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DELMAR NURSING & REHABILITATION CENTER

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DELMAR NURSING & REHABILITATION CENTER VS
All other Nursing Homes USA
General
City DELMAR   vs 0% Nursing Homes USA have DELMAR
State attribute explanation DE   vs 0.3% Nursing Homes USA have DE
Street 101 E. DELAWARE AVENUE  
Zip Code 19940  
Phone 3028463077  
Overall Star Rating
(1.11 lower than average)
vs
3.11

Health Inspections Star Rating
(1.83 lower than average)
vs
2.83

Nurse Staffing Star Rating
(0.83 higher than average)
vs
3.17

Quality Measures Star Rating
(1.69 higher than average)
vs
3.31

RN Only Star Rating
(0.83 higher than average)
vs
3.17

Number of Certified Beds
109  (0.06 higher than average)
vs
108.94

Total Number of Residents
104  (12.75 higher than average)
vs
91.25

Percent of Occupied Beds
95 % (11.35 % higher than average)
vs
83.65 %

Health Survey Date 2/10/2011  
Fire Survey Date 2/9/2011  
Sprinkler Status Fully Sprinklered  vs 90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  vs 91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  vs 56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  vs 93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  vs 54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   vs 66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  vs 90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  vs 31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  vs 99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
(57.16 lower than average)
vs
58.16

Total Enforcement Actions Count
(54.31 lower than average)
vs
56.31

# of deficiencies 30  
Staff Information
Number of Residents
94  (2.62 higher than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.66  (0.11 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.84  (equals average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.50  (0.09 lower than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.04  (5.45 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.04  (0.06 lower than average)
vs
0.10

Environmental Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 06/23/2011
date Of Correction: 07/21/2011 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 02/10/2011
date Of Correction: 05/16/2011 

Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Provide Housekeeping And Maintenance Services.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #4 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 07/15/2010
date Of Correction: 09/09/2010 

Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 08/24/2009
date Of Correction: 10/27/2009 

Mistreatment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 07/15/2010
date Of Correction: 09/09/2010 

Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Try To Resolve Each Resident's Complaints Quickly.
survey Date: 06/23/2011
date Of Correction: 07/21/2011 

Deficiency #2 Scope: Some
level Of Harm: 1
deficiency: Listen To The Resident Or Family Groups Or Act On Their Complaints Or Suggestions.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #5 Scope: Many
level Of Harm: 1
deficiency: Give Each Resident A Notice Of Rights, Rules, Services And Charges. Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items And Services Medicaid Covers And Which The Resident Must Pay For.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 06/23/2011
date Of Correction: 07/21/2011 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 06/23/2011
date Of Correction: 07/21/2011 

Deficiency #3 Scope: Many
level Of Harm: 1
deficiency: Develop Policies And Procedures For Influenza And Pneumococcal Immunizations.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Residents With Reduced Range Of Motion Get Proper Treatment And Services To Increase Range Of Motion.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 07/15/2010
date Of Correction: 09/09/2010 

Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 07/15/2010
date Of Correction: 09/09/2010 

Resident Assessment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 05/15/2012
date Of Correction: Not Available 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 06/23/2011
date Of Correction: 07/21/2011 

Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Set Up An Ongoing Quality Assessment And Assurance Group To Review Quality Deficiencies Quarterly, And Develop Corrective Plans Of Action.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Pharmacy Service Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.
survey Date: 02/10/2011
date Of Correction: 05/03/2011 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 02/10/2011
date Of Correction: 04/28/2011 

Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.
survey Date: 02/10/2011
date Of Correction: 05/03/2011 

Miscellaneous Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Other Fire Safety Features Required By Fire Safety Codes.
survey Date: 07/26/2011
date Of Correction: 09/20/2011 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
20 % (5.09 % lower than average)
vs
25.09 %

Percent of long-stay residents whose need for help with daily activities has increased
75.2 % (42.25 % higher than average)
vs
32.95 %

Percent of long-stay residents who self-report moderate to severe pain
7.4 % (9.26 % lower than average)
vs
16.66 %

Percent of long-stay high-risk residents with pressure ulcers
9.1 % (3.48 % lower than average)
vs
12.58 %

Percent of long-stay residents who lose too much weight
6.5 % (5.33 % lower than average)
vs
11.83 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
6.5 % (9.13 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
2.20 % (11.26 % lower than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
3.2 % (25.18 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
75.2 % (31.52 % higher than average)
vs
43.68 %

Percent of short-stay residents who self-report moderate to severe pain 16.3:1 % 
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
69.6 % (15.04 % lower than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
80.4 % (3.54 % lower than average)
vs
83.94 %

Percent of short-stay residents who newly received an antipsychotic medication
(44.9 lower than average)
vs
45.90

Percent of long-stay residents experiencing one or more falls with major injury
75.2 % (59.68 % higher than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
15.6 % (9.79 % lower than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
75.2 % (51.5 % higher than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain
5.2 % (8.9 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
9 % (0.22 % lower than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
6.2 % (2.3 % lower than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
27.6 % (15.78 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
7 % (3.65 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
4.2 % (5.38 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
1 % (18.86 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
75.2 % (36.67 % higher than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
75.2 % (64.47 % higher than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
11.9 % (12.86 % lower than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
76.5 % (4.94 % lower than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
86.2 % (11.45 % higher than average)
vs
74.75 %

Percent of short-stay residents who newly received an antipsychotic medication
1.8 % (15.54 % lower than average)
vs
17.34 %



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