Inspection Reports for
Delta South Nursing &Amp; Rehabilitation
640 COLONEL GEORGE E DAY PARKWAY, SIKESTON, MO, 63801-0624
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
17.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
218% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
88% occupied
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Life Safety
Census: 53
Deficiencies: 2
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to ensure the proper use of power strips and extension cords in patient care areas, which did not meet NFPA 70 electrical wiring requirements. This deficiency had the potential to affect all occupants of the building.
Deficiencies (2)
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure proper use of power strips in patient care areas, with devices plugged into power strip adapters and a microwave plugged into a basic power strip, contrary to NFPA 70 requirements.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained in accordance with NFPA 70, 1999 edition, as referenced by the K920 deficiency.
Report Facts
Facility census: 53
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
Annual Inspection
Census: 53
Deficiencies: 9
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as an annual survey of Delta South Nursing & Rehabilitation to assess compliance with federal regulations and state requirements.
Findings
The facility was found deficient in multiple areas including documentation of advance directives, maintaining a safe and homelike environment, quarterly assessment submissions, provision of ADL care, pharmacy services, medication error rates, infection control, and food safety. Plans of correction were submitted addressing these deficiencies.
Deficiencies (9)
F578: The facility failed to consistently document a code status for one resident, violating advance directive requirements.
F584: The facility failed to provide a safe, clean, and comfortable homelike environment, including issues with shower curtains, floor cleanliness, and maintenance.
F638: The facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for four residents.
F677: The facility failed to provide proper incontinent care and scheduled showers to sampled residents.
F755: The facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of, and reconciled, including issues with controlled substances.
F758: The facility failed to ensure psychotropic drugs were only given when necessary and properly monitored for all residents.
F759: The facility failed to maintain a medication error rate of less than 5 percent, with an error rate of 13.33 percent observed.
F812: The facility failed to store and distribute food under sanitary conditions, including issues with cleanliness and food labeling.
F880: The facility failed to establish and maintain an infection prevention and control program to prevent communicable diseases.
Report Facts
Facility census: 53
Medication error rate: 13.33
Number of residents sampled: 14
Number of deficiencies cited: 9
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: 45
Deficiencies: 10
Date: Aug 31, 2023
Visit Reason
The inspection was conducted as an annual survey of Delta South Nursing & Rehabilitation to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including failure to complete significant change assessments, accuracy of Minimum Data Set (MDS) assessments, comprehensive care plans, discharge summaries, infection control, medication management, nurse aide training, and tuberculosis screening. The facility submitted a plan of correction addressing these deficiencies.
Deficiencies (10)
F637: The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of admission to hospice for one resident. The facility census was 45.
F641: The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for sampled residents. The facility census was 45.
F656: The facility failed to implement comprehensive care plans with specific interventions tailored to meet individual resident needs for five sampled residents. The facility census was 45.
F661: The facility failed to complete a comprehensive discharge summary for two sampled discharged residents. The facility census was 45.
F690: The facility failed to ensure appropriate catheter care and obtain necessary orders for Foley catheters for sampled residents. The facility census was 45.
F698: The facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and dialysis center for residents receiving dialysis. The facility census was 45.
F730: The facility failed to provide annual individual performance reviews or evaluations and regular in-service education for two certified nursing assistants. The facility census was 45.
F755: The facility failed to ensure staff reconciled narcotics and controlled substances accurately and maintain proper records. The facility census was 45.
F880: The facility failed to establish and maintain an infection prevention and control program including hand hygiene, isolation precautions, and tuberculosis screening for residents. The facility census was 45.
F947: The facility failed to conduct required in-service training for nurse aides, including dementia management and abuse prevention training. The facility census was 45.
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
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 2
Date: Aug 31, 2023
Visit Reason
The inspection was conducted to assess compliance with fire safety regulations, specifically regarding combustible decorations in the facility.
Findings
The facility failed to restrict the use of combustible decorations in accordance with National Fire Protection Association (NFPA) standards. Four candles with wicks were observed in resident room #207, posing a potential fire hazard.
Deficiencies (2)
K753 Combustible decorations were used in the facility without meeting NFPA fire safety criteria, including the presence of four candles with wicks in resident room #207.
A2009 The storage of unnecessary combustible materials in the building presented a fire hazard, violating 19 CSR 30-85.022(5).
Report Facts
Facility census: 45
Deficiencies cited: 2
Inspection Report
Life Safety
Census: 50
Deficiencies: 8
Date: Jul 30, 2021
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Delta South Nursing & Rehabilitation.
Findings
The facility failed to maintain adequate exit illumination, maintain the facility free of combustible materials in smoking areas, and maintain the facility free of temporary wiring. Additionally, oxygen storage was not properly secured and emergency lighting requirements were not met.
Deficiencies (8)
K281 Illumination of Means of Egress: The facility failed to maintain adequate exit illumination, affecting all residents and staff. Exterior courtyard exit pathways had no exit illumination.
K741 Smoking Regulations: The facility failed to maintain the facility free of combustible materials in smoking areas, potentially affecting all residents and staff. Cigarette butts were found in the trash can in the north courtyard.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain the facility free of temporary wiring, with an extension cord in use in the living area. This affected all residents and staff.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to store oxygen tanks in a safe manner, potentially affecting all residents and staff. A freestanding oxygen tank was found in room 208.
A2010 Oxygen Storage: Oxygen storage was not in accordance with NFPA 99 standards, with safety caps and cylinder support issues noted. Refer to K923 for details.
A2050 Emergency Lighting: The facility did not meet emergency lighting requirements for safety of residents and others using exits and corridors. Refer to K281 for details.
A2057 Ashtrays Noncombustibles/Safe/Disposal: Designated smoking areas lacked proper ashtrays of noncombustible material and safe design. Refer to K741 for details.
A3037 Extension Cords/Duplex Receptacles: Extension cords were not UL-approved or properly used, violating safety standards. Refer to K920 for details.
Report Facts
Facility census: 50
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
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 15, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation were conducted on 1/15/21 to assess compliance with CMS and CDC recommended practices for COVID-19.
Complaint Details
The complaint investigation was related to infection control practices for COVID-19 and was found to be unsubstantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this onsite visit.
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 3
Date: Nov 12, 2020
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess compliance with infection prevention and control requirements related to COVID-19.
Findings
The facility was found to be out of compliance with infection control practices, including improper use of facemasks by staff, lack of a surveillance plan to screen residents for COVID-19 symptoms, and inadequate documentation of resident screenings. Several infection prevention and control deficiencies were identified.
Deficiencies (3)
F880 Infection prevention and control: The facility failed to maintain proper infection control practices including staff not wearing facemasks appropriately and not performing hand hygiene before and after touching facemasks.
F880 The facility did not implement a surveillance plan to screen residents for signs and symptoms of COVID-19 for three sampled residents.
F880 The facility failed to document resident screenings for COVID-19 symptoms and lacked a formal screening process.
Report Facts
Facility census: 46
Residents sampled for COVID-19 screening: 4
Residents not screened for COVID-19 symptoms: 3
Residents assigned to CNAs for temperature checks: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed improperly handling facemask and interviewed regarding infection control practices |
| LPN D | Licensed Practical Nurse | Observed wearing N95 facemask during inspection |
| LPN C | Licensed Practical Nurse | Observed wearing N95 facemask and standing near LPN A |
| Administrator | Interviewed regarding facility infection control policies and staff compliance | |
| CNA A | Certified Nursing Assistant | Interviewed about temperature checks and resident monitoring |
Inspection Report
Routine
Deficiencies: 0
Date: Sep 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 13
Date: Jul 18, 2019
Visit Reason
The inspection was an annual survey of Delta South Nursing & Rehabilitation to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including resident rights, accounting and records of personal funds, notice requirements before transfer/discharge, accuracy of assessments, comprehensive care plans, medication management, nutrition and hydration, and food safety. Several residents were affected by these deficiencies.
Deficiencies (13)
F550 Resident Rights: The facility failed to ensure the dignity of one resident by not covering a large urinary drainage bag for privacy.
F568 Accounting and Records of Personal Funds: The facility failed to follow generally accepted accounting procedures, resulting in unreconciled resident trust account balances.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify the Office of the State Long-Term Care Ombudsman of resident transfers/discharges as required.
F641 Accuracy of Assessments: The facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for one resident.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to ensure individualized care plans for four residents reflecting their needs and conditions.
F657 Care Plan Timing and Revision: The facility failed to develop and revise care plans timely and comprehensively for residents.
F658 Services Provided Meet Professional Standards: The facility failed to follow professional standards for medication storage and administration for one resident.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to use proper transfer techniques and gait belts for one resident, risking injury.
F692 Nutrition/Hydration Status Maintenance: The facility failed to follow dietitian recommendations and ensure adequate nutrition and hydration for one resident.
F698 Dialysis: The facility failed to ensure communication and coordination of care with the dialysis center for one resident.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to conduct required annual in-service education for nurse aides.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure proper use and documentation of psychotropic medications for one resident.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store and prepare food under sanitary conditions, increasing risk of foodborne illness.
Report Facts
Facility census: 37
Sampled residents: 12
Deficiency completion dates: Various corrective action completion dates mostly by 08/29/2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident dignity and care plan issues |
| Bookkeeper | Interviewed regarding resident trust account reconciliation | |
| Administrator | Facility Administrator | Interviewed regarding transfer notifications and care plan oversight |
| MDS Coordinator | Interviewed regarding accuracy of assessments and care plans | |
| Registered Nurse | RN | Interviewed regarding medication administration and dialysis communication |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food safety and sanitation |
| Certified Nursing Assistant | CNA | Observed regarding resident transfers and gait belt use |
Inspection Report
Life Safety
Census: 37
Deficiencies: 10
Date: Jul 18, 2019
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements at Delta South Nursing & Rehabilitation.
Findings
The facility failed to establish and maintain a comprehensive emergency preparedness program and did not meet several life safety code requirements related to means of egress and oxygen storage. Deficiencies affected all residents and staff.
Deficiencies (10)
E001: The facility failed to establish a complete and comprehensive emergency preparedness program including required policies, procedures, training, and testing. The facility census was 37.
E004: The facility failed to develop and maintain an emergency preparedness plan that is reviewed and updated annually, lacking evacuation plans, approval sheets, and checklists. The census was 37.
E009: The facility failed to document efforts to collaborate with local, tribal, regional, State, and Federal emergency preparedness officials. The census was 37.
E015: The facility failed to develop and implement policies and procedures for subsistence needs for staff and patients during emergencies, including food, water, medical, and pharmaceutical supplies. The census was 37.
E025: The facility failed to develop policies and procedures for arrangements with other facilities to maintain continuity of services during emergencies. The census was 37.
E026: The facility failed to include policies describing its role in providing care and treatment at alternate sites under a 1135 waiver. The census was 37.
E037: The facility failed to provide required emergency preparedness training and maintain documentation for all staff. The census was 37.
E039: The facility failed to conduct required emergency preparedness exercises and maintain documentation of testing. The census was 37.
K211: The facility failed to maintain all-weather egress routes free of obstructions, affecting all residents and staff. The census was 37.
K923: The facility failed to properly store empty oxygen cylinders and failed to educate staff on proper storage, potentially affecting all residents and staff. The census was 37.
Report Facts
Facility census: 37
Deficiencies cited: 10
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 11
Date: Jul 11, 2018
Visit Reason
The document is a Plan of Correction submitted by Delta South Nursing & Rehabilitation following a survey conducted on 07/11/2018. It addresses deficiencies cited during the inspection.
Findings
The facility failed to meet multiple regulatory requirements including issuing proper Medicare notices, checking Certified Nurses' Assistant Registry, providing timely transfer and discharge notices, completing quarterly assessments, maintaining accurate Minimum Data Set (MDS) assessments, developing comprehensive care plans, discharge planning, activity programs, and maintaining medication error rates below 5%.
Deficiencies (11)
F582 Medicaid/Medicare Coverage/Liability Notice. The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) and Notice to Medicare Provider Non-coverage (NOMNC) for residents whose Medicare covered services had ended.
F607 Develop/Implement Abuse/Neglect Policies. The facility failed to check the Certified Nurses' Assistant Registry for all staff to ensure they did not have a Federal Indicator for abuse/neglect.
F623 Notice Requirements Before Transfer/Discharge. The facility failed to notify residents and their representatives in writing of transfers and discharges for five sampled residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer. The facility failed to provide written notification of the bed-hold policy to residents or their representatives at the time of transfer for four sampled residents.
F638 Qrtly Assessment at Least Every 3 Months. The facility failed to complete a quarterly assessment for one resident outside of the 12 sampled residents.
F641 Accuracy of Assessments. The facility failed to document a complete and accurate Minimum Data Set (MDS) assessment for two residents.
F657 Care Plan Timing and Revision. The facility failed to update and revise care plans with the interdisciplinary team or involve residents in developing care plans for two residents.
F660 Discharge Planning Process. The facility failed to develop and implement an effective discharge planning process for one resident discharged to home.
F679 Activities Meet Interest/Needs Each Resident. The facility failed to offer weekend activities to two residents and four others outside the sample.
F759 Free of Medication Error Rts 5 Prcnt or More. The facility failed to maintain a medication error rate of less than five percent, with an error rate of 8% affecting two residents.
F809 Frequency of Meals/Snacks at Bedtime. The facility failed to offer bedtime snacks to two residents and four others outside the sample.
Report Facts
Facility census: 37
Medication error rate: 8
Medication error opportunities: 25
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 11, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and Emergency Preparedness requirements for Delta South Nursing & Rehabilitation.
Findings
The facility met the applicable provisions of the 2012 edition of the Life Safety Code and related reference documents. No deficiencies or licensure violations were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Garcia | Administrator | Signed the statement of deficiencies and plan of correction. |
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