Delta Rehabilitation And Healthcare Center

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). During an interview with the ADM on 7/31/25 at 9:00 AM, she acknowledged that the corporate office was responsible for submitting the PBJ information. She confirmed that administrative staffing hours were not included in the data submitted, which contributed to the inaccurate representation of staffing levels.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Further review of the assessment revealed Resident #58’s discharge occurred on 7/1/25, but the MDS was not completed and/or transmitted, which exceeded the required 14-day timeframe. Section Z0500B (completion date) of the MDS was left unsigned. Review of the RAI Manual, Chapter 2, Section 2.7, revealed a Discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 initialed as administered for all days in June. Record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 6/26/25 revealed under Section N, Resident #3 was documented as not taking an anticoagulant medication. A telephone interview with the Regional Case Mix Manager on 7/30/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 . On 7/29/2025 at 11:34 AM during an observation and interview with Resident #36, it was noted that the resident had dark facial hair on her upper lip, approximately one-fourth of an inch long, along with sparce hair on her chin. The resident expressed a desire for more frequent shaving, stating, They usually shave me about every two weeks. I would like it to be clean shaven more often. On 7/30/2025 at 8:27 AM during an interview and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for one (1) of four (4) residents reviewed for ADL's. (Resident #36). Findings include: Review of facility policy titled, Activities of Daily Living (ADL), Supporting revised March 2018, revealed, Policy Statement .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . During an observation and interview on 7/29/2025 at 11:34 AM with Resident #36, it was noted that the resident had dark facial hair, approximately one-fourth of an inch long on her upper lip, along with sparce hair on her chin. The resident expressed a desire for more frequent shaving, stating, They usually shave me about every two weeks. I would like it to be clean shaven more often. During an interview and observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility policy review, and record review, the facility failed to ensure medications were securely stored in the medication room for one (1) of four (4) medication storage areas observed in the facility. Findings include: Review of the facility policy titled “Storage of Medications,” last reviewed [DATE], revealed: “Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . During the initial entrance tour of the facility on [DATE] at 6:10 PM, the medication room door on the A-hallway was observed to be open, with multiple medication cards sitting on a counter visible from the hallway. Also observed was a cup with what appeared to be medication sitting on a small cabinet, also visible from the hallway. During an observation and interview with Registered Nurse (RN) #1 on [DATE] at 6:13 PM, she confirmed the medication room door was open and stated it should never be left open. She stated the medications on the cards on the counter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure adaptive equipment was provided to a resident during dining for one (1) of seven (7) residents reviewed for dining. Resident #3 Review of the facility policy titled “Assistance with Meals” reviewed 6/18/25, revealed, “Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them .” An observation on 7/28/25 at 6:24 PM of Resident #3 revealed she was lying in bed. She was holding a regular spoon and dipping it into a divided plate that contained remnants of the pureed dinner meal. Record review of the 7/28/25 dinner meal ticket revealed Resident #3 was listed to have a weighted spoon and fork. Record review of Resident #3's Diet Requisition Form dated 2/5/25 revealed under, Request for services: Divided plate and weighted utensils. An observation and interview with Registered Nurse (RN) #1 on 7/28/25 at 6:31 PM confirmed Resident #3 did not have weighted utensils. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record reviews, and facility policy reviews, the facility failed to ensure that a resident was free from significant medication errors when Licensed Practical Nurse (LPN) #1 failed to administer prescribed antianxiety medications for one (1) of four (4) residents reviewed for medication administration. Resident #1. Based on interviews and record reviews the State Agency (SA) determined that all corrective actions had been implemented as of 11/14/24 and the facility was in compliance on 11/15/24, prior to the SA entrance on 2/12/25. This was cited as Past Non-Compliance. Findings Include: A record review of the facility policy titled Administering Medications with a revision date of April 2019 revealed Medications are administered in a safe and timely manner and as prescribed .22. The individual administering the medication initials the resident's Medication Administrator Record (MAR) on the appropriate line after giving each medication and before administering the next ones . A review of the facility investigation dated 11/15/24 revealed that on 11/13/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review the facility failed to safely administer a resident's medication when staff failed to check the five rights of medication administration and sign the medication as administered for two (2) of five (5) residents observed during medication administration observations. (Resident #2 and #54). Findings include: A review of the facility policy titled, Administering Medications revised April 2019 revealed, Policy heading: Medications are administered in a safe and timely and as prescribed . Policy Interpretation and implementation: .10. The individual administering the medications checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . 22. The individual administering the medication initials the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones . An observation of the Respiratory Therapist (RT) on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility document reveiew the facility failed to notify the Resident Representative (RR) of a change in a medication dosage for one (1) of four (4) residents reviewed for notification. Resident # 1 Findings include: Record review of a typed document, undated, and signed by the Administrator revealed (Proper name of facility) does not have a policy related to notification of the responsible party of changes in Physician orders or treatments. Record review of the Complaint Intake information provided to the State Agency from the Resident Representative (RR) in reference to Resident #1 revealed she was not notified of the increase in the administration of a Fentanyl patch from 25 micrograms per hour (mcg/hr) to Fentanyl 50 mcg/hr. A phone interview prior to survey entrance on 9/8/23 at 2:00 PM, with Resident #1's RR, revealed all of the information regarding the complaints regarding her father-in-law was in the intake information provided to the agency. Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and facility document review the facility failed to provide a clean environment, as evidenced by staff failure to remove soiled items from the shower room for one (1) of two (2) shower rooms observed for cleanliness. Findings include: Record review of a typed document, undated, and signed by the Administrator revealed (Proper name of facility) does not have a policy related to the cleaning of shower rooms. An observation of the A wing shower room on 9/12/23 at 8:20 AM, revealed four (4) adult briefs saturated with a yellow liquid on the floor of the shower room. Two (2) of the briefs were on an open trash bag and 2 briefs were directly on the floor. A wash cloth with a dry light brown substance on it was draped over the safety bar in the middle shower stall. An observation and interview with Certified Nursing Assistant (CNA) #1 on 9/12/23 at 8:21 AM, revealed housekeeping was responsible for mopping the floors, but the CNA giving showers is responsible for picking up linen and throwing away briefs. She verified that there were 4 soiled adult…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and facility policy review the facility failed to ensure staff administered and removed transdermal Fentanyl patches as ordered for one (1) of four (4) residents reviewed for the use of Fentanyl patches. Resident # 1. Findings include: Record review of the facility policy, titled Administering Medications with a revision date of April 2019, revealed Policy Heading: Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame .10. The individual administering the medication checks the label THREE (3) times to verify .right dosage . Record review of the facility's investigation dated 7/9/23 at 15:56 (3:56 PM), revealed Incident Description: Certified Nursing Assistant (CNA) from previous hospice company notified resident's family whom notified staff that resident had four Fentanyl patches present while she was giving resident a bath. Two (2) of the patches…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide a clean and sanitary environment and a building in good repair, as evidenced by, urine odors, unclean fall mat and resident room floors for four (4) of 65 residents reviewed. Resident #2, #17, #27, and #33. Findings include: Resident #17 An observation, on 10/25/22 at 11:10 AM, revealed there was no doorknob on the inside of Resident #17's room door. This observation revealed Licensed Practical Nurse (LPN) #1 entered the room and when she tried to exit, was unable to open the door. LPN #1 revealed that she forgot that the resident did not have a doorknob. An observation, on 10/25/22 at 11:42 AM, revealed Resident #17 knocking on her room door from the inside. This observation revealed the Director of Nurses (DON) walking past Resident #17's room door and heard the knocking, opened the door, and realized that Resident #17 could not open the door to get out. This observation revealed the DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff and resident interviews, record review and facility policy review, the facility failed provide access to the call light for one (1) of 64 residents observed Resident #2 Findings include: Review of the policy titled, Answering the Call Light, revised March 2021, revealed, Purpose . The purpose of this procedure is to ensure timely responses to the resident's requests and needs. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. An observation and interview on 10/25/22 at 10:58 PM, with Resident #2 revealed he did not have a call light and he could not call for help. Resident #2's call light was observed to be caught under the base board that was lifted and loose from the floor and was laying on the floor under the dresser next to resident's bed. An observation on 10/25/22 at 03:56 PM, revealed that Resident #2's call light was still observed to be stuck under the baseboard on the floor behind his dresser. An observation on 10/26/22 at 08:45 AM, revealed Resident #2's call light was still on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.