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Delavan Health Services Inspection Report, Violations & Safety Grade (DELAVAN, Wisconsin)

905 E GENEVA ST, DELAVAN, Wisconsin 53115

Phone: 2627286319

CMS Overall:5/5

Overview & Bed Count

Certified Beds
50
Avg Residents/Day
39.3
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Walworth
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall5/5
Health5/5
Staffing4/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityWisconsin AvgDifference
RN Hours per Resident per Day1.170.98+0.18
Total Nurse Hours per Resident per Day3.484.25-0.77
CMS Staffing Rating4/53.7/5-
Nursing Staff Turnover28.2%46.7%-

Health Citation History

6 health citations on record

DateCategoryDescriptionSeverity
2026-08-06Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.E – Moderate Harm Potential
2024-12-19Infection Control DeficienciesProvide and implement an infection prevention and control program.F – Moderate Harm Potential
2024-08-19Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2023-09-27Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2023-09-27Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential
2023-09-27Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential

Fire Safety Citation History

34 fire safety citations on record

DateCategoryDescriptionSeverity
2026-08-06Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.E – Moderate Harm Potential
2026-08-06Egress DeficienciesProvide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.E – Moderate Harm Potential
2026-08-06Smoke DeficienciesInstall an approved automatic sprinkler system.E – Moderate Harm Potential
2026-08-06Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2026-08-06Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2026-08-06Egress DeficienciesHave correct number of accessible exits for each story.D – Moderate Harm Potential
2026-08-06Smoke DeficienciesConstruct fire resistant interior walls.D – Moderate Harm Potential
2026-08-06Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.D – Moderate Harm Potential
2024-12-19Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2024-12-19Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2024-12-19Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.E – Moderate Harm Potential
2024-12-19Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.E – Moderate Harm Potential
2024-12-19Egress DeficienciesHave correct number of accessible exits for each story.D – Moderate Harm Potential
2024-12-19Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.D – Moderate Harm Potential
2024-12-19Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.D – Moderate Harm Potential
2024-12-19Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.C – Minimal Harm Potential
2023-09-27Emergency Preparedness DeficienciesConduct risk assessment and an All-Hazards approach.F – Moderate Harm Potential
2023-09-27Egress DeficienciesProvide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.F – Moderate Harm Potential
2023-09-27Egress DeficienciesInstall emergency lighting that can last at least 1 1/2 hours.F – Moderate Harm Potential
2023-09-27Smoke DeficienciesFollow proper procedures when the fire alarm was out of service for more than 4 hours.F – Moderate Harm Potential
2023-09-27Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2023-09-27Smoke DeficienciesFollow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.F – Moderate Harm Potential
2023-09-27Miscellaneous DeficienciesProvide a written emergency evacuation plan.F – Moderate Harm Potential
2023-09-27Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2023-09-27Miscellaneous DeficienciesHave restrictions on the use of highly flammable decorations.F – Moderate Harm Potential
2023-09-27Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.F – Moderate Harm Potential
2023-09-27Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.F – Moderate Harm Potential
2023-09-27Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2023-09-27Egress DeficienciesAdd doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.E – Moderate Harm Potential
2023-09-27Egress DeficienciesHave correct number of accessible exits for each story.E – Moderate Harm Potential
2023-09-27Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2023-09-27Smoke DeficienciesProvide properly protected cooking facilities.E – Moderate Harm Potential
2023-09-27Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2023-09-27Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.E – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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