DELHAVEN MANOR

Nursing Home Inspector

5460 DELMAR BLVD
SAINT LOUIS, MO 63112
St Louis City County
Phone: 314-361-2902
Provider Number: 265392
Last Inspection: 08/31/2017

About the Nursing Home

Number of Beds: 156
Number of Residents: 56
Beds Available: 100
Percent Occupancy: 36%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Individual
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

11

Facility
25

County
21

MO
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

11

2017
30

2016
21

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/31/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 10/10/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 10/10/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 10/10/2017
 

9/1/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 10/16/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 10/16/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 10/16/2016
 
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Isolated : Minimal 3 10/16/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/16/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 10/16/2016
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Pattern : Minimal 4 10/16/2016
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Minimal 4 10/16/2016
 

11/19/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 1/3/2016
 
Failed To: Completely assess the resident at least every twelve months. Pattern : Minimal 4 1/3/2016
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Pattern : Minimal 4 1/3/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 1/3/2016
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 1/3/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 1/3/2016
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

5/3/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 6/17/2016
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 6/22/2016
 

3/17/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 4/30/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 4/30/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MO State Avg
Number of Residents 56 101.29 74.26
Registered Nurses 0.51 0.46 0.60
Licensed Practical / Vocational Nurses 0.92 0.72 0.72
Certified Nursing Assistants 2.11 2.24 2.43
Total Staff Hours 3.54 3.42 3.75

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MO State Avg%
of high risk long-stay residents with pressure ulcers 13 7 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 86 88
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96 89 93
of long-stay residents experiencing one or more falls with major injury 1 2 4
of long-stay residents who have depressive symptoms 0 1 3
of long-stay residents who lose too much weight 9 4 7
of long-stay residents who received an antianxiety or hypnotic medication 10 19 26
of long-stay residents who received an antipsychotic medication 10 17 18
of long-stay residents who self-report moderate to severe pain 5 7 7
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 24 14 15
of long-stay residents whose need for help with daily activities has increased 30 12 14
of long-stay residents with a catheter inserted and left in their bladder 3 1 2
of long-stay residents with a urinary tract infection 9 3 4
of low risk long-stay residents who lose control of their bowels or bladder 19 26 32
of short-stay residents assessed and appropriately given the pneumococcal vaccine 79 50 74
of short-stay residents who newly received an antipsychotic medication 0 11 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 50 48 68
of short-stay residents with pressure ulcers that are new or worsened 5 2 2