A list of the most recent deficiencies for Delhaven Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-25 | 2023-08-26 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-30 | 2023-08-26 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-06-30 | 2023-08-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-30 | 2023-08-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-30 | 2023-08-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-30 | 2023-08-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-30 | 2023-08-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-30 | 2023-08-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-30 | 2023-08-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-30 | 2023-08-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-06 | 2023-08-05 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-27 | 2023-05-16 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-12-23 | 2023-01-30 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-12-23 | 2023-01-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-23 | 2022-12-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-23 | 2022-12-23 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-08-24 | 2021-09-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-25 | 2021-08-20 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-10-11 | 2019-11-25 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-10-11 | 2019-11-25 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-10-11 | 2019-11-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-10-11 | 2019-11-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-10-11 | 2019-11-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-11 | 2019-11-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-11 | 2019-11-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-11 | 2019-11-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-11 | 2019-11-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-11 | 2019-11-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-11 | 2019-11-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-11 | 2019-11-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-11 | 2019-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-11 | 2019-11-25 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-10-11 | 2019-11-25 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-10-11 | 2019-11-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-08-24 | 2018-10-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-08-24 | 2018-10-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-24 | 2018-10-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-24 | 2018-10-08 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-08-24 | 2018-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-24 | 2018-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-24 | 2018-10-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-08-24 | 2018-10-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-24 | 2018-10-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-24 | 2018-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-24 | 2018-10-08 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-08-24 | 2018-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-24 | 2018-10-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-08-24 | 2018-10-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-24 | 2018-10-08 | N |
| Use approved construction type or materials. | Fire Safety | 2018-08-24 | 2018-10-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-08-24 | 2018-10-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-08-24 | 2018-10-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-24 | 2018-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-24 | 2018-10-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-24 | 2018-10-08 | N |
