Delaney Park Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Delaney Park Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 3, 2023

  Based on interview, and record review, the facility failed to protect a resident's right to be free from neglect by not obtaining his history of actual attempts to end his life and neglected to provide appropriate care and services for behavioral needs for 1 of 3 residents reviewed for neglect, out of a total sample of 11 residents, (#1). Resident #1, a [AGE] year-old male, with physical and cognitive impairment was admitted to the facility on [DATE]. The facility failed to obtain the resident's history of suicide attempts from his family and on [DATE], resident #1 threatened to end his life. The facility implemented one-to-one (1:1) supervision and consulted the psychologist and psychiatrist. […]

• Immediate jeopardy, isolatedF740Mar 3, 2023

  Based on interview and record review, the facility failed to prevent a vulnerable, cognitively, and mentally impaired resident, from ending his life and failed to implement the psychologist's recommendations and failed to do a Level II Preadmission Screening and Resident Review (PASARR) assessment for 1 of 3 residents reviewed for behavioral health services, out of a total sample of 11 residents, (#1). Resident #1, a [AGE] year-old male, with physical and cognitive impairment was admitted to the facility on [DATE]. The facility failed to obtain the resident's history of suicide attempts from his family and on [DATE], resident #1 threatened to end his life. The facility implemented one-to-one (1:1) supervision and consulted the psychologist and psychiatrist. […]

• No harm, potential for more than minimal, widespreadF882Jul 18, 2025

  Based on interview, and record review, facility failed to ensure the facility had an Infection Preventionist responsible for the facility's Infection Prevention and Control Program (IPCP) with qualifications and current specialized training to ensure implementation, monitoring and managing the IPCP.Findings:On 7/14/25 at 3:40 PM, the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) was responsible for overseeing the IPCP. She said the position had been vacant for 3 weeks and she was designated by the Administrator as the Infection Preventionist required to work at least part-time in addition to working full-time as the DON.Review of the Job Description for the ADON included the summary of position as responsible for assisting with developing, organizing,… […]

• No harm, potential for more than minimal, patternF584Jul 18, 2025

  Based on observation, and interview, the facility failed to maintain a homelike environment in 30 resident rooms on one of two floors, (100 wing) by failing to maintain ceiling vent covers with a clean and sanitary surface.Findings:Observations of resident rooms on the first floor on 7/14/25 at 2:10 PM, revealed ceiling vent covers with a variance in color over the entire surface area from black to white. The surface also had rust-colored substance around the edges. (photographic evidence obtained)In an interview with the resident representative for resident # 85, she stated she has asked staff to address the unsanitary appearance of the vents because they did not look clean and appeared as if they have a mold-like substance or accumulation of debris on the surface.On 7/15/25 at 10:30 AM,… […]

• No harm, potential for more than minimal, patternF880Jul 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control policies and procedures were followed to implement the infection prevention and control plan by failing to initiate enhanced barrier precautions for 24 residents on one of two floors (100 unit), failed to ensure transmission-based isolation was the least restrictive for one of two residents reviewed for transmission-based precautions, (#30); failed to document process surveillance, including identification of pertinent process surveillance from the infection control risk assessment, and failed to follow transmission-based precautions to help prevent the spread of infection on one of two wings, (100 wing) for 2 of 2 residents reviewed for transmission-based precautions (#82, and #30), of a… […]