Delavan Health Services

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review and staff interviews, the facility did not always ensure that 2 out of 4 (R27, R9) residents reviewed with pressure injuries received the necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing. R27 was admitted to the facility with areas of skin impairment to the right lateral ankle- noted to be a stage 3 open area. An area to the right great toe which was noted to be a stage 3 open area and dark blue/purple areas on bottom of feet, possible DT (Deep Tissue). The facility failed to comprehensively assess these areas upon first observation and also failed to obtain a treatment for these areas from 11/4-11/15/21. The facility did not update the individual plan of care with interventions that would assist in healing these areas. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the facility-wide assessment was reviewed and updated at least annually. This had the potential to effect all 40 Residents. The facility did not review and update the facility assessment since 11/1/2017. The facility assessment was last reviewed with QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvment) committee on 11/28/17. Findings Include: Surveyor reviewed the facility's Facility Assessment Tool policy dated 10/2017 and notes the following: Requirement Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their Resident population and the resources the facility needs to care for their Residents. Guidelines for Conducting the Assessment 3. [...]