Delavan Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 36 residents. * The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Reflect changes in program members - Include the Infection Preventionist (IP) - Identify control measures based on where Legionella could grow and spread and identify how to monitor the control measures and risks - Identify acceptable ranges of control limits and corrective actions to take when control limits are not met * The facility did not implement Enhanced Barrier Precautions (EBP) for 1 resident (R13) when R13 required EBP as recommended by the Center for Disease Control (CDC) and per the facility's policy. Findings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment, alleged violations are thoroughly investigated for 2 of 6 (R1 and R3, R4) reviewed for abuse. A review of the facility self-report involving R1, showed an allegation of neglect and the investigation into this allegation is not complete. R1 reported that her legs were wet, she was in pain, and had asked for her dressing to be changed and none of those needs were met. A review of the facility self-report involving R3 and R4, showed an allegation of abuse. R3 reported R4 touched R3 above the breast and 1-2 inches below the collar bone. Findings include: The facility's policy Abuse, Neglect and Exploitation last revised on 715/22 includes, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure a fall was thoroughly investigated, along with a corrective intervention, in a transport van. This was discovered with 1 (R11) of 5 residents reviewed with accidents. * R11 had a fall in a transport van on 4/1/23 and there was not an investigation completed at the time of the event. There was no documented corrective action/intervention from this fall. Findings include: Surveyor reviewed the policy and procedure for Fall Prevention and Management Guidelines dated 11/8/2022. - Section 7. When any resident experiences a fall, the facility will: 5) Environmental review for possible factors; 6) Contributing factors to the fall; 9.b) Complete an incident report in Risk Management; 9.e.) Document all assessments and actions. On 09/25/23 at 09:11 AM Surveyor spoke with R11. R11 goes out to dialysis three times a week. R11 indicated they fell in the van twice because of no seatbelt. R11 thought it was a couple months ago. R11 did not have any injury. R11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not always ensure that 1 (R8) out of 4 residents reviewed, were given psychotropic medications for valid reasons, with appropriate behavioral interventions and adequate monitoring. * R8 was administered scheduled Quetiapine Fumarate (Seroquel- antipsychotic) and Venlafaxine (Effexor-antidepressant) with no identified targeted behaviors for staff to be monitoring in order to determine the effectiveness of each medication. Findings include: On 9/27/23 the facility's policy and procedure titled Psychotropic Medications dated 10/24/22 was reviewed and read: the facility will identify an indication for use. The indications for use of any psychotropic drug will be documented in the medical record. The resident's response to medication, including progress toward goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. R8 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia and Bipolar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure the medication error rate was below 5%. During medication pass, surveyors observed 3 errors out of 36 opportunities with a medication error rate of 8.33%. * 2 (R35 and R31) of 4 residents observed during medication administration did not receive their medication as ordered. R35 received one spray of Futicasone nasal spray in each nostril instead of two sprays as per physician order. R35 received 2 puffs of the Fluticasone inhaler instead of the physician order of one puff. On 9/26/23 at 7:47am, R31 was administered Metoprolol Succinate ER 25 mg when it should have been held if R31's heart rate was below 60. R31's heart rate was 59. Findings include: 1. On 9/26/23 at 8:03 a.m. Surveyor observed RN-F administer medications to R35. R35 was administered Fluticasone Proprionate nasal suspension 50 mcg/act one spray in each nostril. R35 was also administered Fluticasone Propionate HFA Inhalation Aerosol 110 mcg/act two quick puffs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility did not follow an effective infection control program to help prevent the transmission of infections for 1 (R34) of 5 residents observed for medication administration and for 14 ( R17, R2, R4, R29, R246, R10, R43, R42, R26, R18, R21, R38, R37, and R41) of 40 residents observed during meal tray pass. During medication administration on 6/14/22, Licensed Practical Nurse (LPN)-D touched 2 pills with her bare hands and placed them in the med cup for R34. LPN-D dropped a pill onto the medication cart and then picked it up with her bare hands and placed it in the med cup for R34. LPN-D administered the potentially cross contaminated pills to R34. During 2 meals, staff did not perform hand hygiene inbetween delivering meal trays to 16 residents potentially cross contaminating food trays. Findings include: Surveyor reviewed the facility's Administering Medications policy with a revision date of April 2019. Documented was: Policy Statement Medications are administered in a safe and timely manner, and as prescribed . 25. Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that 1 (R21) of 12 sampled Residents were reasonably accommodated by providing Residents access to a call light. Findings include: Surveyor reviewed the facility's Call Light, Use of policy and procedure effective June 2017 and notes the following: Purpose * To respond promptly to Resident's call for assistance. * To ensure call system is in proper working order. Procedure 8. When providing care to Resident, be sure to position the call light conveniently for the Resident to use. Tell the Resident where the call light is and show him/her how to use the call light. 9. Orient all new Residents to the call light at the bedside as well as the call light in the bathroom, shower, or tub rooms. Have the Resident demonstrate the use of the call light to be sure he/she understands your instructions. 11. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. R21 was admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure each Resident received adequate supervision or assistance devices to prevent accidents for 1 (R38) of 4 Residents reviewed for falls. * R38 had a fall on 6/11/22. R38 has an intervention documented on R38's care plan to not place R38 in a nightgown until ready for bed and to encourage R38 to stay in common area after supper to detour R38 from attempting to self transfer to bed. R38's fall incident report documented R38 was placed in night gown and left in R38's wheelchair. Findings Include: Surveyor reviewed the facility's Fall Prevention and Management Guidelines policy and procedure revised 3/10/21 and noted the following: Policy The facility will maintain a fall prevention and management program. Fall Prevention and Management Guidelines Objectives: *Limit or prevent the occurrence of falls with the parameters that can be controlled through structured program interventions. Details of Key Elements B. Plan of Care 1. Specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews the facility did not always ensure that 1 out of 1 residents reviewed (R9) who entered the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterized was necessary. R9 was admitted with a stage #4 pressure ulcer to the sacral wound. R9 was also noted to be incontinent of urine. On 11/1/21, the Wound MD ordered for R9 to have an indwelling catheter put in place to aide in healing of the sacral wound. The facility did not develop a plan of care with interventions to prevent urinary tract infections while the catheter was in use as well as did not have a goal for the removal of the catheter when R9's clinical condition no longer demonstrated that the catheterization was necessary. This is evidenced by: R9 was admitted on [DATE] with diagnosis that included Multiple Sclerosis, abnormal posture, muscle weakness generalized, insomnia, mood disorder, visual hallucinations, major depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not always ensure that 2 out of 5 (R7 and R9) residents reviewed for unnecessary medications and the daily use of a Anti-psychotic medication were comprehensively assessed for possible adverse consequences such as Tardive dyskinesia (abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected.) Monthly medication reviews, completed by the licensed Pharmacist, recommenced over a period of several months that both R7 and R9 have an AIMS (Abnormal Involuntary Movement Scale) assessment conducted to determine if there may be any adverse consequences to the continued use of a psychotropic medications. The facility did not respond to these recommendations in a timely manner. This is evidenced by: 1. R7 was admitted on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.