01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-12-19 | 1 | 2024-12-19 | 8 |
| Cycle 2 | 2023-09-27 | 4 | 2023-09-27 | 18 |
| Cycle 3 | 2022-06-15 | 7 | 2022-06-15 | 11 |
CMS CCN 5253242026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Delavan Health Services
905 E Geneva St · Delavan, WI 53115 · Walworth County
Certified beds50CMS provider file
Recent citation rows49current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
49 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 13 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-12-19 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · FIREK0241Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have correct number of accessible exits for each story.
Correction field: Waiver has been granted · 2025-01-172024-12-19 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · FIREK0521Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · FIREK0712Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · FIREK0761Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-08-19 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-09-11 · complaint2023-09-27 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement 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.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0223Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0241Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have correct number of accessible exits for each story.
Correction field: Waiver has been granted · 2023-10-252023-09-27 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0346Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-27 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2023-10-2503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- NSHF OPERATIONS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/24/2017
- MILLS, DAVIDIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST20% · since 06/29/2017
- CIBC BANK USAOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 12/31/2024
- BAUMANN, TROYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/29/2017
- HOEHN, JEFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/29/2017
- CIBC BANK USAOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/31/2024
- CLIFTONLARSONALLEN LLPOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/22/2018
- CONTINUUM THERAPY PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2025
- NORTH SHORE HEALTHCARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2017
- NSH REHAB LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2025
- WIPFLI LLPOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2025
- BAUMANN, TROYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2017
- BELONGIA, CHRISTINAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2019
- GEE, DARRENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/30/2021
- GREER, LAURENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/29/2023
- HOEHN, JEFFREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2017
- HOLMSTROM, LAURAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2017
- PATZER, COLLEENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/14/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.21per resident day
RN hours1.15per resident day
Weekend nurse hours2.88per resident day
Staff turnover34.2%CMS reported field
06 / LOCAL RECORDS
Open the Wisconsin ledger →Other published facilities nearby
No second facility in the same city met the directory rule.