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Deficiency Records for Delhi Rehabilitation and Nursing Center
A list of the most recent deficiencies for Delhi Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Delhi Rehabilitation and Nursing Center. 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 | 2024-07-30 | 2024-09-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-30 | 2024-09-26 | 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 | 2024-07-30 | 2024-09-26 | 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 | 2024-07-30 | 2024-09-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-30 | 2024-09-26 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-30 | 2024-09-26 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2024-07-30 | 2024-09-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-07-30 | 2024-09-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-07-30 | 2024-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-30 | 2024-09-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-07-30 | 2024-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-30 | 2024-09-18 | 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 | 2024-07-30 | 2024-09-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-07-30 | 2024-09-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-08 | 2023-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-08 | 2023-11-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-22 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-22 | 2023-05-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-02 | 2022-03-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-02-01 | 2022-03-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-02 | 2022-03-29 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-02-02 | 2022-03-29 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-02 | 2022-03-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-02 | 2022-03-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-02 | 2022-03-29 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-02-02 | 2022-03-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-02-02 | 2022-03-29 | 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 | 2022-02-02 | 2022-03-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-02 | 2022-03-29 | 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 | 2022-02-02 | 2022-03-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-02 | 2022-03-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-02 | 2022-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-02 | 2022-03-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-02 | 2022-03-29 | 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 | 2022-02-02 | 2022-03-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-02 | 2022-03-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-07 | 2022-03-02 | 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 | 2022-01-07 | 2022-03-02 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-01-07 | 2022-03-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-03-02 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-09-18 | 2019-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-18 | 2019-11-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-18 | 2019-11-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-18 | 2019-11-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-09-18 | 2019-11-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-18 | 2019-11-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-18 | 2019-11-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-09-18 | 2019-11-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-09-18 | 2019-11-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-18 | 2019-11-11 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-18 | 2019-11-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-18 | 2019-11-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-18 | 2019-11-11 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-09-18 | 2019-11-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-18 | 2019-11-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-09-18 | 2019-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-18 | 2019-11-11 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-09-18 | 2019-11-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-09-18 | 2019-11-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-18 | 2019-11-11 | N |
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