Delta Grande Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Delta Grande Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605Apr 8, 2026

  Based on record review and interview, the facility failed to ensure a resident that received psychotropic drugs had a gradual dose reduction was not subjected to chemical restraints for 1(#8) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #8 received a dose reduction for an antipsychotic medication in a timely manner. Findings:Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depressive episodes, and psychotic disturbance.Review of quarterly MDS dated [DATE], Section C, revealed a BIMS score of 9 which indicated moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF692Apr 8, 2026

  Based on observations, record reviews, and interviews, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to ensure the resident received his diet as ordered for 1 (#41) of 2 residents reviewed for nutrition. Findings:Review of the facility policy and procedure dated 01/15/2026: Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol revealed the following, in part:Treatment/Management:1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes.a. […]

• No harm, potential for more than minimal, patternF604Feb 19, 2025

  Resident #61 Review of the medical record revealed sample resident #61 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, heart disease, agitation, pacemaker, and dementia. The resident resided in the locked unit. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively impaired and needed assistance with all activities of daily living. Review of the physical restraint section revealed no restraints documented as being used for the resident. Review of the February 2025 physician's orders revealed no order for a lap tray to the wheelchair to aide in trunk control or the monitoring of the lap tray release every two hours. On 02/17/2025 at 1:45 p.m., observation revealed resident #61 had a lap tray on the wheelchair. […]

• No harm, potential for more than minimal, patternF695Feb 19, 2025

  Based on observation, record review and interview the facility failed to ensure the nurse monitored the resident's oxygen saturation as ordered for 1 (#7) of 1 resident's reviewed with an order to monitor the oxygen saturation every shift. Resident #7 Review of the record for resident #7 revealed diagnoses in part of non-traumatic acute subdural hemorrhage, chronic pain, acute upper respiratory infection, chronic respiratory failure, tracheostomy status, muscle spasm, conversion disorder with seizures or convulsions, flaccid hemiplegia, hemiplegia affecting the left dominant side, and aphasia. […]

• No harm, potential for more than minimal, patternF726Feb 19, 2025

  Based on record review and interviews, the facility failed to ensure that nursing staff were able to demonstrate competencies and skills necessary to care for residents needs for 2 (#2 and #41) of 2 sampled residents. The facility failed to have documentation of peg site care and foley catheter care for resident #2, and failed to have documentation of edema monitoring for resident #41. Findings: Resident #2 Review of the record revealed an admitted [DATE] with diagnoses including Parkinson's disease with dyskinesia, vascular dementia, urinary retention, chronic kidney disease, unspecified protein-calorie malnutrition, schizophrenia, profound intellectual disabilities, urinary tract infection, and acute cystitis without hematuria. […]