Delta South Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Delta South Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF690Aug 31, 2023

  Based on observation, interview and record review, the facility failed to obtain an order for a Foley catheter (a flexible tube inserted into the bladder to drain urine), catheter care and provide a diagnosis for the use of a catheter for two residents (Resident #34 and #42) out of two sampled residents and one resident (#197) outside the sample. The facility failed to ensure placement of the catheter tubing and drainage bags for one resident (Resident #42) out of two sampled residents and one resident (Resident #197) outside the sample. […]

• No harm, potential for more than minimal, patternF755Aug 31, 2023

  Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two medication carts and one medication storage room. This had the potential to affect all residents. The facility census was 45. Review of the facility's policy titled, Controlled Substances, dated April 2019, showed: - The facility will follow all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances; - Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; - Controlled medications are counted at the end of each shift. […]

• No harm, potential for more than minimal, patternF880Aug 31, 2023

  Based on observation, interview and record review, the facility failed to perform hand hygiene between glove changes during incontinent care for two residents (Residents #18 and #21) out of four sampled residents and one resident (Resident #4) outside the sample. The facility failed to perform hand hygiene between residents when medications were administered for three residents (Residents #33, #197, and #198) out of three sampled residents. The facility failed to ensure in the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) by not completing the admission TB screening and/or a yearly risk assessment for symptoms for five residents (Residents #3, #7, #12, #18, and #34)… […]

• No harm, potential for more than minimal, patternF641Jul 30, 2021

  Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Resident #17, #18, and #39) and five residents (Resident #3, #7, #24, #32, and #38) outside the 13 sampled residents. The facility census was 50. 1. Observation of Resident #3 on 7/28/21 at 1:48 P.M., showed two quarter sized bedrails (one-quarter the length of a full size bedrail, not considered a restraint (a device used to restrict movement), up on both sides of the bed. […]

• No harm, potential for more than minimal, patternF812Jul 30, 2021

  Based on observation, interview, and record review the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices affected one resident (Resident #40) outside the sample and had the potential to affect all residents. The facility census was 50. Observation of the bread storage rack, on 7/27/21 at 9:30 A.M., showed: - One package of [NAME] Spunkmeyer banana muffins, opened and not dated when opened; - One loaf of [NAME] cinnamon bread opened and not dated when opened. […]