Inspection Reports for
Delta South Nursing &Amp; Rehabilitation
640 COLONEL GEORGE E DAY PARKWAY, SIKESTON, MO, 63801-0624
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
124% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
53 residents
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 3
Date: Nov 7, 2024
Visit Reason
The inspection was conducted based on complaint #MO00243948 regarding failure to provide proper incontinent care and scheduled showers for residents.
Complaint Details
Complaint #MO00243948 triggered the investigation into incontinent care and shower scheduling issues.
Findings
The facility failed to provide proper incontinent care for two residents and failed to provide scheduled showers for one resident. Additionally, the facility failed to perform hand hygiene and glove changes during incontinent care for three residents, violating infection prevention protocols.
Deficiencies (3)
Failed to provide proper incontinent care for residents #1 and #19, including incomplete cleaning of peri areas.
Failed to provide scheduled showers for resident #37, missing five out of ten scheduled showers.
Failed to perform hand hygiene and change gloves appropriately during incontinent care for residents #1, #19, and #251.
Report Facts
Missed scheduled showers: 5
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in findings related to improper incontinent care and failure to perform hand hygiene and glove changes. |
| CNA M | Certified Nursing Assistant | Named in findings related to improper incontinent care and failure to perform hand hygiene and glove changes. |
| CNA C | Certified Nursing Assistant | Named in findings related to failure to perform hand hygiene and glove changes during incontinent care. |
| Administrator | Provided statements on expected care standards and policies. | |
| Director of Nursing | Director of Nursing (DON) | Provided statements on expected care standards and policies. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided statements on expected care standards and policies. |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 9
Date: Nov 7, 2024
Visit Reason
The inspection was conducted based on complaint investigations and regulatory oversight of Delta South Nursing & Rehabilitation to assess compliance with resident rights, safety, care, medication administration, infection control, and facility environment.
Complaint Details
Complaint #MO00243948 was investigated related to failure to provide scheduled showers and proper assistance with activities of daily living.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of resident code status, failure to provide a safe and homelike environment, untimely submission of quarterly MDS assessments, inadequate assistance with activities of daily living, medication administration errors, improper use and monitoring of psychotropic medications, poor food storage and sanitation practices, and failure to perform proper hand hygiene and glove changes during incontinent care.
Deficiencies (9)
Failed to consistently document a code status for one resident (Resident #101).
Failed to provide a safe, clean, and comfortable homelike environment with multiple environmental issues observed.
Failed to electronically transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for four residents.
Failed to provide proper incontinent care for two residents and failed to provide scheduled showers for one resident.
Failed to implement procedures to ensure medications were accurately administered, documented, disposed of, and reconciled for one resident.
Failed to ensure appropriate diagnosis and monitoring for use of psychotropic medications for two residents.
Failed to maintain medication error rates below 5%, with 4 errors in 30 opportunities (13.33% error rate).
Failed to store and distribute food under sanitary conditions, including unlabeled and undated food items and buildup of grime and grease in kitchen equipment.
Failed to perform hand hygiene and glove changes during incontinent care for three residents.
Report Facts
Facility census: 53
Medication error rate: 13.33
Missed scheduled showers: 5
Late MDS submissions: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in findings related to improper incontinent care and hand hygiene |
| CNA M | Certified Nursing Assistant | Named in findings related to improper incontinent care and hand hygiene |
| CNA C | Certified Nursing Assistant | Named in findings related to improper incontinent care and hand hygiene |
| LPN F | Licensed Practical Nurse | Named in medication administration and controlled substances findings |
| CMT G | Certified Medication Technician | Named in medication administration errors |
| Director of Nursing | Director of Nursing (DON) | Named in multiple interviews regarding deficiencies and expectations |
| Administrator | Facility Administrator | Named in multiple interviews regarding deficiencies and expectations |
| Social Services Director | Social Services Director (SSD) | Named in interviews regarding code status and MDS submissions |
| Housekeeper A | Named in interview regarding environmental concerns | |
| Housekeeper B | Named in interview regarding environmental concerns | |
| Maintenance Supervisor | Named in interview regarding environmental concerns and maintenance logs | |
| Dietary Manager | Named in interview regarding kitchen sanitation and cleaning | |
| Kitchen Employee I | Named in interview regarding kitchen sanitation and cleaning | |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in interview regarding shower documentation |
Inspection Report
Routine
Census: 45
Deficiencies: 10
Date: Aug 31, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident assessments, care planning, discharge procedures, catheter care, dialysis services, nurse aide performance, pharmaceutical services, infection control, and nurse aide education.
Findings
The facility was found deficient in multiple areas including failure to complete timely significant change Minimum Data Set (MDS) assessments, inaccurate resident assessments, incomplete care plans, lack of comprehensive discharge summaries, inadequate catheter orders and care, insufficient dialysis monitoring, failure to conduct nurse aide performance reviews and in-service training, failure to reconcile narcotics at shift changes, lapses in hand hygiene and infection control practices, and incomplete tuberculosis (TB) screening and documentation.
Deficiencies (10)
Failed to complete a significant change Minimum Data Set (MDS) within 14 days of admission to hospice for one resident.
Failed to ensure accuracy of Minimum Data Set (MDS) assessments for residents, including smoking status and discharge information.
Failed to implement complete care plans with individualized interventions for five residents.
Failed to complete comprehensive discharge summaries for two discharged residents.
Failed to obtain physician orders and diagnoses for Foley catheter use and failed to ensure proper catheter care and placement for three residents.
Failed to provide documentation of ongoing assessments, monitoring, and communication related to dialysis care for one resident.
Failed to provide nurse aide annual performance reviews and regular in-service education for two certified nursing assistants.
Failed to ensure staff reconciled narcotics at each shift change for two medication carts and one medication storage room.
Failed to perform hand hygiene between glove changes during incontinent care and between residents during medication administration; failed to complete admission TB screening and annual TB risk assessments for five residents.
Failed to conduct at least 12 hours of nurse aide in-service education per year for two certified nursing assistants.
Report Facts
Facility census: 45
Narcotic count missed opportunities: 18
Narcotic count missed opportunities: 21
Narcotic count missed opportunities: 24
Narcotic count missed opportunities: 22
Narcotic count missed opportunities: 37
Narcotic count missed opportunities: 24
Narcotic count missed opportunities: 45
Narcotic count missed opportunities: 33
Narcotic count missed opportunities: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in relation to lack of annual performance reviews and in-service education |
| CNA H | Certified Nursing Assistant | Named in relation to lack of annual performance reviews and in-service education |
| CNA F | Certified Nurse Assistant | Named in relation to failure to perform hand hygiene between dirty and clean care |
| CNA E | Certified Nurse Assistant | Named in relation to failure to perform hand hygiene between dirty and clean care |
| CNA H | Certified Nurse Assistant | Named in relation to failure to perform hand hygiene between dirty and clean care |
| CMT A | Certified Medication Technician | Named in relation to failure to perform hand hygiene during medication administration |
| Director of Operations | Director of Operations | Provided statements regarding expectations for MDS completion, catheter care, dialysis monitoring, narcotic counts, and infection control |
| Administrator | Administrator | Provided statements regarding expectations for MDS completion, catheter care, narcotic counts, and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statements regarding catheter care and narcotic counts |
| Registered Nurse C | Registered Nurse | Provided statements regarding dialysis communication and monitoring |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 15
Date: Jul 30, 2021
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements including resident rights, care planning, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate advance directive documentation, failure to issue proper Medicare non-coverage notices, improper use and documentation of restraints, failure to check employee abuse registry, incomplete and inaccurate Minimum Data Set (MDS) assessments, inadequate baseline and comprehensive care plans, failure to plan for discharge, improper medication regimen reviews especially related to antipsychotic medications, unsafe food storage practices, and failure to provide pneumococcal vaccine education and documentation.
Deficiencies (15)
Failed to ensure accuracy of residents' advance directives regarding resuscitation code status for two residents.
Failed to issue Notice of Medicare Non-Coverage (NOMNC) forms with required information and documentation for three residents.
Failed to assess and document use of chair alarm as a restraint and failed to have physician order for chair alarm for one resident.
Failed to check Certified Nurse Aide (CNA) Registry prior to employment for one new employee.
Failed to complete admission Minimum Data Set (MDS) within 14 days for one resident.
Failed to complete significant change MDS within 14 days of admission to hospice for one resident.
Failed to accurately code MDS for physical restraints and dialysis, and failed to code chair alarm correctly for multiple residents.
Failed to ensure baseline care plans included specific interventions and failed to provide written summary of baseline care plan to residents or representatives for three residents.
Failed to implement individualized comprehensive care plans to meet residents' physical, mental, and psychosocial needs for four residents.
Failed to update and revise care plans with specific interventions and failed to include residents or representatives in care plan meetings for three residents.
Failed to ensure discharge planning focused on resident's goals and effective transition to post-discharge care for one resident.
Failed to ensure pharmacist identified and recommended gradual dose reductions for antipsychotic medications and failed to ensure appropriate diagnosis for antipsychotic use for two residents.
Failed to ensure proper diagnosis for antipsychotic medication use and failed to implement gradual dose reductions and non-pharmacological interventions for two residents.
Failed to store and distribute food under sanitary conditions, including unlabeled and undated opened food items and inadequate dishwasher sanitizer monitoring.
Failed to provide pneumococcal vaccine information, education, and documentation of consent/refusal for four residents.
Report Facts
Facility census: 50
Missed dishwasher temperature recordings: 88
Missed dishwasher temperature recordings: 82
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 3
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
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