Delavan Health Services

In the surveyor’s words

From the most serious findings on record at Delavan Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Apr 18, 2022

  Based on record review and interviews, the facility did not ensure a resident's advanced directives for code status were implemented. This was observed with 1 (R1) of 5 sampled residents. R1 was admitted to the facility on [DATE]. At the time of admission, the facility presented a CPR/DNR (cardiopulmonary resuscitation/do not resuscitate) to R1's spouse who indicated R1 wanted to have a DNR for their code status. R1 was their own person and should have made their own decisions. On [DATE] the facility presented the CPR/DNR form to R1 who continued to indicate they wanted DNR as their code status. This form was signed by R1 and witnessed by facility staff. […]

• Immediate jeopardy, isolatedF684Apr 18, 2022

  Based upon interview and record review, the facility failed to ensure 1 (R1) of 5 sampled residents reviewed for a change in condition received care and treatment to reach their highest practicable well-being based upon assessment and current standards of practice, in particular, N6 Wisconsin Nurse Practice Act. On [DATE] R1 was observed in the facility dining room to experience a change in condition that included difficulty breathing including grasping for air and panic while grabbing R1's throat as R1 struggled to breathe. Nursing staff did not complete a thorough assessment that was shared with the physician for consultation on what care and treatment should be provided to R1. […]

• Actual harm, isolatedF686Jun 15, 2022

  Based 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Dec 19, 2024

  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… […]

• No harm, potential for more than minimal, patternF842Aug 6, 2026

  Based on record review and staff interviews, the facility did not ensure 9 out of 12 sampled residents (R9, R10, R11, R3, R13, R8, R2, R4, and R31) medical records contained Physician progress notes. R9, R10, R11, R3, R13, R8, R2, R4, and R31 have Physician-C designated as their Primary Care Physician while residing at the facility. The facility did not maintain Physician-C's progress notes in the residents' medical record. This is evidenced by: Facility policy entitled, Designated Record Set, effective May 2018.Purpose: To describe the documents that comprise the Designated Record Set.The Company maintains the following as the Designated Record Set:The resident Medical Record;The resident Business Office File;The resident Personal Health Records. […]