DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record review, the facility failed to issue Skilled Nursing | |
F 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Based on record review and interview, the facility staff failed to check the Certified |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) Review of the facility personnel records showed the facility hired: – Food Service Staff (FSS) D on 4/9/18, but did not check the CNA Registry; – Certified Nurse Aide (CNA) E on 6/5/18, did not check the CNA Registry. During an interview on 7/10/18 at 10:00 A.M., the Administrator said: – The CNA Registry for Employee D and E had not been checked; – The registry is checked for new employees before hire but these were missed. | |
F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) During an interview on 07/11/18 at 9:10 A.M., the Administrator said they have not been notifying the resident, the resident’s representative or Ombudsman in writing of the reason for transfer because they were not aware they needed to. Record review of the facility’s Discharge/Transfer policy, undated, showed: – The facility will notify the resident and his/her representative anytime the resident is discharged from the facility due to an emergency; – The charge nurse will give a copy to the resident and make a copy and place it in the residents chart; – If the residents representative is not present at the time of discharge, the reason for discharge to be mailed to them with an addressed and stamped envelope for return to the facility; – Social Services will place the signed copy in the residents file. | |
F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) the transfer on 6/11/18. During an interview on 7/11/18 at 9:11 A.M., the Administrator said they have not been notifying the resident and/or the representative of the bed hold policy at the time of discharge. Record review of the facility’s Bed Hold Notification policy, undated, showed: – At the time of emergency discharge from the facility, the resident will be given the Facility Bed Hold Policy; – The charge nurse will make a copy and place it in the residents chart; – If the residents representative is not present at the time of discharge, a bed hold authorization form will be mailed to them with an addressed and stamped envelope for return to the facility; – Social Services will place the signed copy in the residents file. | |
F 0638 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Assure that each resident’s assessment is updated at least once every 3 months. Based on interview and record review, the facility failed to complete a quarterly | |
F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives an accurate assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) – The resident received an anticoagulant seven days during the last seven days. During an interview on 7/9/18 at 3:11 P.M., the MDS Coordinator said the resident was on an anticoagulant but it was discontinued back in January. It was just missed so it is coded wrong. 2. Record review of Resident #33’s nurses’ notes showed: – On 4/26/18 the resident had a fall; – On 4/27/18 the resident transferred and admitted to the hospital; – On 5/4/18 the resident readmitted to the facility after surgery to repair a left [MEDICAL CONDITION]. Record review of resident’s significant change MDS, dated [DATE], showed: – No fall with major injury since admission or prior assessment. During an interview on 7/10/18 at 1:48 P.M., the MDS coordinator said, she just misunderstood and didn’t realize it should have been coded for a fall with major injury at this time. During an interview on 7/11/18 at 9:20 A.M., the Administrator said she would expect the MDS to be coded according to the residents current status. Review of the facility’s Resident Assessment Instrument (a standardized tool to assess residents in long term care settings) MDS policy dated 2/2018, showed: – The process includes accurate and timely completion of the required assessments. | |
F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) Record review of the care plan, dated 11/27/17, showed: – Requires staff assistance related to generalized weakness; – [DIAGNOSES REDACTED]. – Risk for cognitive loss related to intermittent confusion, falls, constipation, adverse effects of [MEDICAL CONDITION] drug medication use, and incontinence; – Occasional pain; – Potential for pressure ulcer development related to immobility. During an interview on 07/09/18 10:19 A.M., Resident #16 said did not know what a care plan was and had never been ask to attend a meeting. During an interview on 7/10/18 at 10:25 P.M., the MDS Coordinator said they were not having any interdisciplinary team quarterly care plan meetings. He/she had not been involving the residents in developing the care plans and making decisions regarding their care. During an interview on 7/10/18 at 11:40 A.M., the Director of Nursing (DON) said she would expect the the residents to be involved in developing the care plans. During an interview on 7/11/18 at 10:20 A.M., the Administrator said there should be a care plan meeting on admission, annual, quarterly, and any significant change MDS. Record review of the facility’s Care Plan Policy, revised 2/2018, showed: – Care planning is critical to the quality of service in any care home; – Planned action should reflect personal choices identified through interview with the individual, family, interdisciplinary team, and the MDS assessment and Care assessment Areas (CAA’s); – The care plan should be the means by which the identified needs and wishes of the individual are recorded; – It ensures that care is offered consistently by well-informed staff, aware of the individual care needs; – Care plan will be updated with quarterly, annual, and significant change MDS’s; – The care plan it itself is a guide for care listing both strengths and weakness, with individualized goals and interventions to accomplish them. | |
F 0660 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Plan the resident’s discharge to meet the resident’s goals and needs. Based on interview and closed record review, the facility failed to ensure a discharge |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0660 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) During an interview on 7/11/18 at 10:00 A.M., the Director of Nursing (DON) said: – He/she did not know if a discharge plan had been completed on the resident; – A discharge plan should have been completed on the resident. Record review of the facility’s undated Discharge Summary and Plan showed: – When a resident’s discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment; – When the facility anticipates a resident’s discharge to a private residence, another nursing care facility, a discharge summary and post discharge plan will be developed which will assist the resident to his or her new living environment. | |
F 0661 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on interview and closed record review, the facility failed to complete a | |
F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide activities to meet all resident’s needs. Based on interview, and record review the facility failed to offer weekend activities to |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) – They have two designated areas where they keep the puzzles, word games and cards for the residents to use; – Most of the time on the weekends the residents do the activities themselves since he/she is not there every weekend; – The residents have brought it up to him/her that they would like someone to be there on the weekends to help them with activities and he/she is working on that. Record review of the facility’s (MONTH) (YEAR) activity calendar showed: – Word search activity for Saturdays; – Magazine reading activity for Sundays. Record review of the facility’s (MONTH) (YEAR) activity calendar showed: – Word search activity for Saturdays and coffee and donuts for one Saturday; – Magazine reading activity for Sundays. Record review of the facility’s (MONTH) (YEAR) activity calendar showed; – Word search activity for Saturdays; – Magazine reading activity for Sundays and a movie scheduled for one Sunday. Record review of the facility’s undated Activity Programs Policy showed:- Activity programs designed to meet the needs of each resident are available on a daily basis; – Are offered at hours of convenient to the residents, including evenings, holidays and weekends. | |
F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) symptomatic with dizziness. Record review of the the Medications Administration record (MAR), dated (MONTH) (YEAR), showed: – [MEDICATION NAME] (treat high blood pressure and heart failure) 20 mg one tablet daily at 8:00 A.M., and 8:00 P.M., dated 6/27/18; – Call the physician if the systolic blood pressure (SBP) (the amount of pressure in your arteries during the contraction of your heart muscle) is less than 110 or the resident is symptomatic with dizziness. Medication administration observations on 7/10/19 at 8:24 A.M., showed: – CMT G punch out the last tablet from a medication card that label read [MEDICATION NAME] 10 mg take one by mouth daily; – CMT G said he/she needed another 10 mg tablet to make 20 mg of [MEDICATION NAME]; – CMT G pulled a new medication card, punched out one tablet into the medication cup; – The label on the new medication card read [MEDICATION NAME] 20 mg; – Total [MEDICATION NAME] 30 mg; – The surveyor stopped CMT G from administering the 30 mg of [MEDICATION NAME] to the resident. During an interview on 7/10/18 at 8:30 A.M., CMT G said he/she thought the second medication card was the same as the first [MEDICATION NAME] 10 mg card. He/she did not read the dose on the the card only the name of the medication. During an interview on 7/11/18 at 8:45 A.M., the Director of Nursing said all medication label should be read and match the orders before giving any medications. CMT G should have read the labels on the medication cards and the orders. Record review of the Identifying and Managing Medication Errors and Adverse Consequences Policy, dated 11/2017, showed: – Strive to prevent medication errors and adverse medication consequences and to identify and mange them appropriately when they occur. – Follow relevant clinical guidelines and manufacturer’s specifications for use, dose, administration, duration, and monitoring for the medication; – The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident attending physician immediately; – Nursing staff will document appropriately detailed accounts of any incidents. | |
F 0809 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review the facility failed to offer bedtime |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265862 |
| (X3) DATE SURVEY COMPLETED 07/11/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER DELTA SOUTH NURSING & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 640 COLONEL GEORGE E DAY PARKWAY | |||||||||
For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. |
(X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
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F 0809 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) – They get snacks during the daytime but they sure don’t get any snacks at bedtime; – They would like to have a snack at bedtime. During observation on 7/10/18 from 6:55 P.M. to 8:05 P.M., showed: – Staff did not ask Residents #4, #6, #14, #15, #23,and #27 if they wanted a bedtime snack; – A tray containing one pitcher of juice and four graham crackers sat on the counter of the nurse’s station for the 300 and 400 resident halls; During an interview on 7/10/18 at 7:55 P.M., Certified Nurse Aide (CNA) A said: – Bedtime snacks are set out on the counter at the nurse’s station for the residents to get themselves; – He/she usually does not offer the residents a bedtime snack. During an interview on 7/10/18 at 7:57 P.M., Licensed Practical Nurse (LPN) C said: – The bedtime snacks are set out on the counter at the nurse’s station for the residents to get themselves; – Usually staff don’t ask the residents if they want a bedtime snack. During an interview on 7/10/18 at 8:00 P.M., CNA B said: – Bedtime snacks are usually set out on the counter at the nurse’s station for the residents to get themselves; – He/she usually does not offer the residents a bedtime snack, but they do have access to the kitchen at night, so if a resident request a snack, they can go to the kitchen and get one for them. During an interview on 7/11/18 at 10:00 A.M., the Administrator said: – She thought the residents were being asked at night if they want a bedtime snack; – The residents will be offered a bedtime snack. Record review of the facility’s policy and procedure for snacks dated 3/20/17 showed: – It is the policy of this home that all residents will be offered HS snack (bedtime or after evening meal) on a daily basis and that acceptance or refusal of this snack will be documented by nursing services; – Snacks will be delivered from dietary to nursing services prior to the kitchen’s closing for the evening. | |