Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 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.
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 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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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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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 | — | 3 | 1 |
| Atrium Place Health And Rehabilitation | 1.6 mi | — | 2 | 0 |
| Christian Extended Care & Rehabilitation | 1.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.