Inspection Reports for
Delhaven Manor
5460 DELMAR BLVD, SAINT LOUIS, MO, 63112-3104
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
24.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
349% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
38% occupied
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 8
Date: Nov 13, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident funds, medication administration, infection control, food safety, and other care standards at Delhaven Manor.
Findings
The facility was found deficient in multiple areas including timely notice and conveyance of personal funds, surety bond security, resident rights notices, accuracy of assessments, dialysis care, medication error rates, food safety, and infection prevention and control. Deficiencies were cited with varying severity levels and corrective actions were planned.
Deficiencies (8)
F569 Notice and Conveyance of Personal Funds: The facility failed to ensure timely completion of third party liability forms and conveyance of funds within 30 days for discharged residents.
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain a surety bond sufficient to protect resident funds, with a bond amount less than the required amount based on average resident trust fund balances.
F574 Required Notices and Contact Information: The facility failed to provide accessible information on the State Survey Agency hotline number to residents and visitors.
F641 Accuracy of Assessments: The facility failed to assure residents' Minimum Data Set assessments accurately reflected their status for two sampled residents.
F698 Dialysis: The facility failed to ensure residents receiving dialysis had documented assessments and monitoring, and lacked a copy of the dialysis contract.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to maintain a medication error rate below 5%, with an 8.11% error rate observed.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to label, date, and cover food properly and maintain kitchen equipment in proper working order.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program, including signage, PPE use, and staff training.
Report Facts
Resident census: 60
Medication error rate: 8.11
Medication error opportunities: 37
Surety bond amount: 75000
Average resident trust fund balance: 52000
Required surety bond amount: 78000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to findings and plan of correction approval | |
| Director of Nursing | DON | Mentioned in interviews regarding dialysis contract and infection control |
| Business Office Manager | BOM | Interviewed regarding third party liability forms and surety bond |
| Licensed Practical Nurse | LPN | Interviewed regarding dialysis services and documentation |
| Certified Medication Technician | CMT | Observed administering medications and involved in medication error findings |
| Assistant Director of Nursing | ADON | Observed providing wound care and infection control |
Inspection Report
Routine
Census: 60
Deficiencies: 8
Date: Nov 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident funds, assessments, infection control, medication administration, food safety, dialysis care, and other facility operations.
Findings
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.
Deficiencies (8)
Failed to ensure third party liability (TPL) forms were completed within 30 days for final accounting for residents who expired.
Failed to maintain a surety bond sufficient to ensure protection of resident funds.
Failed to provide accessible information on the location of the State Survey Agency hotline number.
Failed to assure residents' Minimum Data Set (MDS) accurately reflected residents' status for hospice care.
Failed to ensure residents receiving dialysis had documented assessments and monitoring and failed to have a copy of the dialysis contract.
Failed to ensure medication error rate was less than 5%, with an observed error rate of 8.11%.
Failed to label, date, and cover food in the kitchen and failed to ensure kitchen equipment was clean and in proper working order.
Failed to place signage and follow indications for enhanced barrier precautions for residents with pressure ulcers and indwelling devices; failed to keep urinary catheter bag off the floor; failed to store nebulizer mask in a clean container.
Report Facts
Residents affected: 3
Census: 60
Surety bond amount: 75000
Average resident trust fund balance: 52000
Required bond amount: 78000
Medication error rate: 8.11
Medication opportunities observed: 37
Medication errors observed: 3
Dialysis assessments completed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding TPL forms and surety bond sufficiency |
| Administrator | Administrator | Interviewed regarding surety bond, State Survey Agency hotline posting, dialysis contract, medication administration, infection control, and kitchen conditions |
| Director of Nursing | Director of Nursing | Interviewed regarding State Survey Agency hotline posting, dialysis contract, medication administration, and infection control |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding dialysis care and documentation |
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed regarding dialysis communication form |
| Certified Medication Technician D | Certified Medication Technician | Observed and interviewed regarding medication administration errors |
| Director of Dietary Services | Director of Dietary Services | Interviewed regarding kitchen food labeling, cleaning, and equipment maintenance |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed providing wound care without gown and interviewed regarding infection control |
| Certified Nurse Aide C | Certified Nurse Aide | Observed providing care without gown and interviewed regarding infection control |
Inspection Report
Life Safety
Census: 60
Capacity: 156
Deficiencies: 10
Date: Nov 13, 2024
Visit Reason
The inspection was conducted as an emergency preparedness investigation and life safety code survey to assess compliance with emergency management and fire safety regulations.
Findings
The facility failed to update its emergency management plan annually and did not maintain proper emergency communication plans or emergency power system procedures. Deficiencies were also found in the installation and maintenance of the fire alarm system, sprinkler system, electrical systems, and smoking regulations.
Deficiencies (10)
E004 Emergency Plan. The facility failed to update the emergency management plan annually and did not ensure staff had access to the updated plan in emergency situations.
E030 Names and Contact Information. The facility failed to develop and maintain an emergency communication plan with current contact information for staff and volunteers accessible in emergencies.
E039 EP Testing Requirements. The facility failed to conduct required emergency plan exercises and drills annually or biennially as mandated.
E041 Hospital CAH and LTC Emergency Power. The facility failed to implement emergency power system procedures including generator location, fuel supply, and staff training.
K341 Fire Alarm System - Installation. The facility failed to properly install and maintain fire alarm system components including manual alarm boxes and smoke detector sensitivity testing.
K345 Fire Alarm System - Testing and Maintenance. The facility failed to maintain and test the fire alarm system quarterly and annually with proper documentation.
K353 Sprinkler System - Maintenance and Testing. The facility failed to maintain sprinkler system inspection and testing records and did not complete required inspections.
K531 Elevators. The facility failed to maintain elevator certifications and monthly fire fighter operation testing as required.
K741 Smoking Regulations. The facility failed to ensure safe self-closing metal containers for ash disposal and did not maintain smoking area compliance.
K918 Electrical Systems - Essential Electric System Maintenance and Testing. The facility failed to complete annual generator inspections and maintain emergency power system testing.
Report Facts
Facility capacity: 156
Resident census: 60
Deficiencies cited: 10
Inspection Report
Census: 61
Capacity: 156
Deficiencies: 2
Date: Aug 14, 2024
Visit Reason
The inspection was conducted to assess compliance with staffing and licensing requirements, specifically regarding proper driver licensing for staff transporting residents and employment of a qualified full-time social worker as required by facility licensing standards.
Findings
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.
Deficiencies (2)
Facility failed to ensure staff transporting residents held the proper Class E driver's license in accordance with Missouri state regulations.
Facility failed to employ a qualified full-time social worker with a bachelor's degree in a human services field and one year of supervised social work experience.
Report Facts
Census: 61
Total licensed capacity: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Driver G | Transportation staff | Named in deficiency for not holding a Class E driver's license while transporting residents |
| Social Worker | Social Worker Assistant / Social Services Designee | Named in deficiency for not meeting qualifications of a qualified full-time social worker |
| Administrator | Interviewed regarding staff licensing and social worker qualifications |
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate deficiencies related to behavioral health services and compliance with regulatory requirements.
Findings
The facility failed to provide necessary behavioral health care services for a resident with substance use disorder and escalating behaviors. The deficiency was initially cited at an immediate jeopardy level but was lowered to a class II level after corrective actions were implemented.
Deficiencies (2)
F740 Behavioral health services. The facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being, including addressing alcohol use and verbal/physical aggression. The facility did not inform staff how to handle the resident's escalating behaviors.
A4075 Nursing care per resident condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency cited at F740.
Report Facts
Census: 62
Deficiency counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Named in relation to resident's aggressive behavior and intoxication incidents |
| Administrator | Informed of immediate jeopardy and involved in corrective actions | |
| Director of Nursing | Director of Nursing | Notified about resident incidents and involved in corrective actions |
| Certified Medication Technician A | Certified Medication Technician | Reported resident's combative and verbally aggressive behavior |
| Certified Medication Technician B | Certified Medication Technician | Reported resident's aggressive behavior and intoxication |
| CNA C | Certified Nursing Assistant | Reported resident's intoxication frequency |
| Social Worker | Social Worker | Reported resident's substance use issues and counseling offers |
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide necessary behavioral health care and services for a resident with substance use disorder and aggressive behaviors.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide necessary behavioral health care and services for a resident with substance use disorder and aggressive behaviors.
Report Facts
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Named in incident where resident grabbed and pushed him/her; filed grievance against resident |
| Administrator | Informed of immediate jeopardy and involved in discussions about resident behavior | |
| Director of Nursing | DON | Notified of resident incidents and involved in care planning discussions |
| Certified Medication Technician A | CMT | Reported resident's intoxication and aggressive behavior to nurse |
| Certified Medication Technician B | CMT | Reported resident's frequent intoxication and aggressive behavior to nurse |
| LPN D | Licensed Practical Nurse | Reported resident's intoxication and described facility policy gaps |
| Social Worker | Aware of resident's substance use issues and offered counseling and Alcohol Anonymous | |
| Resident #2's physician | Physician | Notified of resident intoxication and ordered medication hold; commented on facility's failure to manage resident behavior |
Inspection Report
Plan of Correction
Census: 61
Capacity: 156
Deficiencies: 6
Date: Jun 17, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding pharmacy services, staff qualifications, and social worker requirements at Delhaven Manor.
Findings
The facility failed to maintain accurate controlled substance records and signatures on drug count sheets, lacked a qualified social worker for its licensed bed count, and employed a staff member without the required Class E driver's license for transporting residents.
Deficiencies (6)
F755 Pharmacy Services: The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation for narcotic medications.
A4071 Controlled Substance Reconcile/Record: The facility did not maintain an accurate system of records for receipt and disposition of controlled drugs, resulting in a Class II deficiency.
F839 Staff Qualifications: The facility failed to ensure staff transporting residents held the proper Class E driver's license as required by Missouri state regulations.
F850 Qualifications of Social Worker >120 Beds: The facility failed to employ a qualified social worker on a full-time basis despite being licensed for 156 beds.
A4003 Operator/Administrator Responsibilities: The administrator failed to ensure compliance with laws and rules, including oversight of staff qualifications and social services program.
A4100 Social Service Program: The facility did not designate a qualified staff member responsible for the social services program as required.
Report Facts
Census: 61
Total licensed beds: 156
Deficiencies cited: 6
Inspection Report
Routine
Census: 61
Capacity: 156
Deficiencies: 3
Date: Jun 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pharmaceutical services, staff licensing, social worker qualifications, and narcotic medication handling at Delhaven Manor.
Findings
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.
Deficiencies (3)
Failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation for narcotic count books.
Failed to ensure staff transporting residents in company vehicles held the proper Class E driver license as required by Missouri state regulations.
Failed to employ a qualified full-time social worker with a bachelor's degree and required experience for a facility licensed for more than 120 beds.
Report Facts
Census: 61
Total licensed capacity: 156
Controlled drug count sheet signature omissions: 12
Controlled drug count sheet signature omissions: 8
Controlled drug count sheet documentation omissions: 35
In-service attendance: 7
In-service non-attendance: 5
Social worker hire date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Driver G | Transportation | Named in finding for operating facility van without proper Class E driver's license |
| Registered Nurse (RN) | Interviewed regarding narcotic medication counting procedures | |
| Staffing Coordinator | Certified Medication Technician (CMT) | Interviewed about narcotic medication administration and counting on 4th floor |
| Director of Nurses (DON) | Director of Nurses | Interviewed about narcotic medication counting and in-service training |
| Social Worker | Social Services Designee (SSD) | Named in finding for not meeting qualifications for social worker position |
| Administrator | Administrator | Interviewed regarding narcotic medication administration, driver licensing, and social worker qualifications |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 3
Date: Apr 19, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations regarding resident care, abuse prevention, medication administration, and other professional standards at Delhaven Manor.
Findings
The facility was found deficient in ensuring residents were free from abuse and neglect, and in meeting professional standards for medication administration. Multiple incidents of resident-to-resident physical and verbal abuse were documented, and medication administration errors and documentation deficiencies were noted.
Deficiencies (3)
F600 Freedom from Abuse and Neglect: The facility failed to ensure one resident's right to be free from physical abuse was violated during an altercation between two residents. The census was 62.
F658 Services Provided Meet Professional Standards: The facility failed to ensure services met professional standards by not following physician orders for two residents, including medication administration omissions and lack of documentation.
F760 Residents are Free of Significant Medication Errors: The facility failed to ensure residents were free of significant medication errors by not administering medications as ordered and not documenting reasons for omissions.
Report Facts
Resident census: 62
Sample size: 5
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 3
Date: Apr 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged physical abuse incident between two residents and concerns about medication administration and adherence to physician orders.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to ensure one resident's right to be free from physical abuse when another resident hit him in the face.
Failed to follow physician orders for medication administration for two residents, with multiple missed doses and lack of documentation or communication.
Failed to ensure residents are free from significant medication errors, including failure to administer medications and document reasons for omissions.
Report Facts
Residents affected: 5
Census: 62
Missed medication doses for Resident #1: 6
Missed medication doses for Resident #4: Multiple
Lithium level: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Observed Resident #4 being struck and assisted him after the incident |
| CNA G | Certified Nurse Assistant | Intervened during altercation between residents |
| CMT D | Certified Medication Technician | Called stat page during altercation and interviewed about medication administration issues |
| CNA F | Certified Nurse Assistant | Witnessed altercation and described events |
| RN H | Registered Nurse | Interviewed regarding medication administration issues |
| Administrator | Interviewed about abuse expectations and medication administration policies | |
| Director of Nursing | DON | Interviewed about abuse expectations and medication administration policies |
| Assistant Director of Nursing | ADON | Interviewed about medication administration documentation issues |
| Hospital Staff A | Provided lab results and medical opinion on lithium level and resident aggression | |
| Resident's Physician | Interviewed about medication omissions and potential negative outcomes |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 7
Date: Feb 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to resident care concerns, including failure to provide reasonable accommodations and inadequate care planning for a resident with fall risks and injuries.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate resident care, failure to assist a resident with mobility needs, and failure to prevent falls and injuries. The complaint was substantiated based on multiple findings.
Findings
The facility failed to provide reasonable accommodations and assistance to a resident, resulting in multiple falls and injuries. The facility also failed to develop and implement comprehensive care plans addressing the resident's specific needs and failed to conduct proper fall investigations and interventions.
Deficiencies (7)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to provide reasonable accommodation of needs and preferences for one resident when staff failed to assist him/her out of bed upon request.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement a comprehensive care plan addressing the resident's specific needs, including fall interventions and mood/socialization changes.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to identify potential safety hazards and implement safety interventions after a resident's fall resulting in a fracture and subsequent additional falls.
F740 Behavioral Health Services: The facility failed to provide necessary behavioral health care and services to address the resident's emotional and psychosocial needs, causing feelings of isolation and sadness.
A4074 Protective Oversight, Voluntary Leave: The facility failed to ensure protective oversight and supervision for residents on voluntary leave.
A8013 Right to Plan Care/Refuse Treatment: The facility failed to afford residents the opportunity to participate in planning their care and treatment and to refuse treatment with informed consent.
A8042 Resident Lives Not Regulated/Controlled: The facility failed to ensure residents' personal lives were not regulated or controlled beyond reasonable adherence to policies necessary for orderly management and safety.
Report Facts
Resident census: 60
Sample size: 3
Sample size: 7
Compliance date: Mar 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker G | Interviewed regarding resident's care and mood | |
| Therapist D | Interviewed regarding resident's fall and therapy responsibilities | |
| Certified Medication Technician (CMT) F | Interviewed regarding resident's mobility and care | |
| Certified Nurse Assistant (CNA) E | Interviewed regarding resident's fall and care | |
| Activity Assistant H | Interviewed regarding resident's activities before and after fall | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding fall investigations and care plan |
| Licensed Practical Nurse (LPN) J | Licensed Practical Nurse | Interviewed regarding resident care information |
| Therapy Manager D | Interviewed regarding resident's fall and therapy |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 4
Date: Feb 23, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to accommodate resident needs, inadequate care planning, safety hazards leading to falls and injuries, and failure to provide necessary behavioral health care and services for Resident #1.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to reasonably accommodate the needs and preferences of Resident #1, resulting in falls and injury including a C-2 fracture.
Failure to develop and implement a comprehensive care plan addressing Resident #1's fall risks, mood changes, and socialization needs.
Failure to ensure the resident's environment was free from accident hazards, specifically leaving the bed remote under the resident causing bed elevation and injury.
Failure to provide necessary behavioral health care and services to Resident #1, resulting in feelings of isolation and sadness.
Report Facts
Census: 60
Falls: 3
Laceration size: 1
Date of falls: Falls occurred on 2/6/24, 2/10/24, and 2/20/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker G | Social Worker | Provided information on resident's psychosocial status and care needs |
| Therapy Manager D | Therapy Manager | Assisted resident after falls and provided information on therapy involvement |
| Certified Medication Technician CMT | Certified Medication Technician | Provided observations on resident's care and activity participation |
| Director of Nursing | Director of Nursing | Provided expectations on resident care and fall investigations |
| CNA E | Certified Nurse Assistant | Reported observations related to resident falls and care |
Inspection Report
Census: 60
Deficiencies: 1
Date: Aug 25, 2023
Visit Reason
The inspection was conducted to assess compliance with staffing requirements, specifically the presence of a registered nurse on duty for at least 8 consecutive hours a day, 7 days a week.
Findings
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.
Deficiencies (1)
Failure to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
Report Facts
Census: 60
Dates with no RN coverage: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding RN staffing and employment start date | |
| Staffing Coordinator | Interviewed regarding RN staffing referral to DON | |
| Administrator | Interviewed regarding staffing practices and recruitment efforts |
Inspection Report
Life Safety
Census: 57
Capacity: 156
Deficiencies: 10
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code investigation to assess compliance with federal, state, and local emergency preparedness requirements and the Life Safety Code of the National Fire Protection Association.
Findings
The facility failed to update its emergency preparedness plan annually and did not maintain required emergency lighting, self-closing doors in hazardous areas, kitchen range hood maintenance, fire alarm system documentation, and fire safety features such as smoke barriers and elevator fire service. Multiple deficiencies were cited that had the potential to affect all residents and staff.
Deficiencies (10)
E004 Emergency Plan. The facility failed to update the emergency preparedness plan at least annually, affecting all occupants.
K291 Emergency Lighting. The facility failed to ensure emergency lighting was tested monthly and annually as required by NFPA code.
K321 Hazardous Areas - Enclosure. The facility failed to equip doors to hazardous areas with self-closing devices, impacting residents and staff.
K324 Cooking Facilities. The facility failed to maintain the kitchen range hood according to NFPA code, including cleaning and inspection.
K345 Fire Alarm System - Testing and Maintenance. The facility failed to provide documentation of annual fire alarm inspection and ensure all components were tested and visually inspected.
K363 Corridor - Doors. The facility failed to maintain corridor doors to ensure proper fire resistance and closing, creating impediments to door closure.
K372 Subdivision of Building Spaces - Smoke Barrier. The facility failed to maintain smoke barrier walls with required fire resistance rating.
K531 Elevators. The facility failed to ensure monthly inspection and testing of elevators equipped with Firefighter's Service.
K918 Electrical Systems - Essential Electric System. The facility failed to complete an annual inspection of the emergency power generator as required.
K923 Gas Equipment - Cylinder and Container Storage. The facility failed to properly store oxygen cylinders and maintain storage areas according to NFPA code.
Report Facts
Facility Capacity: 156
Resident Census: 57
Deficiencies Cited: 10
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 9
Date: Jun 30, 2023
Visit Reason
The inspection was a recertification survey and complaint survey conducted from 06/26/2023 to 06/30/2023 to assess compliance with federal regulations for long term care facilities.
Complaint Details
The survey included a complaint investigation component as noted in the initial comments. Specific substantiation status is not explicitly stated.
Findings
The facility was found not in substantial compliance with requirements, citing deficiencies in accounting and records of personal funds, PASARR screening, activities of daily living care, mobility treatment, dialysis care, psychotropic drug use, and medical record maintenance. The facility census was consistently reported as 57 during the survey.
Deficiencies (9)
F568 Accounting and Records of Personal Funds. The facility failed to provide quarterly financial statements to 2 of 24 residents with resident trust accounts.
F645 PASARR Screening for Mental Disorder and Intellectual Disability. The facility failed to ensure Level 1 PASARRs were accurately completed prior to admission for 2 of 3 residents reviewed.
F677 ADL Care Provided for Dependent Residents. The facility failed to provide necessary assistance with activities of daily living for 2 of 17 residents reviewed, including proper fingernail care.
F688 Increase/Prevent Decrease in Range of Motion/Mobility. The facility failed to provide treatment to prevent further decrease in range of motion for 1 of 2 residents reviewed.
F698 Dialysis. The facility failed to ensure ongoing communication and assessment related to dialysis care for 1 of 2 residents reviewed.
F758 Free from Unnecessary Psychotropic Medications/PRN Use. The facility failed to provide adequate monitoring of psychotropic drug effects and responses for 1 of 5 residents reviewed.
F760 Residents are Free of Significant Medication Errors. The facility failed to ensure 1 of 3 residents receiving insulin was free from significant medication errors.
F727 RN 8 Hrs/7 days/Wk, Full Time DON. The facility failed to use a registered nurse for at least 8 consecutive hours a day, 7 days a week, including no RN scheduled on weekends.
F842 Resident Records - Identifiable Information. The facility failed to maintain complete, accurate, organized, and readily accessible medical records for 5 of 24 residents reviewed.
Report Facts
Facility census: 57
Residents reviewed for PASARR: 3
Residents reviewed for ADL care: 17
Residents reviewed for mobility: 2
Residents reviewed for dialysis: 2
Residents reviewed for psychotropic drug monitoring: 5
Residents reviewed for medication errors: 3
Residents reviewed for medical records: 24
Facility census (August 2023): 60
Inspection Report
Routine
Census: 57
Deficiencies: 9
Date: Jun 30, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident trust account management, PASARR screening, activities of daily living assistance, range of motion care, dialysis services, nursing staffing, psychotropic medication monitoring, medication administration, and medical record retention.
Findings
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.
Deficiencies (9)
Failed to provide quarterly financial statements to residents with trust accounts.
Failed to ensure accurate and complete Level 1 PASARR screening prior to admission for some residents.
Failed to provide adequate assistance with activities of daily living, resulting in residents having long, dirty fingernails.
Failed to provide appropriate care to maintain or improve range of motion, including failure to apply prescribed orthotic splint for contracture management.
Failed to ensure ongoing communication and monitoring related to dialysis care, including incomplete dialysis communication forms.
Failed to have a registered nurse on duty for at least 8 consecutive hours a day, 7 days a week.
Failed to provide evidence of adequate monitoring for effects of psychotropic medications, including lack of behavior documentation.
Failed to ensure insulin was administered as ordered according to sliding scale and proper documentation was completed.
Failed to retain complete, accurate, organized, and readily accessible medical records for multiple residents.
Report Facts
Residents with trust accounts not receiving quarterly statements: 2
Residents reviewed for PASARR: 3
Residents reviewed for ADL assistance: 17
Residents reviewed for limited range of motion: 2
Residents reviewed for dialysis: 2
Facility census: 57
Residents reviewed for psychotropic medication monitoring: 5
Residents reviewed for insulin administration: 3
Residents reviewed for medical records retention: 24
Facility census: 60
Weekend dates with no RN coverage: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Interviewed regarding dialysis communication forms and insulin administration |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding dialysis communication forms and insulin administration |
| Administrator | Interviewed regarding multiple deficiencies including trust accounts, PASARR, dialysis, staffing, medication administration, and record retention | |
| Director of Nursing | DON | Interviewed regarding PASARR, dialysis, staffing, medication administration, and record retention |
| Certified Nursing Assistant #5 | CNA | Interviewed regarding fingernail care for Resident #23 |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding fingernail care for Resident #23 |
| Medical Director | MD | Interviewed regarding nail care and contracture management |
| Restorative Certified Nursing Assistant #8 | RCNA | Interviewed regarding application of orthotic splint for Resident #23 |
| Social Services Director | SSD | Interviewed regarding behavior documentation |
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 2
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with discharge planning process regulations and related resident care requirements at Delhaven Manor.
Findings
The facility failed to ensure an effective discharge planning process addressing residents' discharge goals, caregiver involvement, and coordination with community resources. The census at the time was 52 residents.
Deficiencies (2)
F660 Discharge Planning Process: The facility failed to implement an effective discharge planning process that addresses resident discharge goals, caregiver involvement, and coordination with community resources.
A8015 30 Day Notice-Transfer/Discharge: The facility did not meet the requirement to notify residents and responsible parties at least 30 days in advance of transfer or discharge except in emergencies.
Report Facts
Census: 52
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator interviewed and signed the report and plan of correction |
Inspection Report
Census: 52
Deficiencies: 1
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's discharge planning process and ensure it addressed discharge goals, caregiver support, referrals to local agencies, and resident involvement.
Findings
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.
Deficiencies (1)
Failure to ensure a discharge planning process addressing discharge goals, caregiver support, referrals, and resident involvement.
Report Facts
Residents Affected: 4
Census: 52
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 4
Date: Dec 23, 2022
Visit Reason
The inspection was conducted due to a complaint investigation concerning the facility's policies and practices related to permitting residents to return after hospitalization, discharge summaries, and quality of care issues including resident monitoring and medication administration.
Complaint Details
The complaint investigation found an imminent danger Class I level violation related to resident monitoring and care. The investigation included interviews and record reviews confirming failures in resident monitoring, discharge planning, and return policies. Resident #1 was found deceased with no timely nursing checks. Resident #3 and #4 had incomplete discharge summaries. The complaint was substantiated with immediate jeopardy identified.
Findings
The facility failed to follow its written policy permitting residents to return after hospitalization, failed to provide discharge summaries including medication reconciliation and post-discharge plans, and did not ensure adequate monitoring of residents, resulting in a resident found deceased without timely checks. Deficiencies were cited related to resident return policies, discharge summaries, and quality of care including nursing staff rounds and medication administration documentation.
Deficiencies (4)
F626: The facility failed to follow its written policy permitting residents to return after hospitalization for one resident, including lack of documentation and communication regarding bed hold and emergency transfers.
F661: The facility failed to ensure a discharge summary including medication reconciliation and post-discharge plan of care was completed for two residents, with missing documentation and discharge notices.
F684: The facility failed to monitor one resident adequately, resulting in the resident being found deceased with signs of rigor mortis and no timely nursing checks during the night shift.
F725: The facility failed to provide sufficient nursing staff with appropriate competencies and skills to assure resident safety and care, including lack of nurse coverage on the third floor during a night shift.
Report Facts
Resident census: 50
Resident census: 52
Resident census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shantau Rice Lintha | Administrator | Signed the plan of correction and named in relation to findings on resident return and discharge policies |
| Nurse D | Named in relation to resident monitoring and rounds during night shift | |
| Certified Medication Technician (CMT) E | Named in relation to resident monitoring and medication administration | |
| Certified Medication Technician (CMT) A | Named in relation to resident monitoring and medication administration | |
| Regional Nurse | Named in relation to notification and investigation of resident death | |
| Director of Nursing (DON) | Named in relation to discharge planning and investigation of resident death | |
| Administrator | Named in interviews regarding facility policies and resident transfers |
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 2
Date: Aug 24, 2021
Visit Reason
The document is a Plan of Correction submitted by Delhaven Manor in response to deficiencies cited during a survey completed on 08/24/2021.
Findings
The facility was found not in compliance with the requirement to be free from misappropriation/exploitation of resident property, specifically involving one resident (#6) with impaired cognitive function. The facility failed to ensure the resident was free from misappropriation when a personal check for $13,999 was written with assistance from the facility administrator without notifying the responsible party or ensuring cognitive capacity to make financial decisions.
Deficiencies (2)
F602: The facility failed to ensure one resident was free from misappropriation of property when the facility administrator assisted with writing a personal check of $13,999 without notifying the responsible party or ensuring the resident's cognitive status was sufficient to make financial decisions.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, as evidenced by the deficiency cited at F602.
Report Facts
Resident census: 51
Check amount: 13999
Date of survey completion: Aug 24, 2021
Plan of correction completion date: Sep 8, 2021
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 2
Date: Jun 25, 2021
Visit Reason
The inspection was conducted to investigate deficiencies related to abuse/neglect policies following an incident involving two residents in a consensual sexual relationship and the facility's failure to develop and implement adequate policies and training.
Findings
The facility failed to develop and implement written policies and procedures to assess residents' capacity to consent to sexual contact and did not provide timely staff training after the incident. Documentation and investigation processes were incomplete, and residents' families and physicians were not notified.
Deficiencies (2)
F607: The facility failed to develop and implement written abuse/neglect policies including assessing residents' capacity to consent to sexual contact and did not provide timely training after an incident involving two residents. Documentation and investigation of the incident were incomplete and lacked required notifications.
A8023: The facility did not meet the requirement to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, as evidenced by the deficiency cited at F607.
Report Facts
Census: 57
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 30, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation from 04/27/2021 through 04/30/2021.
Complaint Details
No state licensure deficiencies were cited as a result of this complaint only investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices for COVID-19.
Complaint Details
The complaint investigation was related to COVID-19 infection control practices and was found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 1
Date: Oct 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from 10/03/2020 through 10/16/2020 to assess compliance with emergency preparedness regulations and skin integrity related to pressure ulcers.
Findings
The facility was found in compliance with COVID-19 emergency preparedness requirements but failed to ensure proper treatment and prevention of pressure ulcers for residents. Deficiencies were identified related to inconsistent assessment, treatment, and documentation of pressure ulcers in several residents.
Deficiencies (1)
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to ensure staff provided necessary treatment and services to promote healing and prevent infection of pressure ulcers. Staff did not consistently assess, complete treatments as ordered, or notify physicians of deterioration in residents' pressure ulcers.
Report Facts
Census: 59
Residents with pressure ulcers identified: 7
Residents sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Hawkins | RN, LNHA | Performed head to toe skin assessment and reviewed wound care orders for residents #2 and #3 |
Inspection Report
Routine
Deficiencies: 0
Date: Sep 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 09/01/2020 through 09/04/2020 to assess compliance with CMS and CDC recommended practices and relevant regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 4
Date: Aug 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and complaint investigation were conducted due to allegations of abuse, neglect, and failure to follow background screening and reporting requirements.
Complaint Details
The complaint investigation was substantiated. The facility failed to screen a newly hired CNA against the Employee Disqualification List, failed to report an allegation of neglect involving a resident injury within required timeframes, and failed to ensure adequate supervision and safe use of mechanical lifts, resulting in resident harm.
Findings
The facility failed to develop and implement abuse and neglect policies, failed to conduct required Employee Disqualification List (EDL) background checks, failed to report alleged violations timely, and failed to ensure adequate supervision and safe use of mechanical lifts, resulting in resident injury. The facility was found noncompliant with multiple regulatory requirements related to abuse prevention, reporting, and resident safety.
Deficiencies (4)
F607: The facility failed to develop and implement abuse and neglect policies, including screening newly hired employees against the Employee Disqualification List (EDL). A Certified Nursing Assistant (CNA) was employed for 40 days without required EDL checks.
F609: The facility failed to report allegations of abuse and neglect immediately and failed to ensure adequate supervision during resident transfers, resulting in a resident injury from a malfunctioning Hoyer lift and subsequent laceration and hematoma.
F610: The facility failed to conduct a thorough investigation of alleged abuse and neglect, including failure to complete required documentation and timely reporting to the Department of Health and Senior Services (DHSS).
F689: The facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, specifically failing to maintain proper operation and supervision of mechanical lifts, resulting in resident injury.
Report Facts
Census: 63
Sample size: 4
Days CNA employed without EDL check: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in findings related to failure to screen against EDL and improper use of Hoyer lift causing resident injury. |
| Kameron Wilson | LNHA | Named in Plan of Correction regarding abuse and neglect policy education and reporting. |
| HR Director D | Named in Plan of Correction regarding completion of pre-hire screenings and EDL checks. | |
| LPN B | Licensed Practical Nurse | Documented resident injury notification and assessment during investigation. |
| DON | Director of Nursing | Interviewed regarding expectations for EDL checks and investigation procedures. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 26, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 05/21/20 through 05/26/20 to assess compliance with CDC and CMS recommended practices and federal emergency preparedness regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Census: 59
Deficiencies: 16
Date: Oct 11, 2019
Visit Reason
Routine inspection of Delhaven Manor nursing home to assess compliance with regulatory requirements including resident rights, financial management, care planning, medication management, safety, dietary services, hospice care, and facility maintenance.
Findings
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.
Deficiencies (16)
Failed to ensure resident requests for trust fund withdrawals under $100 were honored same day and allowed negative balances in resident trust accounts.
Failed to provide documentation of quarterly resident trust fund statements to residents.
Failed to maintain bond amount at least 1.5 times average monthly balance of residents' personal funds.
Failed to provide dignified dining experience by serving meals on cafeteria trays and leaving lids on tables.
Failed to provide written notice of bed hold policy to residents or representatives at time of hospital transfers.
Failed to accurately code Minimum Data Set assessments regarding life expectancy and tracheostomy/oxygen use.
Failed to update care plans to reflect new pressure ulcers, fall interventions, and nutritional orders.
Failed to ensure proper documentation and clarification of medication orders including diagnoses, code status, oxygen flow, and catheter use.
Allowed residents to keep cigarettes and lighters on their person contrary to smoking policy; failed to secure razors and repair exposed wiring in shower call light.
Failed to provide thorough dialysis assessments, orders, monitoring, and communication with dialysis centers for residents receiving dialysis.
Failed to establish accurate narcotic count reconciliation with signatures at shift changes.
Failed to ensure medication error rate was less than 5%, with two medication errors noted.
Failed to follow puree recipes to ensure food was prepared to conserve nutritive value and flavor for residents on pureed diets.
Failed to ensure food was dated when placed in walk-in refrigerator and reach-in cooler.
Failed to collaborate with hospice providers in coordinated care plans and maintain documentation during hospice provider transition.
Failed to ensure call light systems were functional in all resident shower rooms on second and third floors.
Report Facts
Census: 59
Negative resident trust fund balances: 8
Medication error rate: 7.69
Narcotic count shifts missing signatures: 10
Narcotic count shifts missing signatures: 10
Narcotic count shifts missing signatures: 5
Narcotic count shifts missing signatures: 4
Bond amount: 35000
Average monthly balance: 27533.67
Required bond amount: 42000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication errors, narcotic counts, care plan updates, and hospice collaboration |
| Administrator | Administrator | Interviewed regarding resident trust fund access, smoking policy, call light system, and hospice care |
| Certified Medication Technician A | Certified Medication Technician | Observed administering medications and interviewed regarding medication availability and narcotic counts |
| Dietary Manager | Dietary Manager | Interviewed regarding puree food preparation and food labeling |
| Licensed Practical Nurse I | Licensed Practical Nurse | Interviewed regarding bed hold policy distribution |
| Licensed Practical Nurse F | Licensed Practical Nurse | Observed skin assessment and interviewed regarding pressure ulcer care |
| Certified Nurse Aide E | Certified Nurse Aide | Observed providing incontinence care and skin assessment |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS coding and care plan updates |
| Maintenance Director | Maintenance Director | Interviewed regarding call light system testing and repair |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 16
Date: Oct 11, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Delhaven Manor nursing facility.
Findings
The facility was found noncompliant with multiple federal regulations including management of personal funds, safe environment, care planning, medication administration, food safety, and resident rights. Deficiencies affected all residents and included issues with resident trust fund accounts, care plans, medication errors, and safety hazards.
Deficiencies (16)
F 567 Protection/Management of Personal Funds. The facility failed to ensure resident requests for funds were honored timely and resident trust fund accounts were overdrawn for eight residents.
F 568 Accounting and Records of Personal Funds. The facility failed to maintain accurate accounting and provide quarterly resident trust fund statements to residents.
F 570 Surety Bond-Security of Personal Funds. The facility failed to maintain a sufficient surety bond amount to cover residents' personal funds.
F 584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to provide a dignified dining experience and maintain a safe, clean environment, including exposed wiring in a shower room.
F 625 Notice of Bed Hold Policy Before/Upon Transfer. The facility failed to provide written notice of bed hold policy to residents or representatives at transfer.
F 641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set (MDS) for residents, including life expectancy and tracheostomy care.
F 657 Care Plan Timing and Revision. The facility failed to ensure care plans were updated timely to reflect residents' current needs and conditions.
F 658 Services Provided Meet Professional Standards. The facility failed to ensure staff obtained necessary diagnoses and orders for medications and treatments for residents.
F 689 Free of Accident Hazards/Supervision/Devices. The facility failed to maintain a safe environment by allowing residents to keep cigarettes and razors unsupervised and failed to repair exposed wiring.
F 698 Dialysis. The facility failed to provide consistent dialysis services and monitoring for residents requiring dialysis.
F 755 Pharmacy Services/Procedures/Pharmacist/Records. The facility failed to maintain accurate narcotic count records and ensure nursing staff counted controlled medications properly.
F 759 Free of Medication Error Rates 5 Percent or More. The facility failed to maintain medication error rates below 5%, with a 7.69% error rate documented.
F 804 Nutritive Value/Appear, Palatable/Prefer Temp. The facility failed to follow puree recipes and ensure food was dated and stored properly.
F 812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to maintain proper food storage temperatures and sanitation.
F 849 Hospice Services. The facility failed to collaborate with hospice providers and maintain documentation of hospice care and services.
F 919 Resident Call System. The facility failed to maintain functional call light systems in shower rooms, affecting all residents who showered there.
Report Facts
Resident census: 59
Negative balances: 8
Medication error rate: 7.69
Surety bond amount: 35000
Required bond amount: 42000
Inspection Report
Life Safety
Census: 59
Capacity: 156
Deficiencies: 9
Date: Oct 11, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related regulations, including emergency preparedness and fire safety standards.
Findings
The facility failed to maintain emergency egress lighting for two of four exits, directional exit signage in three smoke compartments, kitchen range hood suppression system maintenance, sprinkler system maintenance, fire drill completion, smoking area ashtray disposal, electrical receptacle testing, and emergency generator inspections. These deficiencies had the potential to affect all residents, staff, and occupants.
Deficiencies (9)
K281 Illumination of Means of Egress: The facility failed to maintain emergency egress lighting for two of four exits, with lights not connected to battery power and requiring manual operation.
K293 Exit Signage: The facility failed to maintain directional exit signage in three smoke compartments, with exit signs lacking directional arrows.
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood suppression system in accordance with NFPA 96 standards, with missing maintenance documentation.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads free of debris and foreign materials, with several heads covered with tape and paint and heads loaded with dust and cobwebs.
K712 Fire Drills: The facility failed to ensure fire drills were completed on each shift quarterly, with four of four quarters reviewed showing deficiencies in drill completion.
K741 Smoking Regulations: The facility failed to ensure metal containers for ashtray disposal were available in the designated smoking area on the third floor.
K914 Electrical Systems - Maintenance and Testing: The facility failed to ensure non-hospital grade electrical receptacles in resident sleeping areas were tested annually, with no documentation of testing found.
K918 Electrical Systems - Essential Electric System: The facility failed to provide a remote manual stop station and annunciator for the emergency generator and failed to ensure weekly visual inspections of the generator and components.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage according to NFPA code, with improper storage and lack of separation of full and empty cylinders.
Report Facts
Facility capacity: 156
Resident census: 59
Fire drill quarters reviewed: 4
Inspection Report
Plan of Correction
Census: 59
Deficiencies: 13
Date: Aug 24, 2018
Visit Reason
The document is a Plan of Correction submitted by Delhaven Manor following a facility inspection conducted on 08/24/2018 to address cited deficiencies.
Findings
The facility was found deficient in multiple areas including resident self-determination, privacy and dignity, comprehensive assessments, medication administration, infection control, food safety, and pressure ulcer prevention. The facility census was 59 at the time of inspection.
Deficiencies (13)
F561 Self-determination: The facility failed to promote resident choice for getting out of bed at preferred times due to insufficient staff assistance.
F578 Advance Directives: The facility failed to ensure accurate resident code status documentation and communication for one resident.
F583 Privacy and Confidentiality: The facility failed to provide privacy during personal care for two residents, including failure to pull privacy curtains.
F636 Comprehensive Assessments: The facility failed to complete comprehensive Minimum Data Set assessments timely for three residents.
F638 Quarterly Review Assessments: The facility failed to complete resident assessments at least every 3 months for five residents.
F641 Accuracy of Assessments: The facility failed to provide accurate resident assessments related to medication for nine residents.
F656 Comprehensive Care Plans: The facility failed to develop and implement individualized care plans for seven residents, including side rail use and oxygen use.
F657 Care Plan Timing and Revision: The facility failed to update care plans timely for six residents.
F686 Treatment and Services to Prevent/Heal Pressure Ulcers: The facility failed to provide adequate care and documentation for pressure ulcers for one resident.
F759 Medication Errors: The facility failed to administer medications with an error rate less than 5 percent, with three medication errors observed.
F812 Food Procurement, Storage, Preparation, and Sanitary Conditions: The facility failed to ensure food was prepared under safe and sanitary conditions, including improper sanitizing of dishes.
F838 Facility Assessment: The facility failed to conduct a complete facility-wide assessment to determine necessary resources for resident care.
F880 Infection Prevention and Control: The facility failed to maintain an effective infection control program, including hand hygiene and use of gloves during incontinence care.
Report Facts
Facility census: 59
Medication errors: 3
Residents sampled: 26
Inspection Report
Life Safety
Census: 59
Capacity: 156
Deficiencies: 17
Date: Aug 24, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and fire safety regulations at Delhaven Manor, including evaluation of emergency preparedness training, fire alarm systems, door locks, emergency lighting, sprinkler systems, and electrical equipment.
Findings
The facility was found deficient in multiple areas including emergency preparedness training, fire alarm system maintenance, door lock mechanisms, emergency lighting functionality, sprinkler system inspections, and electrical equipment safety. Several deficiencies were classified as Class II, indicating moderate severity.
Deficiencies (17)
E037 Emergency Preparedness Training. The facility failed to ensure all newly hired and existing staff were trained annually on emergency preparedness policies and procedures. Training records showed no documentation of emergency preparedness training for any staff.
E039 Emergency Preparedness Testing. The facility staff failed to conduct a community all-hazards approach drill and at least one other full drill or tabletop exercise annually. Records showed no participation in drills or emergencies activating the emergency plan within the past year.
K161 Building Construction Type and Height. The facility failed to maintain the Type II (111) protected construction standard by not sealing openings in ceilings, affecting two smoke sections. The facility had a capacity of 156 and a census of 59 at the time of survey.
K222 Egress Doors. The facility failed to ensure exit doors opened with the fire alarm activation, lacked slide bolts on main entrance doors, and required manual release of locked doors. This affected all residents and staff.
K291 Emergency Lighting. The facility failed to ensure emergency lights on east and west stairwells functioned properly during testing. Emergency lighting did not illuminate when tested, potentially affecting all residents.
K345 Fire Alarm System - Testing and Maintenance. The facility failed to ensure a semiannual fire alarm inspection was completed by a certified inspector. Records showed no semiannual fire alarm inspection.
K353 Sprinkler System - Maintenance and Testing. The facility failed to ensure quarterly sprinkler system inspections were completed. The maintenance supervisor and outside contractor did not complete required quarterly inspections.
K920 Electrical Equipment - Power Cords and Extension Cords. The facility failed to ensure electrical equipment was used safely, with overloaded power strips, extension cords used as permanent wiring, and uncovered outlets in emergency supply room. This affected three smoke compartments.
A2018 Complete Fire Alarm System Requirements. The facility failed to have a complete fire alarm system installed and maintained according to NFPA 101 standards. Deficiency referenced to K222.
A2019 Fire Alarm System-Test/Maintain. The facility failed to test and maintain the fire alarm system as required by NFPA 72. Deficiency referenced to K345.
A2031 Inspections Completed, Certification Annually for Sprinkler System. The facility failed to have inspections and certifications completed annually by a qualified service representative. Deficiency referenced to K353.
A2041 Door Locks. The facility failed to ensure door locks met NFPA 101 requirements for emergency egress. Deficiency referenced to K222.
A2050 Emergency Lighting. The facility failed to provide emergency lighting of sufficient intensity and duration as required. Deficiency referenced to K291.
A2064 Fire Safety Training Requirements-employee. The facility failed to provide fire safety training to all employees during orientation and at least every six months. Deficiency referenced to E037 and E039.
A3001 Substantially Constructed/Maintained. The facility failed to maintain the building in good repair, including sealing ceiling penetrations affecting smoke barriers. Deficiency referenced to K161.
A3030 Electrical Wiring & Equipment Maintained. The facility failed to ensure electrical wiring and equipment were installed and maintained according to code, including improper use of extension cords. Deficiency referenced to K920.
A3037 Extension Cords/Duplex Receptacles. The facility failed to ensure extension cords were UL-approved and used properly, preventing hazards. Deficiency referenced to K920.
Report Facts
Facility census: 59
Facility capacity: 156
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