Delta Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Delta Rehabilitation and Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jul 31, 2025

  Based on staff interview, record review, and Payroll-Based Journal (PBJ) staffing data review, the facility failed to submit PBJ data accurately to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. 2nd Quarter, 2025 (January 1 through March 31, 2025) Findings Include: Review of the typed statement on facility letterhead dated 7/30/25 and signed by the Administrator (ADM) revealed that the facility did not have a policy on PBJ submission. Record review of the “PBJ Staffing Data Report” revealed the facility triggered for excessively low weekend staffing for the 2nd quarter, 2025 (January 1 through March 31, 2025). […]

• No harm, potential for more than minimal, patternF689Oct 28, 2022

  Based on observation, staff and resident interview, policy review and record review, the facility failed to prevent the likelihood of an injury related to a fall, during a van transport, as evidenced by failure to use chest and lap seat belts for three (3) of four (4) residents reviewed for van transport. Resident #11, Resident #25, and Resident # 41. Findings include: Resident #41 Review of the facility policy titled, Driver and Vehicle Safety Policy, revised 2015, revealed, .Seat belts are worn at all times . Residents are properly secured at all times. Record review of the facility incident report revealed Resident #41 had an incident on 10/1/22 when he fell out of his wheelchair while riding in the nursing facility's transport van from an appointment at the [CONDITION(S)] unit. […]

• No harm, potential for more than minimal, isolatedF640Jul 31, 2025

  Based on staff interview and record review, the facility failed to ensure a Discharge Minimum Data Set (MDS) was completed and transmitted within the required timeframes in accordance with the Resident Assessment Instrument (RAI) Manual for one (1) of 21 residents reviewed for MDS assessments. (Resident #58) Findings include: Review of a typed statement on facility letterhead dated 7/30/25 revealed the facility does not have a policy on MDS completion. The statement further indicated that the interdisciplinary team follows the RAI manual. Record review of the Discharge MDS for Resident #58 revealed the assessment was not completed or transmitted within the timeframes outlined in the RAI User’s Manual. […]

• No harm, potential for more than minimal, isolatedF641Jul 31, 2025

  Based on staff interview and record review, the facility failed to accurately complete section N of the Minimum Data Set (MDS) for a resident taking anticoagulant medication for one (1) of five (5) residents reviewed for unnecessary medications. Resident #3 Findings include: Review of the typed statement on facility letterhead read, “(Proper name of the facility) does not have a policy on MDS completion. (Proper Name of the facility's) Interdisciplinary Team follows the RAI (Resident Assessment Instrument) manual.” Record review of Resident #3’s June 2025 Medication Administration Record (MAR) revealed an order dated 3/1/25, “Rivaroxaban (blood thinner) oral tablet 10 mg (milligrams) Give 10 mg (milligrams) via PEG (Percutaneous Endoscopic Gastrostomy) tube in the morning,” which was… […]

• No harm, potential for more than minimal, isolatedF656Jul 31, 2025

  Based on observation, staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for one (1) of the twenty-one resident care plans reviewed. (Resident #36). Findings Include Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered with review date January 2023, revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . […]