
-Food crumbs and debris around the double sink and on the shelf above the double sink;
-Food crumbs and debris on the floor behind and underneath the cooking equipment;
-Food crumbs on the floor around the preparation table;
-Grease build up on the range hood;
-A pile of empty boxes in front of the three sink sanitizer;
-On [DATE] at 7:11 A.M.:
-A food stained trash can and one rug inside the double sink;
-Several rugs inside the three sink sanitizer;
-Grease build up on the range hood;
-Food crumbs inside the trays located inside the countertop shelf;
-Dust buildup on the fan in the dish machine room;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
-Two detergent buckets of sanitizing solution and cloths, on top of the counter next to
the food. Staff used the cloths during meal preparation;
-On [DATE] at 1:19 P.M.:
-Grease buildup on the range hood;
-Dust buildup on the fan in the dish machine room;
-Food crumbs on the floor behind and underneath the cooking equipment;
-On [DATE] at 11:37 A.M.:
-A trash can next to the preparation table without a lid;
-Food crumbs on the floor behind and underneath the cooking equipment;
-Buildup of grease on the range hood;
-Box of trash on the floor in front of the walk in cooler;
-Food crumbs around the double sink.
5. Observation of the walk in freezer, showed:
-On [DATE] at 3:35 P.M.:
-An open box of frozen cookies;
-An open box of fish fillet;
-Buildup of frost on the left side of the fan, approximately 12 inches by 5 inches;
-Dirt and food debris on the floor;
-On [DATE] at 11:39 A.M.:
-Buildup of frost on the left side of the fan, approximately 12 inches by 5 inches;
-Dirt and food debris on the floor;
-On [DATE] at 7:11 A.M.:
-Buildup of frost on the left side of the fan, approximately 12 inches by 5 inches;
-Dirt and food debris on the floor;
-On [DATE] at 1:19 P.M.:
-An open box of waffles;
-Buildup of frost on the left side of the fan, approximately 12 inches by 5 inches;
-On [DATE] at 11:37 A.M.:
-Buildup of frost on the left side of the fan, approximately 12 inches by 5 inches;
-Dirt and food debris on the floor.
6. Observation of the walk in cooler, showed:
-On [DATE] at 3:35 P.M.:
-A box of chicken tenders on the floor in the middle of the walk in cooler;
-Unwrapped sliced American cheese;
-Open carton of apple juice not dated with use within ten days of opening documented on
the carton;
-Open carton of cranberry juice not dated with use within ten days of opening documented
on the carton;
-Open carton of grape juice not dated with use within days of opening documented on the
carton;
-Food crumbs and debris on the floor under the shelves;
-On [DATE] at 11:30 A.M. and [DATE] at 7:11 A.M.:
-Food crumbs and debris on the floor underneath the shelves;
-On [DATE] at 12:19 P.M.:
-Open container of sliced meat, undated;
-Open container of sliced peaches, undated;
-Food crumbs and debris on the floor underneath the shelves;
-Open container of nectar consistency orange juice, dated ,[DATE];
-Open container of nectar consistency water, undated;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
-On [DATE] at 11:37 A.M.:
-Food crumbs and debris on the floor underneath the shelves;
-Uncovered sliced cake on the rack.
7. Review of the facility’s 2014 Dishwashing policy, showed:
-Check the dishwashing machine each morning before first set of dishes are to be washed.
This is usually before the breakfast meal and again in the PM or generally before the
supper meal. If the dishwashing machine has not been used for several hours, it is
generally recommended to allow the dishwashing machine to cycle to allow the dishwashing
machine to come up to proper function. Check the dials to ensure that the wash and rinse
cycles are achieving proper temperature per manufacturer guidelines. If a chemical
sanitizer is used, check the concentration using the correct test tape for type of
sanitizer in use. If not at the correct hot water temperature or the proper chemical
sanitizing concentration, do not proceed to wash dishes. Empty dishwashing machine, check
nozzles, and empty bottom screen and restart the dishwashing machine;
-Further review of the policy, showed no documentation of the minimum temperature required
for proper sanitation.
Observation and interview on [DATE] at 11:45 A.M., showed Dietary Aide M tested the hot
water dish machine. He/she ran a cycle and checked the temperature gauge. He/she checked
the gauge to see if it moved to show the final rinse was 180 degrees Fahrenheit (F).
He/she said they do not use test strips, they only check the temperature gauge. If the
temperature gauge did not move, they would call to have the dish machine serviced. A
second cycle started with the surveyor’s test strip on a dish. Dietary Aide M removed the
strip, and confirmed the strip turned black to indicate proper hot water sanitization.
Dietary aide M said they used to have test strips, but not anymore.
8. Observation of the 200 Hall Dining room, on [DATE] at 8:14 A.M., showed:
-At least 20 residents sat in the dining room;
-No sneeze guard on the steam table;
-At 8:41 A.M., Dietary Aide (DA) O put on gloves, unwrapped the scoops and placed them
into the individual pans of food on the steam table. Picked up a bowl, placed his/her
fingers inside on the food area of the bowls and placed the bowls on top of the steam
table for staff to serve to the residents;
-Without changing his/her gloves, took 7 more bowls, separated them by touching the inside
of the bowls with his/her fingers and thumb and served up hot cereal into the bowls;
-He/she picked up a plastic container, opened the lid, filled 4 bowls of cheerios, pressed
the plastic container up against his/her chest to close the top, picked up another plastic
container and filled a bowl of bran flakes, with his/her thumb placed inside of the bowl
on the food surface area;
-At 8:51 A.M., the Registered Dietician (RD), entered the dining room, walked over, said
something to DA O, and DA O removed the gloves, washed his/her hands and put on clean
gloves. After he/she had changed gloves, he/she picked up 4 bowls with his/her thumb on
the inside of the bowl, picked up the plastic container of cheerios and filled the 4
bowls. He/she pressed the container against the front of his/her shirt while opening and
closing the container;
-DA O picked up slices of bacon, sausage links and toast with his/her gloved fingers and
plated them;
-Between plating food, DA O placed his/her gloved hands on the metal top of the steam
table while he/she waited for staff to deliver the plates of food to the residents;
-At 8:57 A.M., DA O said he/she had finished plating food for the resident’s, removed
his/her gloves and left the dining area.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
9. During an interview on [DATE] at 2:09 P.M., the dietary manager said if there are food
or beverages opened without a label or date, she would expect staff to throw it away. Once
cartons of juice have been opened, she would expect there to be a date. The thickened milk
is good for three days, and thickened juice is good for 7 days. She would expect all food
to be completely wrapped and covered. The walk in cooler is to be cleaned, swept and
mopped daily. The freezer is cleaned every Wednesday. She was aware that it had not been
cleaned due to shortage of staff. She confirmed that the freezer floor had not been
cleaned. A company cleans the range hood, but the last time they were at the facility was
[DATE]. They were supposed to come in January, but they did not show up. The dish machine
room should be cleaned daily because it is used to dry dishes. The dish machine is tested
on ce a week on Fridays. It is de-limed, but staff are supposed to look at the gauge every
day. If it is not working properly, they call the manufacturer. The dietary manager
confirmed that staff would not know if the temperature reached 130 degrees F or 180
degrees F by physically touching the dishes, so a test strip would be needed and the dish
machine should be tested daily. The soup kettle is cleaned with hot soapy water, rinsed,
and sanitized. The dietary aide boiled it over with the soup, so the hose was used to
clean underneath the kettle. The dietary manager would expect the trash cans to be
covered. The dietary manager did not know why there were rugs inside the three sink
sanitizer or the double sink, but they should not have been there. She would expect staff
to wipe down the preparation table and sinks after each meal to ensure there was no food
crumb buildup. The dietary manager would expect staff to change gloves and wash their
hands to prevent cross contamination during meal service.

F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and
all bed rails and mattresses must attach safely to the bed frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to conduct regular
inspection of all bed frames, mattresses and bed rails as a part of a regular maintenance
program to identify areas of possible entrapment, for three out of the 35 sampled
residents (Resident #90, #65, and #117.) The census was 223 with 193 in certified beds.
1. Review of Resident #90’s care plan, dated 12/26/18, showed:
-Problem: Risk for falls related to history of stroke, falls , poor muscle control,
decreased mobility, unassisted attempts to stand/transfer/ambulate, poor safety awareness
and a history of falling;
-Goal: To manage/prevent future falls and the potentials for injury;
-Interventions: Low bed, floor mat at bedside and bed against wall.
Observation 2/13/19 at 10:57 A.M., 2/14/19 at 11:13 A.M. and on 2/15/19 at 5:30 A.M.,
showed the resident’s bed against the wall with a bed rail on the opposite side. The loose
bed rail rattled back and forth when moved, creating a 4-5 inch gap in between the
mattress and bed rail.
2. Review of Resident #65’s care plan, dated 12/5/18, showed:
-Problem: At risk for falls related to multiple [MEDICAL CONDITION] with left sided
weakness;
-Goal: Will be free of falling and will remain free from injury thru the next review;
-Intervention: Call light within reach. Assess for ability to understand use of call light
and ability to utilize.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
Observation of the resident’s room, showed on 2/13/19 at 2:46 P.M., on 2/14/19 at 7:51
A.M., and on 2/19/19 at 10:42 A.M., the resident’s bed located near the wall with a bed
rail up on the right side. The loose bed rail rattled back and forth when moved, creating
a 4-5 inch gap in between the mattress and bed rail.
3. Review of Resident #117’s care plan, dated 12/26/18, showed:
-Problem: High risk for falls related to decreased mobility and use of [MEDICAL CONDITION]
drugs;
-Goal: Will not have any future falls;
-Intervention: Give verbal reminders not to transfer without assistance.
Observation of the resident’s room, showed on 2/13/19 at 1:20 P.M., on 2/14/19 at 1:58
P.M., and on 2/19/19 at 11:33 A.M., bilateral (both sides) side rails attached to the
resident’s bed, in the upright position. Both loose side rails, shook back and forth and
up and down when moved creating a 4-5 inch gap in between the mattress and bed rails.
4. During an interview on 2/20/18 at 3:18 P.M., the Director of Nursing (DON) said the
Maintenance Director said he looks at bed rails when he is on rounds. The facility does
not keep a maintenance log of repairs or checks of bed rails in use in the facility.
5. During an interview on 2/21/19 at 9:05 A.M., the DON said said all beds in facility are
Invacare beds.
Review of the Invacare user manual, dated 2012, showed:
-Inspect the wheel locks for correct locking action before actual use;
-After any adjustments, repair or service and before use, make sure all attaching hardware
is tightened securely;
-Annual maintenance check:
-When evaluating the condition of rail attachments it is necessary to consider all
aspects of the bed-rail system. Including consideration of the rails, mattress, and bed
systems;
-Inspect the covering of the bed’s control panel and the patient control panel to assure
that the covering is not cracked or damaged;
-Inspect for damaged or loose wiring;
-Inspect for secure grounding;
-Inspect rails latches. Ensure that all rails engage and lock as specified;
-Lubricate rail pivot points as needed with white [MEDICATION NAME] grease;
-Inspect bed, rails, assist rails or assist bars for the presence of tubing end carps and
replace as required;
-Lubricate all mechanical hinge points, bushings, and surface contact point with white
[MEDICATION NAME] grease;
-Inspect for wear of clevis pins and hitch pins and replace if worn or missing;
-Inspect the rails for noticeable scratches and chips.
-Quarterly maintenance check:
-Unplug bed from wall outlet and verify battery function, if equipped.
6. Review of the facility’s bed mobility assist devices policy, dated November, (YEAR),
showed:
-Purpose: To ensure that the use of bed mobility assist devices are utilized when
appropriate and alternatives to their use have been attempted, documented and communicated
to the resident and/or their representative. A consent form must be obtained prior to the
utilization of the assist device;
-A bed mobility device evaluation should be completed by the nurse upon the assessed need,
quarterly, annually, and with significant change thereafter;
-Bed mobility assist device informed consent and release form should be reviewed and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265325

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/21/2019

NAME OF PROVIDER OF SUPPLIER

DELMAR GARDENS NORTH

STREET ADDRESS, CITY, STATE, ZIP

4401 PARKER ROAD
BLACK JACK, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
signed by the resident and/or their representative upon the application of the assist
device and yearly thereafter;
-Environmental staff will install and inspect the assist device for safety prior to use.
Preventative maintenance will continue bi-monthly and as needed to ensure that the assist
device remains secure and that no gap exists between the assist device and the mattress.