Deficiency Records for Delhi Post-Acute
Updated as of July 01, 2020
This is not the most recent data for Delhi Post-Acute. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-05 | 2020-02-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-05 | 2020-02-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-05 | 2020-02-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-10 | 2019-12-31 | Y |
| 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 | 2019-12-10 | 2019-12-31 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-10 | 2019-12-31 | Y |
| 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 | 2019-11-07 | 2019-12-31 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-07 | 2019-12-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-07 | 2019-12-31 | Y |
| Post nurse staffing information every day. | Health | 2019-09-17 | 2019-10-18 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-09-17 | 2019-10-18 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-09-17 | 2019-10-18 | Y |
| 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 |
| Be properly staffed | 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 | 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 |
| 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 | 2019-01-16 | 2019-04-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-16 | 2019-02-28 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2018-04-17 | 2018-05-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-17 | 2018-05-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-08 | 2018-05-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-03-08 | 2018-05-15 | Y |
| 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 |
| 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 |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-05-15 | 2017-06-01 | Y |
| Use approved construction type or materials. | Fire Safety | 2016-11-07 | 2016-12-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2016-11-07 | 2016-12-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-11-03 | 2016-12-12 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-11-03 | 2016-12-12 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-11-03 | 2016-12-12 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-11-03 | 2016-12-12 | N |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2016-11-03 | 2016-12-12 | N |
