Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Delmar Gardens North during CMS and state inspections, most recent first.
Staff failed to protect resident dignity and privacy when they entered rooms without knocking or announcing themselves, including during private visits and while residents were eating or in bed. Call lights were repeatedly left out of reach for some residents, and one resident with significant medical issues waited while crying out for help after a CNA turned off the call light and left the room. Residents also reported the dining room was too cold, with cold air blowing directly on tables under ceiling vents and no timely adjustment to the temperature.
Medication carts and a storage room had loose pills, unlabeled or undated medications, and non-medication items stored with drugs and biologicals. Surveyors found multiple carts with pills scattered in drawers, open containers without dates, items in the narcotics drawer, batteries, a fan, a phone charger, and other personal or unrelated items. Staff gave inconsistent responses about who was responsible for cleaning the carts, and the DON stated staff were expected to follow policy and that no personal items should be on medication carts.
Missing AMA Discharge Documentation: A resident admitted with abdominal abscess and multiple comorbidities was discharged AMA, but the chart lacked progress note documentation of the AMA discharge and did not contain a signed AMA form or other record of the resident's and/or RP's decision. The Administrator stated staff should document the AMA decision in the progress notes and obtain the resident's signature, but those records were not available.
Failure to assess and report a change in condition: A resident with stroke, polyneuropathy, and left elbow bursitis with a draining abscess had physician orders for wound evaluation and an elbow pad, but the MAR showed no assessments during the review period. An LPN said staff only monitored pain and brace use, while the ADON later found a dated bandage absent, drainage present, swelling, and discoloration at the elbow and stated the provider needed clarification of the orders.
Improper catheter storage and incomplete catheter care were observed for two residents with indwelling catheters. One resident with multiple medical conditions was repeatedly found in bed with the catheter bag on the floor instead of hung on the bed frame, despite staff stating it should be off the floor. Another resident with cerebral palsy, cognitive communication deficit, dysphagia, gastrostomy status, and aphasia received peri care from a CNA who did not clean the glans and catheter as required, and the CNA acknowledged not following the proper technique.
Missed and Interrupted G-Tube Feedings: Two residents with g-tubes did not receive ordered nocturnal enteral feedings as prescribed. One resident’s feeding was held because an LPN reported abdominal pain and distention, despite no order for that symptom-based hold, and the other resident’s feeding was stopped early for care and due to staff concern about prior tube displacement. Observations showed the pump off when feedings should have been running, and the DON stated staff should have paused and resumed the pump rather than discontinue it.
A facility failed to implement fall prevention measures, resulting in multiple residents experiencing falls and injuries. A resident was found hanging off a bed not in a low position, leading to bilateral fractured femurs. The facility did not complete required post-fall neurological assessments or update care plans with new interventions. Staff interviews revealed a lack of awareness and adherence to fall risk protocols, contributing to the deficiencies.
A facility failed to provide adequate ADL care for a resident who was cognitively intact and required assistance. The resident refused showers, and staff did not document re-attempts to provide hygiene care. The resident was found in a neglected state, covered in fecal material, and later exhibited labored breathing and other concerning vital signs, leading to a hospital transfer. Staff failed to report and document the resident's refusal of care, and the facility acknowledged the lack of appropriate care and communication.
A resident with multiple chronic conditions was found with a skin tear of unknown origin that was not investigated or documented according to facility policy. The injury was treated, but it was not entered into the wound management system, and the Wound Nurse was unaware of its existence. Interviews confirmed that the required procedures for reporting and investigating such injuries were not followed, and the administrative team was not notified.
Staff left unsecured insulin pens, lancets, pen needles, and sharps containers on unattended medication carts in a care area, with residents present nearby. The medication and sharps were not locked or secured as required by facility policy, and staff confirmed these items should have been secured to prevent unauthorized access.
Staff failed to follow infection control protocols during wound care for two residents, including not changing gloves or sanitizing hands between tasks, using the same gauze pad for multiple wounds, placing supplies on unsanitized surfaces, and contaminating wound care products. LPNs and leadership acknowledged these lapses, which were not in accordance with facility policy.
Failure to Protect Resident Dignity, Call Light Access, and Dining Comfort
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect when staff entered resident rooms without knocking or announcing themselves, failed to keep call lights within reach for some residents, and did not adjust the dining room temperature to a comfortable level for residents seated under cold air vents. These failures affected nine of 36 sampled residents in a census of 171. During observation and interview, a housekeeper entered one resident’s room while the resident was eating breakfast, opened the door without notice, and vacuumed while talking on a cell phone. The resident said staff do this all the time and never knock. In another room, a CNA entered without knocking while the resident was meeting privately with a surveyor, walked between the resident and surveyor, and did not acknowledge them. Two other residents reported staff entering their rooms without knocking or introducing themselves, including one resident who was startled when a CNA appeared beside the bed and another who was frightened when a man entered the room and went into the bathroom without notice. A resident with moderately impaired cognition, left-sided paralysis, chronic kidney disease, legal blindness, and urine retention was observed calling for help and repositioning assistance while in pain. The resident repeatedly used the call light and called out for help over several minutes, while a CNA entered without announcing herself, turned off the call light, said she would get help, and left the room. The resident continued crying and calling for assistance until the CNA returned later. In addition, call lights for other residents were repeatedly observed at the foot of the bed or otherwise out of reach, including one resident whose family said the issue had been brought to nursing staff and another resident who yelled for staff while the call light remained out of reach. The dining room temperature on the 400 hall was also observed to be cold on multiple occasions. Residents seated under ceiling supply vents said the room was too cold, and air measurements showed cold air blowing directly on the tables. One resident asked a CNA to adjust the temperature because he or she was too cold, but the temperature remained unchanged for hours. Residents stated the cold air made it difficult to enjoy meals because food cooled too quickly, and staff acknowledged that the vents blew directly down on the residents seated at those tables.
Medication carts and storage areas contained loose pills, unlabeled items, and personal belongings
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices on multiple medication carts and in a storage room. Review of the facility policy stated medications are to be stored in their original containers, narcotics keys are restricted, outdated or deteriorated medications are to be stored separately, refrigerated medications are to be kept in the locked medication room, and all medication areas are to be locked when not in use. On the 100-hall CMT F cart, surveyors found 40 loose pills under a pull-out tray, 13 loose pills in the second drawer, 30 pills at the back of columns, an open Metamucil canister without a date, polyethylene glycol without an open date, and the narcotics drawer containing an herbal supplement jar with loose change and dollar bills inside. In the 100-hall storage room, vitamin C 500 was open with 12 pills remaining and no open date. Additional observations showed similar problems on other carts. The 200-hall CMT E cart contained batteries in the top drawer, a personal fan in the third drawer, and three aerosol items with floral smells. The 300-hall nurse cart contained polyethylene glycol without an open date, several loose pills of different colors and markings, and a phone charger in the third drawer. The 400-hall CMT cart had loose pills in the third and fourth drawers. The 500-hall CMT cart had loose pills in multiple drawers, including over 50 pills in one drawer. Staff interviews showed differing expectations about who was responsible for cleaning the carts, and the DON stated staff were expected to follow policy and that no personal items should be found on medication carts.
Missing AMA Discharge Documentation
Penalty
Summary
The facility failed to ensure a resident's AMA discharge was documented in the medical record and that appropriate information was communicated to the resident and/or responsible party. Resident #178 was admitted with abdominal abscess and a history of pancreatic cancer, liver cancer, diabetes, acidosis, low hemoglobin, and hypoglycemia. On the day before discharge, the resident was documented as alert and oriented, able to make needs known, and resting in bed during the overnight shift; the next day the resident was discharged at 8:25 A.M. left against medical advice. The resident's record contained no documentation of the AMA discharge in the progress notes and no signed AMA form or other documentation showing the resident's and/or responsible party's decision to leave AMA. The facility's admission agreement stated that a resident may leave against the advice of a physician and would assume full responsibility for the results, but the medical record reviewed did not include the required AMA discharge documentation. During interview, the Administrator stated she expected the resident to sign the AMA discharge form and staff to document the resident's decision to discharge AMA in the progress notes, but the discharge policy and signed AMA form were not provided at the time of exit.
Failure to Assess and Report Change in Wound Condition
Penalty
Summary
The facility failed to document assessments and failed to contact the resident's physician regarding a change of condition for one sampled resident. Resident #11 was cognitively intact and had diagnoses including stroke, localized swelling, mass and lump in the left upper limb, and polyneuropathy. The resident's physician orders included evaluation for left elbow bursitis with a draining abscess, wound care assessment for drainage and dressing needs, and use of an elbow pad except during bathing. A shower sheet documented left forearm dark purple bruising, the elbow pad in place, elbow bursitis abscess, and a small discolored area on the right butt cheek, but the resident's MAR showed no assessments during the period reviewed. During interview, an LPN stated the resident was only monitored for pain and whether the protective elbow brace was on, and said nurses were not required to chart color, size, or monitor the abscess in any way. The ADON later reviewed the specialist orders and stated staff should monitor the site noted on the shower sheet and that the order showed wound management was to evaluate the abscess for drainage. When the elbow was observed, an adhesive brown bandage without a date was present with a small amount of brown dried drainage, swelling, and a light center with a discolored purple outer center. The ADON stated the wound could not be staged due to no prior knowledge of it and said the provider would need to be called to clarify the prior orders. The DON stated staff should have reported wounds to wound management and said the resident going 11 days without a nurse's care could lead to infection risk; the DON also said staff should have charted the wound sooner than 11 days.
Improper Catheter Storage and Incomplete Catheter Care
Penalty
Summary
Appropriate catheter care was not provided for two residents with indwelling catheters. The facility’s catheter care policy required catheter tubing to be checked for positioning, the catheter bag to be attached to the bed frame only, and male catheter care to include cleansing from the urethral opening outward and cleaning the glans and catheter as directed. The facility identified one resident with a Foley catheter who had moderately impaired cognition, left side paralysis, chronic kidney disease, legal blindness, and urine retention, but the resident’s care plan did not identify the catheter. During multiple observations, the resident was lying in bed while the catheter bag was on the floor next to the bed. Staff interviewed stated the catheter should be hung on the bed frame and off the floor, and the DON and Administrator said they expected staff to ensure correct catheter placement before leaving the room. A second resident with an indwelling catheter, cerebral palsy, cognitive communication deficit, dysphagia, gastrostomy status, and aphasia had a care plan addressing UTIs related to blood in the catheter and a current order for catheter care each shift. During observation, a CNA performed peri care, washed hands, and applied gloves, but did not follow the full catheter care technique. The CNA wiped the left and right sides, continued wiping the genitals, touched the indwelling catheter, and wiped the middle of the tube in a downward motion while leaving 2 to 3 inches of the drain from the glans untouched. The CNA stated he/she knew the proper technique for cleansing residents with an indwelling catheter but did not follow it during the care provided. The DON stated staff were expected to follow correct policy and procedure for resident care and that the glans and the medical device inserted into the urethra should be cleaned. The DON also stated that not cleaning the tube could allow bacteria to build up and enter the urethra, leading to a UTI.
Missed and Interrupted G-Tube Feedings
Penalty
Summary
The facility failed to ensure that two residents with gastrostomy tubes received their ordered nocturnal enteral feedings at the specified times. Resident #1 was cognitively intact, had a feeding tube, and diagnoses included diabetes, venous thrombosis and embolism, hemiplegia and hemiparesis from cerebral infarction, and dysphagia. The resident’s orders included checking g-tube placement before feedings and medications, elevating the head of bed to 30 degrees, flushing the tube with water every six hours and before and after medications, and running Glucerna 1.5 at 70 ml per hour overnight from 7:00 P.M. to 7:00 A.M. The care plan directed staff to administer tube feeding as ordered and flush the g-tube as ordered. During interview and observation, Resident #1 stated he/she did not receive tube feeding overnight and was unsure why. The resident was observed in bed with the head of bed elevated and no tube feeding running. An LPN stated the resident’s stomach was hurting and that he/she gave the stomach a rest sometimes, although there were no orders for bloating or distention symptoms to follow. The DON later stated the nurse called the medical provider about the missed feeding but could not speak directly to the provider or leave a message, and that the resident complained of abdominal distention and pain, which led the nurse to hold the nocturnal tube feeding. The resident’s oral intake for the day was documented as 25% at breakfast, 50% at lunch, and 75% at dinner. Resident #55 was cognitively intact, had a feeding tube, and diagnoses included cerebral palsy, cognitive communication deficit, dysphagia, and gastrostomy status. The resident’s care plan stated all nutrition and hydration were provided via g-tube, and the physician’s orders directed continuous nocturnal enteral feeding with the head of bed at 30 degrees. On multiple observations, the resident was found with no tube feeding running at times when it should have been infusing, and one observation showed the resident slumped in bed. An LPN stated the feeding was stopped early due to care being provided and also said the feeding was removed because CNAs had pulled the g-tube out in the past and the resident had previously been hospitalized for tube displacement. The LPN reported the resident received 750 ml of the ordered 1,000 ml nocturnal feeding, while the DON stated nurses would not be expected to discontinue nocturnal tube feeding for care alone and should pause and resume the pump after care.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to maintain an environment free of accident hazards and provide adequate supervision to prevent falls for several residents. Specifically, the facility did not implement care-planned fall interventions for five of seven sampled residents. For instance, a Certified Nurse Aide (CNA) failed to place a resident's bed in a low position, resulting in the resident being found hanging off the bed and subsequently sustaining bilateral fractured femurs. The facility also failed to complete post-fall neurological assessments as ordered by the physician and in accordance with the facility's policy for all sampled residents. The facility did not complete post-fall follow-up documentation each shift for 72 hours after falls for six of the sampled residents. Additionally, the facility failed to update the care plans of two residents with interventions after they experienced falls. The report highlights that the facility's Fall Risk/Fall Prevention Program and Post-Fall Assessment procedures were not adequately followed, leading to these deficiencies. Interviews with staff revealed a lack of awareness and adherence to fall risk protocols. For example, a CNA was unaware that a resident was a fall risk and did not know the bed should be in the lowest position. Furthermore, the facility's documentation and communication regarding fall interventions were inconsistent, as evidenced by discrepancies in the placement of fall mats and the positioning of beds against walls, which were not in line with the care plans.
Failure to Provide Adequate ADL Care for a Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a dependent resident during the evening and overnight shifts. The resident, who was cognitively intact and required assistance from two staff members for ADLs, was left in a state of neglect. On multiple occasions, the resident refused showers, and staff did not document any re-attempts to provide necessary hygiene care. On one occasion, the resident was found covered in fecal material, and despite initial refusals, was eventually persuaded to accept a bed bath. The resident's condition deteriorated, and on the morning of the following day, the resident was found to be tachypneic with labored breathing and other concerning vital signs. Emergency Medical Services (EMS) was called, and the resident was transferred to the hospital for further evaluation. Staff members failed to report the resident's refusal of care, and there was a lack of communication and documentation regarding the resident's condition and care needs. Interviews with staff revealed that the resident had not received proper ADL care, and there were multiple instances where staff did not report or document the resident's refusal of care. The facility's Assistant Director of Nursing (ADON) and Administrator acknowledged the failure to provide appropriate care and the lack of reporting and documentation by the staff.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and document an injury of unknown origin for a resident, as required by its own policies and procedures. The resident, who had multiple diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, and chronic kidney disease, was found to have a dime-sized skin tear on the left inner arm. There was no documentation explaining how the injury occurred, and it was not observed or explained by the resident. The injury was discovered during routine care, and while the wound was treated and the physician and responsible party were notified, there was no evidence that an investigation was initiated to determine the cause of the injury. Facility policies required that all injuries of unknown origin be reported immediately to the administrative team and investigated to rule out abuse, neglect, or mistreatment. The policies also specified that such injuries should be documented in the wound management system and event summary reports, and that the Wound Nurse should be notified. However, the skin tear was not entered into the wound management documentation, and the Wound Nurse was unaware of the injury or the treatment order. Interviews with nursing staff and administration revealed that the injury was not reported or investigated, and there was no event report or investigation summary related to the incident. The lack of documentation and investigation meant that the administrative team was unaware of the injury, and the required internal review and root cause analysis were not performed. The facility's event summary report did not include the injury, and the wound was not documented in the wound report. Staff interviews confirmed that the expected procedures for reporting and investigating injuries of unknown origin were not followed, resulting in a failure to protect the resident from potential further harm and to comply with regulatory requirements.
Unsecured Insulin Pens and Sharps Left on Unattended Medication Carts
Penalty
Summary
Facility staff failed to ensure that the environment remained free from accident hazards by leaving unsecured insulin pens, lancets, auto shield duo pen needles, and sharps containers on unattended and unsupervised medication/treatment carts in a resident care area. Multiple observations revealed that a red plastic box with drawers labeled for individual residents, containing various types of insulin pens, was left on top of the cart without being locked or otherwise secured. Additional supplies, including lancets and pen needles, were also left in open or easily accessible containers on the cart. Sharps containers, some with unsecured lids, were not attached to the carts and could be easily accessed or removed. These unsecured items were observed on several occasions, with residents walking in the vicinity of the unattended carts. The insulin pens and supplies were not protected from unauthorized access, and the sharps containers had lids that were either not locked or could be easily removed, allowing access to used, potentially contaminated sharps. The facility's own policy required that all drug storage areas, including carts and boxes, be locked when not in use or when left unattended, but this was not followed in these instances. Interviews with facility staff, including the Wound Nurse, Administrator, DON, and ADON, confirmed the observations and acknowledged that the insulin pens, lancets, needles, and sharps should have been secured and locked when not in use. Staff recognized that leaving these items unsecured posed a risk, as residents or visitors could access and potentially misuse the medications or sharps. The staff also confirmed that the observed practices were not in accordance with facility policy or expectations.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to demonstrate proper infection prevention and control practices during wound care for two residents. For one resident with a Stage IV pressure ulcer and multiple wounds, an LPN performed wound care without changing gloves or sanitizing hands between tasks, used the same gauze pad to treat multiple wounds, and failed to treat each wound separately. The LPN also applied ointment to multiple wounds using the same gauze pad and did not follow hand hygiene protocols between dirty and clean tasks. The resident's medical records showed complex medical conditions, including diabetes, dementia, and multiple wounds, with orders for specific wound care treatments that were not properly documented on the printed MAR during an EMR outage. For another resident with a diabetic foot ulcer and multiple comorbidities, a different LPN placed wound care supplies on unsanitized surfaces, including a visibly dirty treatment cart and the resident's bare mattress. The LPN failed to use a barrier cloth, applied wound gel using a dirty gloved finger, touched the medication tube with contaminated gloves, and placed the tube close to the open wound, risking contamination. The LPN also failed to sanitize hands between glove changes and returned potentially contaminated supplies to the treatment cart. Interviews with the involved LPNs, the wound nurse, and facility leadership confirmed that the expected infection control practices were not followed. Staff acknowledged that they should have sanitized hands and changed gloves between tasks, used clean surfaces or barriers for supplies, and avoided contaminating medication tubes and wound supplies. The facility's infection control policy and wound care checklist outlined these requirements, but they were not adhered to during the observed wound care procedures.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Black Jack
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Post Acute | 0.1 mi | ★★★★★ | 1 | 0 |
| Pillars Of North County Health & Rehab Center, The | 1 mi | ★★★★★ | 2 | 0 |
| Crestwood Health Care Center, Llc | 1.2 mi | ★★★★★ | 6 | 1 |
| Atrium Place Health And Rehabilitation | 1.6 mi | ★★★★★ | 2 | 0 |
| Christian Extended Care & Rehabilitation | 1.9 mi | ★★★★★ | 0 | 0 |
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