Deficiency Records for Delhaven Manor
Updated as of October 01, 2019
This is not the most recent data for Delhaven Manor. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-09-06 | 2017-10-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-09-06 | 2017-10-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-09-06 | 2017-10-10 | 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 | 2017-09-06 | 2017-10-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-09-06 | 2017-10-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-09-06 | 2017-10-10 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-08-31 | 2017-10-10 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-31 | 2017-10-10 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-31 | 2017-10-10 | N |
| Approved construction type or materials. | Fire Safety | 2016-09-01 | 2016-10-16 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-09-01 | 2016-10-16 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2016-09-01 | 2016-10-16 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-09-01 | 2016-10-16 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-09-01 | 2016-10-16 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-09-01 | 2016-10-16 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2016-09-01 | 2016-10-16 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-09-01 | 2016-10-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-09-01 | 2016-10-16 | N |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2016-09-01 | 2016-10-16 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-09-01 | 2016-10-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-09-01 | 2016-10-16 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-09-01 | 2016-10-16 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2016-09-01 | 2016-10-16 | N |
