Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Delta Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Inaccurate PBJ staffing data was submitted to CMS after the facility lacked a PBJ submission policy and the ADM confirmed corporate handled the reporting. The PBJ Staffing Data Report showed excessively low weekend staffing, and administrative staffing hours were not included in the data submitted, resulting in an inaccurate representation of staffing levels.
Discharge MDS Not Completed or Transmitted on Time: A resident’s Discharge MDS was not completed or transmitted within the required timeframe after discharge, and the completion date was left unsigned. Facility documentation stated there was no MDS completion policy, and the RAI Manual requires the discharge assessment to be completed and transmitted within 14 days. The Regional Case Mix Coordinator confirmed the assessment was not completed or transmitted according to the RAI Manual; the resident had a hx of Type 2 DM with hyperglycemia.
A resident receiving rivaroxaban via PEG tube had an inaccurate MDS entry in Section N, which stated the resident was not taking an anticoagulant. The MAR showed the blood thinner was ordered and administered throughout the month, and the Regional Case Mix Manager confirmed the MDS was coded incorrectly. The resident had a diagnosis of unspecified dementia with other behavior disturbance and a BIMS score of 3, indicating severe cognitive impairment.
Failure to Develop a Comprehensive Care Plan for Personal Hygiene: A resident with a hx of nontraumatic intracerebral hemorrhage and cerebral infarction had facial hair on the upper lip and chin, and stated a preference for more frequent shaving. A CNA said residents were typically shaved as needed on shower days, and the DON and Administrator confirmed that personal hygiene, including shaving, should have been included in the resident's care plan. The resident's BIMS score was 13, indicating cognitive intactness.
A resident with a history of intracerebral hemorrhage and cerebral infarction was observed with facial hair on the upper lip and chin, and she stated staff usually shaved her about every two weeks even though she wanted to be clean shaven more often. A CNA said residents were shaved as needed on shower days, and the DON and Administrator confirmed residents should be shaved as needed.
Medication storage was not kept secure when the A-hall medication room door was left open and multiple medication cards were visible from the hallway, along with a cup containing a prepared dose on a cabinet. RN confirmed she left the room unsecured while answering the front door, and the DON confirmed the door should never have been left open. The medications observed included discontinued meds from two residents who had expired and a prepared dose of Seroquel.
Failure to provide ordered adaptive eating equipment: A resident with dementia and severe cognitive impairment was observed in bed using a regular spoon with a divided plate containing remnants of a pureed meal, despite records showing a divided plate and weighted utensils were ordered and listed on the meal ticket. RN confirmed the resident did not have the weighted utensils needed to grasp better and feed herself, and the DM stated kitchen staff were responsible for sending the adaptive equipment with the tray.
A resident with an Anxiety Disorder did not receive prescribed Klonopin on nine occasions due to an LPN's failure to administer the medication, despite signing it off as given. The issue was identified when the DON noticed no improvement in the resident's condition and an audit revealed discrepancies in the narcotic control log.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to submit Payroll-Based Journal (PBJ) staffing data accurately to CMS for the 2nd quarter of 2025, covering January 1 through March 31, 2025. Review of the typed statement on facility letterhead dated 7/30/25 and signed by the Administrator showed the facility did not have a policy on PBJ submission. Record review of the PBJ Staffing Data Report showed the facility triggered for excessively low weekend staffing for that quarter. During an interview on 7/31/25 at 9:00 AM, the Administrator stated that the corporate office was responsible for submitting the PBJ information and confirmed that administrative staffing hours were not included in the data submitted, which contributed to the inaccurate representation of staffing levels.
Discharge MDS Not Completed or Transmitted on Time
Penalty
Summary
The facility failed to ensure a Discharge MDS was completed and transmitted within the required timeframes for one resident reviewed for MDS assessments. For Resident #58, the discharge occurred on 7/1/25, but the Discharge MDS was not completed or transmitted within the required 14-day timeframe. Section Z0500B, the completion date, was left unsigned on the assessment. A typed statement on facility letterhead dated 7/30/25 stated the facility did not have a policy on MDS completion and that the interdisciplinary team follows the RAI Manual. Review of the RAI Manual, Chapter 2, Section 2.7, showed that a Discharge assessment is required when a resident is discharged and must be completed within 14 days after discharge and electronically transmitted within 14 days of completion. During a phone interview on 7/30/25, the Regional Case Mix Coordinator confirmed the Discharge MDS for Resident #58 was not completed or transmitted according to the RAI Manual. Resident #58’s record also showed an admission with diagnoses including Type 2 Diabetes with Hyperglycemia.
Incorrect MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to accurately complete Section N of the MDS for a resident receiving anticoagulant therapy. Review of the June 2025 MAR showed an order for rivaroxaban 10 mg via PEG tube in the morning, and the medication was initialed as administered on all days in June. However, the Quarterly MDS with an ARD of 6/26/25 documented the resident as not taking an anticoagulant medication in Section N. A telephone interview with the Regional Case Mix Manager confirmed that the MDS was not coded correctly to reflect rivaroxaban. The resident had been admitted on 2/26/24 with a diagnosis of unspecified dementia with other behavior disturbance, and the Quarterly MDS also showed a BIMS score of 3, indicating severe cognitive impairment.
Failure to Develop a Comprehensive Care Plan for Personal Hygiene
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident, Resident #36. The facility policy titled, Care Plans, Comprehensive Person-Centered, stated that a comprehensive, person-centered care plan with measurable objectives and timetables is to be developed and implemented for each resident to meet physical, psychosocial, and functional needs. During observation and interview, Resident #36 was noted to have dark facial hair on the upper lip and sparse hair on the chin, and the resident stated a desire for more frequent shaving, saying she was usually shaved about every two weeks and wanted to be clean shaven more often. A CNA confirmed that Resident #36 had facial hair on the chin and upper lip and stated that residents were typically shaved as needed on shower days. The DON and Administrator confirmed that personal hygiene, including shaving, should have been included in the resident's care plan and that care plans serve as a guide for staff to follow while providing care. Resident #36 was admitted with diagnoses including Nontraumatic Intracerebral Hemorrhage, Unspecified, and Cerebral Infarction, Unspecified, and the quarterly MDS showed a BIMS score of 13, indicating the resident was cognitively intact.
Failure to Provide Needed Shaving and Personal Hygiene Care
Penalty
Summary
The facility failed to provide ADL care to maintain personal hygiene for one resident reviewed for ADLs. Facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During observation and interview, the resident had dark facial hair on the upper lip and sparse hair on the chin, and stated that staff usually shaved her about every two weeks but that she wanted to be clean shaven more often. A CNA confirmed the resident had facial hair on the chin and upper lip and stated residents were typically shaved as needed on shower days. The DON and Administrator also confirmed that residents should be shaved as needed, and the Administrator stated that unwanted facial hair was an issue, especially for women. Record review showed the resident was admitted with diagnoses including nontraumatic intracerebral hemorrhage and cerebral infarction, and the quarterly MDS showed a BIMS score of 13, indicating the resident was cognitively intact.
Medication Room Left Open With Medications Visible
Penalty
Summary
The facility failed to ensure medications were securely stored in the medication room for one of four medication storage areas observed. During the initial entrance tour, the medication room door on the A-hallway was observed open, with multiple medication cards sitting on a counter visible from the hallway. A cup containing what appeared to be medication was also observed on a small cabinet and was visible from the hallway. During observation and interview, RN #1 confirmed the medication room door was open and stated it should never be left open. She stated the medications on the cards were from two residents who had expired over the weekend, and the medication in the cup was for a resident she had recently prepared before leaving it to answer the front door. She confirmed she failed to shut and secure the medication room and stated the door had been open since she arrived at 5:00 PM. The DON also confirmed the door should never be left open and that the medications on the counter were from two residents who had recently expired. The medications observed on the counter included hydrochlorothiazide, fluoxetine, Wellbutrin, Remeron, Procardia, and Nuedexta.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure adaptive eating equipment was provided to a resident during dining. The facility policy titled “Assistance with Meals” stated that adaptive devices, including special eating equipment and utensils, would be provided for residents who need or request them. Resident #3’s Diet Requisition Form dated 2/5/25 requested a divided plate and weighted utensils, and the 7/28/25 dinner meal ticket listed a weighted spoon and fork for the resident. During an observation on 7/28/25 at 6:24 PM, Resident #3 was lying in bed holding a regular spoon and dipping it into a divided plate containing remnants of a pureed dinner meal. RN #1 observed and confirmed at 6:31 PM that the resident did not have weighted utensils and stated the resident needed them to grasp better and increase her ability to feed herself. The Dietary Manager stated on 7/30/25 that kitchen staff were responsible for ensuring adaptive equipment was sent out with the meal tray and that the resident was supposed to have the equipment to assist her with eating independently. Resident #3 had been admitted with a diagnosis of unspecified dementia with other behavior disturbance, and the quarterly MDS dated 6/26/25 showed a BIMS score of 3, indicating severe cognitive impairment.
Failure to Administer Prescribed Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an LPN did not administer prescribed antianxiety medications. The deficiency involved a resident with an Anxiety Disorder who was supposed to receive Klonopin Oral Tablet 0.5 mg via PEG tube three times a day. However, the LPN failed to administer the medication on nine occasions during November 2024, despite signing off on the Medication Administration Record (MAR) as if the medication had been given. The issue was discovered when the Director of Nursing (DON) noticed no improvement in the resident's condition despite a recent increase in medication. An audit revealed that the LPN had not signed out the medication from the narcotic control log, indicating it was not administered. The LPN admitted to forgetting to give the medication and had charted it as given. This oversight was confirmed through a Medication Error Report and interviews with facility staff.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bolivar Medical Center Ltc | 0.3 mi | ★★★★★ | 0 | 0 |
| Cleveland Community Care Center | 0.8 mi | ★★★★★ | 8 | 0 |
| Walter B Crook Nursing Facility | 9.4 mi | ★★★★★ | 7 | 0 |
| Ruleville Community Care Center | 9.6 mi | ★★★★★ | 13 | 0 |
| Diversicare Of Shelby | 14.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.