A list of the most recent deficiencies for Delavan Health Services. 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-19 | 2023-10-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-19 | 2023-10-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-19 | 2023-10-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-27 | 2023-10-25 | 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 | 2023-09-27 | 2023-10-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-27 | 2023-10-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-19 | 2023-10-25 | 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 | 2023-09-19 | 2023-10-25 | 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 | 2023-09-19 | 2023-10-25 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-19 | 2023-10-25 | 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 | 2023-09-19 | 2023-10-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-15 | 2022-07-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-15 | 2022-07-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-07-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-15 | 2022-07-13 | 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 | 2022-06-15 | 2022-07-13 | 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 | 2022-06-15 | 2022-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-15 | 2022-07-13 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-18 | 2022-05-16 | Y |
| 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 | 2022-04-18 | 2022-04-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-15 | 2021-10-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-11 | 2021-05-12 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-05-11 | 2021-05-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-11 | 2021-05-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-05-11 | 2021-05-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-11 | 2021-05-12 | N |
