Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Delavan Health Services

DELAVAN, WI · 50 certified beds · Last Life Safety survey December 19, 2024

CMS Certification Number 525324 · first certified November 1982

Ownership

Operated by NORTH SHORE HEALTHCARE · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within WI

37 citations — more than 95% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 8 citations; the earlier surveys in the window averaged 14.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (January 2026 to March 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was December 2024. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

Get an email about Delavan Health Services

One email when it happens. No account; stop it any time with one click.

6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 37 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

E-0006

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 37 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	37
Median facility in WI	17
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
June 15, 2022	11
September 27, 2023	18
December 19, 2024	8

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0241	Have correct number of accessible exits for each story.	3	2024-12-19
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2024-12-19
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2024-12-19
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2024-12-19
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	2	2023-09-27
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	2	2023-09-27
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	2	2024-12-19
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2024-12-19

What the citations cover

Citations by CMS category

Smoke Deficiencies 14
Gas, Vacuum, and Electrical Systems Deficiencies 7
Egress Deficiencies 7
Miscellaneous Deficiencies 6
Other 3

Citations by CMS category
Category	Citations
Smoke Deficiencies	14
Gas, Vacuum, and Electrical Systems Deficiencies	7
Egress Deficiencies	7
Miscellaneous Deficiencies	6
Services Deficiencies	2
Emergency Preparedness Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 19, 2024 — 8 citations

Citations issued on December 19, 2024
Tag	What the surveyor checks	Status
K-0241	Have correct number of accessible exits for each story.	Waiver has been granted (January 17, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 17, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 17, 2025)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (January 17, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (January 17, 2025)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (January 17, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 17, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (January 17, 2025)

September 27, 2023 — 18 citations

Citations issued on September 27, 2023
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (October 25, 2023)
K-0222	Add 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.	Deficient, Provider has date of correction (October 25, 2023)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (October 25, 2023)
K-0241	Have correct number of accessible exits for each story.	Waiver has been granted (October 25, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (October 25, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (October 25, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (October 25, 2023)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (October 25, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 25, 2023)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (October 25, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (October 25, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (October 25, 2023)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (October 25, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 25, 2023)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (October 25, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (October 26, 2023)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (October 26, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 26, 2023)

June 15, 2022 — 11 citations

Citations issued on June 15, 2022
Tag	What the surveyor checks	Status
K-0241	Have correct number of accessible exits for each story.	Waiver has been granted (July 13, 2022)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (July 13, 2022)
K-0343	Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.	Deficient, Provider has date of correction (July 13, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 13, 2022)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (July 13, 2022)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (July 13, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 13, 2022)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (July 13, 2022)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (July 13, 2022)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (July 13, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (July 13, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.