Delta Healthcare & Wellness Center, LP

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) when medical records were not provided to the responsible party (R/P) for one of 18 sampled residents (Resident 1) as requested. This failure resulted in Resident 1's R/P not being provided with Resident 1's medical records.

Inspectors wroteBased on interview and record review, the facility failed to provide an itemized statement per the admission agreement to one of 18 sampled (Resident 1) residents when requested. This failure had the potential for Resident 1 to be unaware of services she was being billed for.

Inspectors wroteBased on interview and record review, the facility failed to collaborate care with hospice (specialized form of medical care provided to individuals with terminal illness) for one of 18 sampled residents (Resident 1) when a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was identified to Resident 1's lower back by hospice, and the facility was unaware. This failure had the potential for Resident 1's pressure ulcer to go untreated and worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were used by the discard date, dated when opened, and labeled. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent for two of five sampled residents (Resident 33 and Resident 6). This failure resulted in Resident 33 and Resident 6 receiving medications unsafely and had the potential for adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards for two of eight residents (Resident 7 and Resident 21). This failure had the potential to spread illness to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 196), was assisted to the bathroom when she asked for help. This failure resulted in Resident 196 being frustrated and had the potential for increased incontinence (inability to control urination and/or bowel) and decreased mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of the Advance Directive (legal document outlining a person's healthcare and end of life wishes should the person become unable to verbalize those wishes) status was accurate for one of four sampled residents (Resident 10). This failure resulted in an inaccurate medical record and had the potential for Resident 10's healthcare wishes not to be honored.

Inspectors wroteBased on interview and record review, the facility failed to communicate a nurse-to-nurse report when transferring a resident to the hospital for one of two sampled residents (Resident 1). This failure resulted in the hospital not having any of Resident 1's medical or surgical history.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 196), was administered oxygen according to physician's order. This failure had the potential to result in Resident 196 to experience hypoxia (low levels of oxygen in the body) or hyperoxia (high level of oxygen in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess the skin of one of four sampled residents (Resident 31). This failure resulted in skin breakdown and pain for Resident 31.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning for one of four sampled residents (Resident 10). This failure resulted in Resident 10 falling and sustaining a broken femoral neck (bone that connects upper leg to hip) bone.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 196), post dialysis (mechanical removal of toxins in the blood when the kidneys no longer function adequately) access care was done timely. This failure had the potential for Resident 196's dialysis access to develop an infection or stenosis (narrowing of a vein or artery) which can cause prolonged bleeding and dialysis access failure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for one of 20 sampled residents (Resident 18) when Resident 18 was not administered oxygen (O2) per physician orders. This failure resulted in Resident 18 not receiving oxygen.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medication from the medication cart. This failure had the potential to result in medications administered not to be effective.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate use of an antibiotic (medication used to treat infection) for one of 20 sampled residents (Resident 99). This failure had the potential for unnecessary antibiotic usage leading to antibiotic resistant bacteria (Antimicrobial resistance happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them).

Inspectors wroteBased on interview and record review, the facility failed to provide the minimum square footage as required by regulation in 16 of the facility's resident bedrooms. This failure had the potential to provide insufficient space in the event of an actual emergency.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete Preadmission Screening and Resident Review (PASRR- Federal requirement to screen for mental illness and intellectual disabilities to ensure individuals are placed in nursing homes with appropriate services to meet their needs) Level I Screening, for five of 28 sampled residents (Resident 39, Resident 40, Resident 3, Resident 32, and Resident 28). This failure resulted in a Level II screening not being performed and had the potential for residents to be admitted to the facility without appropriate services available to them.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.

Inspectors wroteBased on interview and record review, the facility failed to maintain the dignity of one of 28 sampled residents (Resident 28), when Resident 28 was not assisted to the bathroom in time and had to urinate and had a bowel movements in his briefs (adult absorbent undergarments). This failure resulted in Resident 28 feeling embarrassed.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 28 sampled residents (Resident 3 and Resident 32) were informed of their Advance Directive (AD- written statement of a person's wishes regarding medical treatment and end of life decisions, made to ensure those wishes are carried out should the person become unable to communicate their wishes) options. This failure had the potential for residents end of life wishes to not be honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - resident assessment and care screening tool) discharge assessment was transmitted within the required time frame for one of one sampled resident (Resident 1). This failure had the potential to negatively affect the provision of necessary care and services for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure for fall prevention program for one of 28 sampled residents (Resident 31), who had incidents of repeated falls. This failure had the potential to result in additional falls with major injuries to Resident 31.

Inspectors wroteBased on interview and record review, the facility failed to ensure care was provided to maintain bowel and bladder continence (ability to sense and control elimination of urine and/or bowel) for one of 28 sampled residents (Resident 28), when Resident 28 was not assisted to the bathroom in time and had to urinate and/or have bowel movements in Resident 28's briefs (adult absorbent undergarments). This failure had the potential for Resident 28 to not maintain his level of continence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure for Oxygen Administration for one of 28 sampled residents (Resident 89). This failure had a potential to result in Resident 89's hypoxia (low oxygen levels in the blood).

Inspectors wroteBased on interview and record review, the facility failed to develop/implement a policy for anticoagulant (medication used to prevent blood clots and to prevent stroke) use for two of 28 sampled residents (Resident 31 and Resident 90). This failure had the potential for Resident 31 and Resident 90 to experience unnoticed excessive bleeding and bruising.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 28 sampled residents (Resident 31), who received psychotropic medication (any drug that is capable of affecting mood, emotions and behavior) was adequately monitored, by failing to properly identify the specific targeted behavior for the use of Prozac (a medication used to treat depression). This failure had the potential for Resident 31 to experience adverse side effects related to psychotropic medication including sedation (drowsiness), dizziness, and may lead to falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the minimum square footage as required by regulation in 15 of the facility's resident bedrooms. This had the potential to provide insufficient space in the event of an actual emergency.