Inspection Reports for
Delhaven Manor

The facility was found deficient in multiple areas including failure to complete third party liability forms timely, insufficient surety bond coverage, lack of posting of State Survey Agency hotline number, inaccurate resident assessments, inadequate dialysis care documentation and contract availability, medication administration errors, improper food labeling and kitchen cleanliness, and failure to implement enhanced barrier precautions for infection control.

The facility failed to ensure that the staff transporting residents held the proper Class E driver's license as required by Missouri state regulations, and failed to employ a qualified full-time social worker with the required education and experience. The census was 61, and the facility was licensed for 156 beds.

The complaint investigation revealed substantiated issues with Resident #2 who exhibited intoxication, verbal and physical aggression, and substance use. Staff failed to adequately monitor or intervene, and the resident was not placed on a behavioral contract as required.

The facility failed to address the behavioral health needs of a resident with substance use disorder, including intoxication and verbal/physical aggression. Staff did not have clear protocols for managing the resident's escalating behaviors, and the resident was not placed on a behavioral contract despite multiple incidents. The facility was cited at the immediate jeopardy level but had implemented corrective actions by the time of the abbreviated survey.

The facility failed to maintain accurate controlled substance records with proper signatures and documentation, did not ensure staff transporting residents had the proper Class E driver's license, and employed a social worker assistant without the required bachelor's degree and experience for a facility of its size.

The complaint investigation was triggered by an altercation on 4/16/24 between Resident #4 and Resident #5, where Resident #5 struck Resident #4 in the face causing him to fall and be transported to the hospital. Multiple interviews with staff and residents confirmed the incident and prior verbal altercations. The facility's investigation and policies on abuse were reviewed. Additionally, concerns about medication administration errors for Residents #1 and #4 were investigated, revealing multiple missed doses without documentation or physician notification.

The facility failed to protect a resident from physical abuse when another resident struck him, resulting in injury and hospital transport. Additionally, the facility failed to administer medications as ordered for two residents, with missing documentation and no communication with physicians, potentially impacting residents' health and behavior.

The complaint investigation focused on Resident #1 who experienced multiple falls, including a fall causing a C-2 fracture due to unsafe environment and lack of staff assistance. The resident reported feeling isolated and depressed due to lack of activity and socialization. The facility failed to conduct fall investigations, update care plans, and provide psychosocial support. The complaint was substantiated with findings of minimal harm or potential for actual harm.

The facility failed to provide reasonable accommodation for Resident #1's needs, including assistance with transfers, fall prevention, and psychosocial support. The resident suffered multiple falls, including one resulting in a C-2 fracture due to a bed remote left under the resident causing the bed to elevate. The facility failed to conduct proper fall investigations, update care plans, and provide adequate social and activity interventions, leading to the resident feeling isolated and depressed.

The facility failed to have a registered nurse scheduled for at least 8 consecutive hours daily, including no RN coverage on weekends during August 2023. Staffing records showed only Licensed Practical Nurses scheduled, and no RN supervisor was listed.

The facility was found deficient in multiple areas including failure to provide quarterly financial statements for resident trust accounts, incomplete or inaccurate PASARR screenings, inadequate assistance with activities of daily living such as nail care, failure to apply prescribed orthotic splints to prevent contractures, incomplete dialysis communication and monitoring, lack of RN coverage on weekends, insufficient monitoring of psychotropic medication effects, insulin administration errors, and failure to retain complete and accessible medical records.

The facility failed to ensure an adequate discharge planning process for Resident #2, including lack of caregiver support, missed appointments for obtaining state ID, and insufficient assistance in arranging discharge despite the resident being his/her own responsible party. The resident was ambulatory and cognitively intact but frustrated by the lack of support.

The facility was found deficient in multiple areas including failure to honor resident trust fund requests timely, negative balances in resident trust accounts, inadequate documentation of resident trust fund statements, insufficient bond coverage for resident funds, undignified dining experience, failure to provide written bed hold notices, inaccurate resident assessments, incomplete care plans, medication management errors, unsafe storage of personal items and razors, malfunctioning call light systems, inadequate dialysis care coordination, improper food handling and labeling, and lack of collaboration with hospice providers.