A list of the most recent deficiencies for Delhi Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-12 | 2023-07-27 | Y |
| Keep all essential equipment working safely. | Health | 2022-12-19 | 2023-01-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-22 | 2022-12-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-11 | 2022-02-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-11 | 2022-02-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-02 | 2021-12-20 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-02 | 2021-12-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-02 | 2021-12-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2021-06-30 | 2021-09-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-28 | 2021-08-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-28 | 2021-08-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-06-28 | 2021-08-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-28 | 2021-08-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-28 | 2021-08-19 | N |
| 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. | Health | 2021-06-28 | 2021-08-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-28 | 2021-08-19 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-06-28 | 2021-08-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-06-28 | 2021-08-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-28 | 2021-08-19 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2021-06-30 | 2021-08-19 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-06-30 | 2021-08-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-30 | 2021-08-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-06-30 | 2021-08-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-30 | 2021-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-30 | 2021-08-19 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-06-30 | 2021-08-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-30 | 2021-08-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-09 | 2021-04-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-09 | 2021-04-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-08 | 2021-04-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-08 | 2021-04-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-28 | 2019-04-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-02-28 | 2019-04-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-28 | 2019-04-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-02-28 | 2019-04-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-28 | 2019-04-26 | N |
| Respond appropriately to all alleged violations. | Health | 2019-02-28 | 2019-04-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-28 | 2019-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-28 | 2019-04-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-02-28 | 2019-04-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-28 | 2019-04-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-02-28 | 2019-04-26 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-02-28 | 2019-04-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-02-28 | 2019-04-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-02-28 | 2019-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-28 | 2019-04-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-26 | 2019-04-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-11 | 2018-02-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-11 | 2018-02-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-01-11 | 2018-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-11 | 2018-02-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-01-11 | 2018-02-28 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-01-11 | 2018-02-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-01-11 | 2018-02-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-01-11 | 2018-02-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-01-11 | 2018-02-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-01-11 | 2018-02-28 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-01-11 | 2018-02-28 | N |
| Provide or obtain dental services for each resident. | Health | 2018-01-11 | 2018-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-11 | 2018-02-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| 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. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-01-12 | 2018-02-28 | N |
