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Deficiency Records for Delta South Nursing and Rehabilitation
A list of the most recent deficiencies for Delta South Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Delta South Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2023-08-31 | 2023-10-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-31 | 2023-10-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-31 | 2023-10-06 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-31 | 2023-10-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-31 | 2023-10-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-31 | 2023-10-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-31 | 2023-10-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-31 | 2023-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-10-06 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-08-31 | 2023-10-06 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-30 | 2021-09-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-30 | 2021-09-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-07-30 | 2021-09-10 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-07-30 | 2021-09-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-30 | 2021-09-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-07-30 | 2021-09-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-30 | 2021-09-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-30 | 2021-09-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-30 | 2021-09-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-30 | 2021-09-10 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-07-30 | 2021-09-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-30 | 2021-09-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-30 | 2021-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-30 | 2021-09-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-30 | 2021-09-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-07-30 | 2021-09-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-30 | 2021-09-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-30 | 2021-09-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-30 | 2021-09-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-18 | 2019-08-29 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-07-18 | 2019-08-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-18 | 2019-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-18 | 2019-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-18 | 2019-08-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-18 | 2019-08-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-18 | 2019-08-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-18 | 2019-08-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-18 | 2019-08-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-18 | 2019-08-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-07-18 | 2019-08-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-18 | 2019-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-18 | 2019-08-29 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-18 | 2019-08-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-18 | 2019-08-29 | N |
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