DELTA SOUTH NURSING & REHABILITATION

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 Facility Advanced Beneficiary Notices (SNFABN) when a resident’s Medicare covered services had ended and Notice to Medicare Provider Non-coverage (NOMNC), for two residents (Residents #86 and #87) out of three sampled residents. The facility census was 37. 1. Review of SNF Beneficiary Protection Notification for Resident #86 showed: – The resident was discharged from skilled services on 5/22/18; – The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted; – No SNFABN letter provided to the resident; – No NOMNC letter provided to the resident. 2. Review of SNF Beneficiary Protection Notification for Resident #87 showed: – The resident was discharged from skilled services on 1/02/18, but remained in the facility; – The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted; – No SNFABN letter provided to the resident; – No NOMNC letter provided to the resident. During an interview on 7/10/18 at 9:46 A.M., the Administrator said she was not aware that a SNFABN letter needed to be filled out and signed along with the NOMNC letter if a resident was discharged from Medicare skilled services and had skilled days remaining. Record review of the facility’s SNFABN policy, undated, showed: -The SNFABN provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. Record review of the facility’s NOMNC form, dated 12/31/11 showed: – Your Medicare provider and /or health plan have determined that Medicare probably will not pay for your current service after the effective date indicated above. – You may have to pay for any services you receive. – Right to appeal this decision; – How to ask for an immediate appeal.
	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 Nurses’ Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected two of five sampled staff. The facility census was 37. Record review of the facility’s undated Reporting Abuse and Neglect Policy showed: – Upon hire and prior to resident contact, all employees will have the Missouri Department of Health and Senior Services Certified Nurse Assistant Registry Search checked to ensure employee has not been found guilty of any criminal acts that would prevent them from working in the Long Term Care Setting in accordance with guidelines set forth by the Missouri Department of Health and Senior Services.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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
Facility Advanced Beneficiary Notices (SNFABN) when a resident’s Medicare covered services
had ended and Notice to Medicare Provider Non-coverage (NOMNC), for two residents
(Residents #86 and #87) out of three sampled residents. The facility census was 37.
1. Review of SNF Beneficiary Protection Notification for Resident #86 showed:
– The resident was discharged from skilled services on 5/22/18;
– The facility initiated the discharge from Medicare Part A Services when benefit days
were not exhausted;
– No SNFABN letter provided to the resident;
– No NOMNC letter provided to the resident.
2. Review of SNF Beneficiary Protection Notification for Resident #87 showed:
– The resident was discharged from skilled services on 1/02/18, but remained in the
facility;
– The facility initiated the discharge from Medicare Part A Services when benefit days
were not exhausted;
– No SNFABN letter provided to the resident;
– No NOMNC letter provided to the resident.
During an interview on 7/10/18 at 9:46 A.M., the Administrator said she was not aware that
a SNFABN letter needed to be filled out and signed along with the NOMNC letter if a
resident was discharged from Medicare skilled services and had skilled days remaining.
Record review of the facility’s SNFABN policy, undated, showed:
-The SNFABN provides information to the beneficiary so that he/she can decide whether or
not to get the care that may not be paid for by Medicare and assume financial
responsibility.
Record review of the facility’s NOMNC form, dated 12/31/11 showed:
– Your Medicare provider and /or health plan have determined that Medicare probably will
not pay for your current service after the effective date indicated above.
– You may have to pay for any services you receive.
– Right to appeal this decision;
– How to ask for an immediate appeal.

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
Nurses’ Assistant (CNA) Registry for all staff to ensure they did not have a Federal
Indicator (a marker given by the federal government to individuals who have committed
abuse/neglect). This affected two of five sampled staff. The facility census was 37.
Record review of the facility’s undated Reporting Abuse and Neglect Policy showed:
– Upon hire and prior to resident contact, all employees will have the Missouri Department
of Health and Senior Services Certified Nurse Assistant Registry Search checked to ensure
employee has not been found guilty of any criminal acts that would prevent them from
working in the Long Term Care Setting in accordance with guidelines set forth by the
Missouri Department of Health and Senior Services.

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete

Event ID: YL1O11

Facility ID: 265862

If continuation sheet
Page 1 of 10

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 Based on interview and record review, the facility failed to notify the resident and the resident’s representative in writing of a facility initiated transfer and failed to notify a representative of the Office of the State Long-Term Care Ombudsman when five residents (Resident #3, #28, #33, #37, and #136) of five sampled residents were transferred to the hospital. The facility census was 37. 1. Record review of Resident #3’s nurse’s notes showed: – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation of a letter notifying the resident, the resident’s representative or the Ombudsman’s office of the resident’s transfer to the hospital. 2. Record review of Resident #28’s nurses notes showed: – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation of a letter notifying the resident, the resident’s representative or the Ombudsman’s office of the resident’s transfer to the hospital. 3. Record review of Resident #33’s nurses notes showed: – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation of a letter notifying the resident, the resident’s representative or the Ombudsman’s office of the resident’s transfer to the hospital. 4. Record review of Resident #37’s nurses notes showed: – The resident transferred to the hospital on [DATE] with no return anticipated. Review of the resident’s record showed no documentation of a letter notifying the resident, the resident’s representative or the Ombudsman’s office of the resident’s transfer to the hospital. 5. Record review of Resident #136’s nurses notes showed: – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation of a letter notifying the resident, the resident’s representative or the Ombudsman’s office of the resident’s transfer to the hospital.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative in writing of a facility initiated transfer and failed to notify
a representative of the Office of the State Long-Term Care Ombudsman when five residents
(Resident #3, #28, #33, #37, and #136) of five sampled residents were transferred to the
hospital. The facility census was 37.
1. Record review of Resident #3’s nurse’s notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation of a letter notifying the
resident, the resident’s representative or the Ombudsman’s office of the resident’s
transfer to the hospital.
2. Record review of Resident #28’s nurses notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation of a letter notifying the
resident, the resident’s representative or the Ombudsman’s office of the resident’s
transfer to the hospital.
3. Record review of Resident #33’s nurses notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE];
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation of a letter notifying the
resident, the resident’s representative or the Ombudsman’s office of the resident’s
transfer to the hospital.
4. Record review of Resident #37’s nurses notes showed:
– The resident transferred to the hospital on [DATE] with no return anticipated.
Review of the resident’s record showed no documentation of a letter notifying the
resident, the resident’s representative or the Ombudsman’s office of the resident’s
transfer to the hospital.
5. Record review of Resident #136’s nurses notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation of a letter notifying the
resident, the resident’s representative or the Ombudsman’s office of the resident’s
transfer to the hospital.

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 Based on interview and record review, the facility failed to provide written notification to the resident or the resident’s representative regarding the bed-hold policy for four residents (Resident #3, #28, #33 and #136) of five sampled residents. The facility census was 37. 1. Record review of Resident #3’s nurses notes showed: – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation the resident or the resident’s representative was informed in writing of the facility’s bed hold policy at the time of the transfer on 3/16/18. 2. Record review of Resident #28’s nurses notes showed: – The resident transferred to the hospital 4/27/18 and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation the resident or the resident’s representative was informed in writing of the facility’s bed hold policy at the time of the transfer on 4/27/18. 3. Record review of Resident #33’s nurses notes showed: – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation the resident or the resident’s representative was informed in writing of the facility’s bed hold policy at the time of the transfer on 4/27/18 and 5/10/18. 4. Record review of Resident #136’s nurses notes showed: – The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation the resident or the resident’s representative was informed in writing of the facility’s bed hold policy at the time of

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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**
Based on interview and record review, the facility failed to provide written notification
to the resident or the resident’s representative regarding the bed-hold policy for four
residents (Resident #3, #28, #33 and #136) of five sampled residents. The facility census
was 37.
1. Record review of Resident #3’s nurses notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of
the transfer on 3/16/18.
2. Record review of Resident #28’s nurses notes showed:
– The resident transferred to the hospital 4/27/18 and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of
the transfer on 4/27/18.
3. Record review of Resident #33’s nurses notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE];
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of
the transfer on 4/27/18 and 5/10/18.
4. Record review of Resident #136’s nurses notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 assessment for one resident (Resident #1) outside of the 12 sampled residents. The facility census was 37. 1. Record review of Resident #1’s Minimum Data Set ((MDS) a federally mandated assessment completed by facility staff) assessments showed: – An admission MDS was completed on 11/8/17; – A quarterly MDS completed on 2/7/18; – No MDS was completed between 2/8/18 and 7/10/18. During an interview on 7/10/18 at 2:33 P.M., the MDS Coordinator said apparently the data base just didn’t show he/she was scheduled for one and she didn’t realize one was due. During an interview on 7/11/18 at 9:15 A.M. the Administrator said that the system did not generate that the MDS was due and it was just missed. In the future, they will have a back-up in place so they won’t be missed. Review of the facility’s Resident Assessment Instrument (RAI) (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; – Quarterly assessments as guidelines in the RAI manual.
	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 Based on interview, and record review, the facility failed to document a complete and accurate, Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility for two (Resident #15 and #33) of 12 sampled residents. The facility census was 37. 1. Record review of Resident#15’s Physician order [REDACTED]. – No order for an anticoagulant (medication that prevents or reduces the coagulation of blood). Record review of the quarterly MDS dated [DATE], showed:

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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
assessment for one resident (Resident #1) outside of the 12 sampled residents. The
facility census was 37.
1. Record review of Resident #1’s Minimum Data Set ((MDS) a federally mandated assessment
completed by facility staff) assessments showed:
– An admission MDS was completed on 11/8/17;
– A quarterly MDS completed on 2/7/18;
– No MDS was completed between 2/8/18 and 7/10/18.
During an interview on 7/10/18 at 2:33 P.M., the MDS Coordinator said apparently the data
base just didn’t show he/she was scheduled for one and she didn’t realize one was due.
During an interview on 7/11/18 at 9:15 A.M. the Administrator said that the system did not
generate that the MDS was due and it was just missed. In the future, they will have a
back-up in place so they won’t be missed.
Review of the facility’s Resident Assessment Instrument (RAI) (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;
– Quarterly assessments as guidelines in the RAI manual.

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**
Based on interview, and record review, the facility failed to document a complete and
accurate, Minimum Data Set (MDS), a federally mandated assessment to be completed by the
facility for two (Resident #15 and #33) of 12 sampled residents. The facility census was
37.
1. Record review of Resident#15’s Physician order [REDACTED].
– No order for an anticoagulant (medication that prevents or reduces the coagulation of
blood).
Record review of the quarterly MDS dated [DATE], showed:

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 Based on interview and record review, the facility failed to update and revise care plans with the interdisciplinary team or involve the residents in developing the care plan and making decisions about his/her care for two residents (Resident #11 and #16) out of 12 sampled residents. The facility census was 37. 1. Record review of Resident #11’s Minimum Data Set ((MDS) (a federally mandated assessment instrument completed by facility staff), showed: – Admission MDS completed 10/19/17; – Quarterly MDS completed 1/18/18 and 4/20/18. Record review of the care plan, dated 11/06/17, showed: – The resident wants to smoke every chance that is available; – Limited mobility due to right above the knee amputation; – [DIAGNOSES REDACTED]. – Risk for falls, constipation due to decreased mobility and chronic pain, adverse bleeding related to receiving anticoagulant medication daily, adverse effects of [MEDICAL CONDITION] drug use, pressure ulcer, and severe pain; – Has a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder. During an interview on 7/09/18 at 11:09 A.M., Resident #11 said he/she had never heard of a care plan meeting and had never been asked to attend a meeting concerning his/her care but would like to attend a meeting. 2. Record review of Resident #16’s MDS’s, showed: – Admission MDS completed 11/09/17; – Quarterly MDS completed 2/01/18 and 5/04/18.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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**
Based on interview and record review, the facility failed to update and revise care plans
with the interdisciplinary team or involve the residents in developing the care plan and
making decisions about his/her care for two residents (Resident #11 and #16) out of 12
sampled residents. The facility census was 37.
1. Record review of Resident #11’s Minimum Data Set ((MDS) (a federally mandated
assessment instrument completed by facility staff), showed:
– Admission MDS completed 10/19/17;
– Quarterly MDS completed 1/18/18 and 4/20/18.
Record review of the care plan, dated 11/06/17, showed:
– The resident wants to smoke every chance that is available;
– Limited mobility due to right above the knee amputation;
– [DIAGNOSES REDACTED].
– Risk for falls, constipation due to decreased mobility and chronic pain, adverse
bleeding related to receiving anticoagulant medication daily, adverse effects of [MEDICAL
CONDITION] drug use, pressure ulcer, and severe pain;
– Has a suprapubic catheter (a surgically created connection between the urinary bladder
and the skin used to drain urine from the bladder.
During an interview on 7/09/18 at 11:09 A.M., Resident #11 said he/she had never heard of
a care plan meeting and had never been asked to attend a meeting concerning his/her care
but would like to attend a meeting.
2. Record review of Resident #16’s MDS’s, showed:
– Admission MDS completed 11/09/17;
– Quarterly MDS completed 2/01/18 and 5/04/18.

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 plan which addressed goals and needs and involved the resident or resident representative and the interdisciplinary team(a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for the resident) in developing a discharge plan for one resident (Resident #36) of one sampled discharged resident. The facility census was 37. 1. Review of Resident #36’s closed record showed: – Resident discharged to home on 5/10/18; – No documentation that addressed the resident’s preference and potential for future discharge; – No documentation of an assessment for the resident’s continued care needs; – No documentation of an interdisciplinary team post discharge plan of care for the resident and/or the resident representative; – No documentation of how care would be coordinated between multiple care givers.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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
plan which addressed goals and needs and involved the resident or resident representative
and the interdisciplinary team(a group of health care professionals from diverse fields
who work in a coordinated effort toward a common goal for the resident) in developing a
discharge plan for one resident (Resident #36) of one sampled discharged resident. The
facility census was 37.
1. Review of Resident #36’s closed record showed:
– Resident discharged to home on 5/10/18;
– No documentation that addressed the resident’s preference and potential for future
discharge;
– No documentation of an assessment for the resident’s continued care needs;
– No documentation of an interdisciplinary team post discharge plan of care for the
resident and/or the resident representative;
– No documentation of how care would be coordinated between multiple care givers.

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 comprehensive discharge summary for one resident (Resident #36) of one sampled discharged resident. The facility census was 37. Record review of Resident #36’s closed medical record showed the resident discharged to the community on 5/10/18 and staff did not complete a comprehensive discharge summary. 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; – There should have been a comprehensive discharge summary completed by the staff. 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 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 two residents (Residents #6 and #15) of 12 sampled residents and four residents (Resident #4, #14, #23, and #27) outside the sample. The facility census was 37. 1. During a group interview on 7/10/18 at 10:15 A.M., Residents #4, #6, #14, #15, #23, and #27 said: – They do not have very much to do on Saturdays and Sundays; – There are very little activities to do on the weekend; – They would like more activities to do on the weekend. During an interview on 7/11/18 at 8:45 A.M., the Activity Director said: – He/she works on the weekend every fifth Saturday and Sunday; – He/she usually has the charge nurse on the weekend to get the puzzles and word games and other card games for the residents to use; – Some of the residents can go and get the games themselves;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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
comprehensive discharge summary for one resident (Resident #36) of one sampled discharged
resident. The facility census was 37.
Record review of Resident #36’s closed medical record showed the resident discharged to
the community on 5/10/18 and staff did not complete a comprehensive discharge summary.
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;
– There should have been a comprehensive discharge summary completed by the staff.
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 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
two residents (Residents #6 and #15) of 12 sampled residents and four residents (Resident
#4, #14, #23, and #27) outside the sample. The facility census was 37.
1. During a group interview on 7/10/18 at 10:15 A.M., Residents #4, #6, #14, #15, #23, and
#27 said:
– They do not have very much to do on Saturdays and Sundays;
– There are very little activities to do on the weekend;
– They would like more activities to do on the weekend.
During an interview on 7/11/18 at 8:45 A.M., the Activity Director said:
– He/she works on the weekend every fifth Saturday and Sunday;
– He/she usually has the charge nurse on the weekend to get the puzzles and word games and
other card games for the residents to use;
– Some of the residents can go and get the games themselves;

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 Based on observation, interview, and record review the facility failed to maintain an error rate of less than five percent (%). There were 25 opportunities with two errors made, for an error rate of 8%. This affected two residents (Resident #28 and #88) and had the potential to affect all residents. The facility census was 37. 1. Record review of Resident #88’s, physician’s orders [REDACTED]. – [MEDICATION NAME] (dilates blood vessels so the blood can flow more easily to the heart) extended release (ER) 30 milligram (mg), take ½ tablet once daily; – [DIAGNOSES REDACTED]. Record review of the Medication Administration Record, [REDACTED] – [MEDICATION NAME] mono ER 30 mg 1/2 tab daily. Observation on 7/10/18 at 8:05 A.M., showed: – The label on the unit dose medication package read [MEDICATION NAME] mono ER 30 mg tab 1/2; – Certified Medication Technician (CMT) G punched out one 30 mg tablet of [MEDICATION NAME]; – The surveyor stopped CMT G from administering [MEDICATION NAME] 30 mg to Resident #88. During an interview on 7/10/18 at 8:10 A.M., CMT G said he/she was not aware that he/she was only to give a 1/2 of a tablet but he/she could see now the label did say to give only a ½ tablet. 2. Record review of Resident #28’s, POS 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

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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**
Based on observation, interview, and record review the facility failed to maintain an
error rate of less than five percent (%). There were 25 opportunities with two errors
made, for an error rate of 8%. This affected two residents (Resident #28 and #88) and had
the potential to affect all residents. The facility census was 37.
1. Record review of Resident #88’s, physician’s orders [REDACTED].
– [MEDICATION NAME] (dilates blood vessels so the blood can flow more easily to the heart)
extended release (ER) 30 milligram (mg), take ½ tablet once daily;
– [DIAGNOSES REDACTED].
Record review of the Medication Administration Record, [REDACTED]
– [MEDICATION NAME] mono ER 30 mg 1/2 tab daily.
Observation on 7/10/18 at 8:05 A.M., showed:
– The label on the unit dose medication package read [MEDICATION NAME] mono ER 30 mg tab
1/2;
– Certified Medication Technician (CMT) G punched out one 30 mg tablet of [MEDICATION
NAME];
– The surveyor stopped CMT G from administering [MEDICATION NAME] 30 mg to Resident #88.
During an interview on 7/10/18 at 8:10 A.M., CMT G said he/she was not aware that he/she
was only to give a 1/2 of a tablet but he/she could see now the label did say to give only
a ½ tablet.
2. Record review of Resident #28’s, POS 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

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 snacks to two residents (Residents #6 and #15) of 12 sampled residents and four residents (Resident #4, #14, #23, and #27) outside the sample. The facility census was 37. 1. During group interview on 7/10/18 at 10:15 A.M., Residents #4, #6, #14, #15, #23, and #27 said: – Staff did not ask if they wanted a bedtime snack; – They could not remember the last time staff asked them for a bedtime snack;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

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
snacks to two residents (Residents #6 and #15) of 12 sampled residents and four residents
(Resident #4, #14, #23, and #27) outside the sample. The facility census was 37.
1. During group interview on 7/10/18 at 10:15 A.M., Residents #4, #6, #14, #15, #23, and
#27 said:
– Staff did not ask if they wanted a bedtime snack;
– They could not remember the last time staff asked them for a bedtime snack;

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(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
SIKESTON, MO 63801

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)
	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.

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