Delhaven Manor

In the surveyor’s words

From the most serious findings on record at Delhaven Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Jul 10, 2024

  Based on interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included alcohol use and verbal/physical aggression, for one resident (Resident #2). The facility failed to address the behaviors and inform staff how to handle the resident's escalating behaviors. The sample was eight. The census was 62. The Administrator was informed on [DATE] of an Immediate Jeopardy (IJ), which began on [DATE]. […]

• Immediate jeopardy, isolatedF684Dec 23, 2022

  Based on interview and record review, facility staff failed to monitor one resident (Resident #1), in accordance with facility stated standards of practice to ensure the health and safety of residents, when facility staff failed to check on the resident at shift change and every two hours. Facility staff reported administering medications to and speaking to the resident on [DATE] at 9:00 P.M. On [DATE] at 9:00 A.M., the resident was found on the floor, with a coat on. The resident did not have signs of life, and he/she had rigor mortis (stiffening of the joints and muscles of a body a few hours after death). The night shift nurse left the facility at approximately 6:00 A.M. without checking on residents with the day shift nurse. […]

• No harm, potential for more than minimal, widespreadF812Nov 13, 2024

  Based on observation and interview, the facility failed to label, date, and cover food in the kitchen. In addition, the facility failed to ensure that kitchen equipment was clean and was in proper working order. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 60. 1. Observations of the kitchen dry storage room, showed: -On 11/6/24 at 11:14 A.M., 11/7/24 at 4:14 P.M., and 11/8/24 at 2:46 P.M.,: -A package of opened mostaccioli noodles wrapped in plastic without a date; -A package of opened cheese flakes wrapped in plastic without a date; -On 11/6/24 at 11:14 A.M. and 11/7/24 at 4:14 P.M., a package of opened stuffing mix wrapped in plastic without a date. 2. Observation on 11/6/24 at 11:14 A.M. […]

• No harm, potential for more than minimal, patternF570Nov 13, 2024

  Based on interview and record review, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. This deficiency had the potential to affect all residents who have money in the resident trust fund. The census was 60. Review of the facility's Surety Bond Invoice, dated 12/28/23, showed a bond amount of $75000. Review of the facility's average resident trust fund balance for the previous twelve months, showed: -A monthly average of $52,000.00; -For this amount, the bond amount should have been $78,000. During an interview on 11/12/24 at 2:00 P.M., the Business Office Manager said she was not aware the amount was not sufficient and would request an increase immediately. The bond amount should have been sufficient. […]

• No harm, potential for more than minimal, patternF880Nov 13, 2024

  42247 45083 Based on observation, interview and record review, the facility failed to place signage and follow indications for enhanced barrier precautions (EBP, an infection control intervention that utilizes personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms (MDROs)) for two residents who had pressure ulcers (open wounds that occur when skin and tissue are damaged by prolonged pressure), and an indwelling urinary catheter (a flexible tube that drains urine from the bladder into a collection bag) (Residents #42 and #38). In addition, the facility failed to ensure the indwelling urinary catheter bag was off the floor for one resident (Resident #38). […]