Inspection Reports for
Delhi Rehabilitation and Nursing Center
41861 State Route 10, Delhi, NY, 13753
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
24 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
371% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jul 30, 2024
Visit Reason
The inspection was a recertification and abbreviated survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including incomplete and untimely comprehensive resident assessments, inadequate development and revision of care plans, failure to provide needed care and services such as transportation and wound care supplies, unsafe medication administration practices, improper storage and labeling of medications, unpalatable and improperly served food, unsanitary food service conditions, and inadequate ventilation in certain areas.
Deficiencies (10)
10 NYCRR 415.11(a)(2): The facility failed to conduct comprehensive resident assessments timely and accurately for 1 of 32 residents reviewed, missing documentation of changes in physical and medical conditions.
10 NYCRR 415.11(c)(1): The facility did not develop and implement comprehensive person-centered care plans with measurable objectives for 2 of 32 residents reviewed, omitting medication use and related care.
10 NYCRR 415.11(c)(2)(i-iii): The facility failed to review and revise comprehensive care plans timely to reflect current resident conditions for 2 of 32 residents, including failure to document completion of antibiotic therapy.
10 NYCRR 415.14(d)(1)(2): The facility did not ensure food and drink were palatable, attractive, and served at safe temperatures for 19 of 32 residents, with complaints of cold, bland, and unappetizing food.
10 NYCRR 415.14(h): The facility failed to store, prepare, distribute, and serve food in accordance with professional standards; the dishwashing machine was not functioning properly and nourishment rooms and servery kitchens were soiled with food debris and dead insects.
10 NYCRR 415.12: The facility did not provide needed care and services to meet residents' physical and psychosocial needs, including missed specialist appointments and lack of wound care supplies during leave of absence for 2 residents.
10 NYCRR 415.12(h)(1): Medications were left unattended at a resident's bedside without assessment for self-administration capability, violating medication administration policies.
10 NYCRR 415.12(1)(2)(ii): The facility failed to implement gradual dose reductions for psychotropic medications for 2 residents, with no documented attempts to taper doses.
10 NYCRR 415.18(d): Drugs and biologicals were not labeled or stored properly; opened medications lacked open or expiration dates, personal items were stored with controlled substances, and narcotic counts were inaccurate.
10 NYCRR 415.29(h): The facility did not provide adequate outside ventilation; air handling systems were malfunctioning causing humid and stuffy conditions in the Family Conference Room.
Report Facts
Residents reviewed: 32
Residents affected: 19
Psychotropic medications ordered: 3
Narcotic count discrepancy: 1
Narcotic count discrepancy: 1
Temperature measurements: 101
Temperature measurements: 76.2
Temperature measurements: 46
Temperature measurements: 49.4
Temperature measurements: 114.6
Temperature measurements: 99.1
Temperature measurements: 51.3
Temperature measurements: 52.2
Temperature measurements: 122
Temperature measurements: 114.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing #1 | Stated care plans should be updated as things change and medications should not be left unattended | |
| Director of Nursing #1 | Stated care plans should be updated quarterly and medications should not be left unattended | |
| Licensed Practical Nurse #5 | Provided information about Resident #24's hospitalizations and wound care | |
| Transportation Scheduler #1 | Provided information about transportation scheduling and rescheduling for Resident #24 | |
| Nurse Practitioner #1 | Stated protocol for missed appointments and telehealth psychiatric services | |
| Licensed Practical Nurse #4 | Stated it was not appropriate to leave medications unattended at bedside | |
| Licensed Practical Nurse #3 | Reported medication storage issues and narcotic count discrepancies | |
| Food Service Director #1 | Acknowledged need to repair dishwashing machine and train staff | |
| Administrator #1 | Provided information about psychiatric services and plans to address ventilation and food service issues | |
| Director of Maintenance #1 | Described air handling system issues and repairs needed |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Jul 30, 2024
Visit Reason
Complaint Survey with 13 health and 4 life safety citations, all Level 2 severity with no actual harm, all corrected by late September 2024.
Findings
Complaint Survey with 13 health and 4 life safety citations, all Level 2 severity with no actual harm, all corrected by late September 2024.
Deficiencies (17)
Care plan timing and revision
Comprehensive assessments & timing
Develop/implement comprehensive care plan
Food procurement, store/prepare/serve-sanitary
Free from unnec psychotropic meds/prn use
Free of accident hazards/supervision/devices
Label/store drugs and biologicals
Maintains effective pest control program
Nutritive value/appear, palatable/prefer temp
Physical environment
Quality of care
Requirements before submitting a request for
Ventilation
Electrical equipment - testing and maintenanc
Ep training program
Fire alarm system - testing and maintenance
Roles under a waiver declared by secretary
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 30, 2024
Visit Reason
The inspection was a recertification and abbreviated survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to update comprehensive care plans reflecting current resident conditions, missed specialist appointments and inadequate wound care supplies during resident leave, unsafe medication administration practices, unpalatable and improperly served food, and pest control issues with insect infestations in kitchen and servery areas.
Deficiencies (5)
F 0657: The facility did not ensure comprehensive care plans were reviewed and revised to reflect resident current conditions for 2 of 32 residents reviewed, including failure to update after resident altercation and incomplete documentation of antibiotic therapy completion.
F 0684: The facility did not provide needed care and services to meet residents' physical and psychosocial needs for 2 of 32 residents, including missed specialist appointments leading to amputation and lack of wound care supplies during leave.
F 0689: The facility did not ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents for 1 of 32 residents; medications were left unattended without assessment for self-administration capability.
F 0804: The facility did not ensure food and drink were palatable, attractive, and served at safe temperatures for 19 of 32 residents; residents reported cold, unappetizing food and test trays confirmed improper temperatures and missing items.
F 0925: The facility did not maintain a pest-free environment and effective pest control program; insect infestations including flies and cockroaches were found in the main kitchen and resident unit serveries, and remediation recommendations were not fully implemented.
Report Facts
Residents reviewed: 32
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 19
Units affected: 3
Resident units serveries inspected: 2
Floor drains inspected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Interviewed regarding care plan updates for Resident #33 | |
| Registered Nurse #1 | Interviewed regarding care plan review and revision process | |
| Assistant Director of Nursing #1 | Interviewed regarding care plan updates and medication policies | |
| Licensed Practical Nurse #5 | Interviewed regarding Resident #24's wound care and hospitalizations | |
| Transportation Scheduler #1 | Interviewed regarding scheduling and rescheduling of Resident #24's appointments | |
| Director of Nursing #1 | Interviewed regarding Resident #24's hospitalizations and appointment notifications | |
| Nurse Practitioner #1 | Interviewed regarding protocol for missed appointments and Out on Pass assessments | |
| Licensed Practical Nurse #4 | Interviewed regarding medication administration policies | |
| Licensed Practical Nurse #3 | Interviewed regarding medication administration and self-administration assessments | |
| Director of Maintenance #1 | Interviewed regarding pest control issues and vendor contract | |
| Administrator #1 | Interviewed regarding pest control remediation efforts |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Sep 8, 2023
Visit Reason
Complaint Survey with 2 health citations (Level 2 severity) related to abuse and neglect and accident hazards, both corrected by November 1, 2023.
Findings
Complaint Survey with 2 health citations (Level 2 severity) related to abuse and neglect and accident hazards, both corrected by November 1, 2023.
Deficiencies (2)
Free from abuse and neglect
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Sep 8, 2023
Visit Reason
The visit was an abbreviated survey to investigate allegations of resident-to-resident sexual abuse, inadequate supervision, and elopement incidents at the nursing facility.
Complaint Details
The survey was complaint-driven, investigating allegations of sexual abuse and inadequate supervision resulting in elopements and resident-to-resident incidents. The complaints were substantiated with multiple incidents documented.
Findings
The facility failed to protect residents from sexual abuse by another resident on two occasions and did not provide adequate supervision to prevent accidents and elopements for several residents. The facility also failed to maintain proper 1:1 supervision as ordered for a high-risk resident.
Deficiencies (2)
F 0600: The facility did not ensure residents were free from sexual abuse by another resident on 7/1/2023 and 8/12/2023, involving inappropriate touching of female residents' breasts by a cognitively impaired male resident.
F 0689: The facility did not provide adequate supervision to prevent accidents and elopements for residents with severe cognitive impairment, including failure to maintain 1:1 supervision as ordered and allowing residents to wander into other residents' rooms or leave the facility undetected.
Report Facts
Residents affected by sexual abuse: 2
Residents affected by inadequate supervision: 3
Duration of 1:1 supervision: 3
Resident #5 elopement duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP #1 | Nurse Practitioner | Ordered 1:1 supervision for Resident #2 after sexual abuse incidents. |
| LPNM #1 | Licensed Practical Nurse Manager | Managed units involved and reported on supervision and incidents related to Resident #2 and Resident #3. |
| RNM #2 | Registered Nurse Manager | Managed units and provided statements regarding supervision failures and resident behaviors. |
| DON | Director of Nursing | Oversaw investigations and supervision orders related to incidents. |
| ADMIN | Administrator | Provided statements on facility policies and incident responses. |
| RNED | Registered Nurse Educator | Conducted investigation for Resident #5 elopement. |
| MD #1 | Physician/Medical Director | Provided medical oversight and statements regarding resident histories and supervision. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Mar 22, 2023
Visit Reason
Complaint Survey with 2 health citations (Level 2 severity) including abuse and neglect and reporting of alleged violations, all corrected by May 12, 2023.
Findings
Complaint Survey with 2 health citations (Level 2 severity) including abuse and neglect and reporting of alleged violations, all corrected by May 12, 2023.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Mar 22, 2023
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse involving inappropriate sexual contact between residents.
Complaint Details
The investigation was complaint-driven based on an allegation that Resident #2 entered Resident #1's room and placed their hand inside Resident #1's incontinence brief without consent during the night of 11/20/2022. The allegation was substantiated by resident statements, video footage, and staff interviews.
Findings
The facility failed to ensure Resident #1 was free from non-consensual sexual contact by Resident #2. The facility also failed to timely report the alleged abuse to the New York State Department of Health within the required 2-hour timeframe.
Deficiencies (2)
F 0600: Protect each resident from all types of abuse including sexual abuse. The facility did not prevent Resident #2 from entering Resident #1's room and making inappropriate sexual advances despite prior care plans addressing such behaviors.
F 0609: Timely report suspected abuse and the results of investigations to proper authorities. The facility failed to report the alleged sexual abuse to the New York State Department of Health within 2 hours of the allegation, reporting over 6 hours late.
Report Facts
Residents reviewed: 5
Residents affected: 1
Residents affected: 3
Hours late reporting abuse: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNM #1 | Registered Nurse Manager | Responsible for care plan implementation and changes; interviewed regarding care plan and incident |
| ADMIN #2 | Former Administrator | Made aware of allegation and called police; interviewed about abuse reporting |
| DON | Director of Nursing | Reviewed video footage and interviewed regarding abuse reporting and investigation |
| NP #1 | Nurse Practitioner | Conducted clinical evaluations of residents involved in the incident |
| LPN #1 | Licensed Practical Nurse | Received abuse report from Resident #1 |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 22, 2022
Visit Reason
Covid-19 Survey with 1 health citation (Level 0 severity) related to responsibilities of providers; required notification, corrected by April 18, 2022.
Findings
Covid-19 Survey with 1 health citation (Level 0 severity) related to responsibilities of providers; required notification, corrected by April 18, 2022.
Deficiencies (1)
Responsibilities of providers; required notif
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Feb 2, 2022
Visit Reason
The survey was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' right to privacy, housekeeping and maintenance, timely reporting of abuse, transfer documentation, comprehensive care planning, discharge planning, activities of daily living assistance, pressure ulcer care, nutritional status monitoring, pain management, staffing levels, dementia care training, medication regimen review, food service safety, and food temperature.
Deficiencies (14)
F 0583: The facility did not ensure residents' mail was delivered unopened, violating residents' right to privacy. This was a repeat deficiency.
F 0584: The facility did not provide effective housekeeping and maintenance services, with walls and floors soiled on 5 of 6 resident units.
F 0609: The facility failed to timely report suspected abuse and neglect for multiple residents and did not investigate or report resident-to-resident incidents appropriately.
F 0622: The facility did not ensure proper documentation and communication for resident hospital transfers, including missing transfer forms and lack of physician communication.
F 0656: The facility failed to develop and implement comprehensive care plans addressing residents' medical, nursing, and psychosocial needs for multiple residents.
F 0660: The facility did not develop, implement, or evaluate an effective discharge planning process for a resident desiring to return home, lacking ongoing discharge plan meetings and social worker involvement.
F 0677: The facility did not ensure residents dependent on staff for ADLs received care consistent with their care plans, including showering, assistance out of bed, and denture/oral hygiene care.
F 0692: The facility did not maintain acceptable nutritional status for multiple residents, failing to obtain weekly weights as ordered, monitor meal intakes consistently, implement nutritional interventions, and ensure residents received all meal items and supplements.
F 0697: The facility did not provide timely pain management to a resident who requested pain medication, resulting in a 24-hour delay after admission.
F 0725: The facility did not ensure sufficient nursing staff to meet resident needs, with Licensed Practical Nurse staffing below desired levels 5 of 6 days and Registered Nurse staffing below desired levels 6 of 6 days.
F 0741: The facility did not ensure staff received adequate dementia care training and guidance to effectively care for residents with dementia.
F 0744: The facility did not provide appropriate treatment and services to a resident with dementia, lacking person-centered care plans and meaningful activities.
F 0756: The facility did not ensure a licensed pharmacist's monthly drug regimen review policy included time frames for process steps and urgent action requirements.
F 0804: The facility did not ensure food was served at appetizing temperatures, with residents receiving cold food and complaints about cold meals.
Report Facts
Deficiencies cited: 13
Licensed Practical Nurses staffing: 12.5
Licensed Practical Nurses staffing: 15
Licensed Practical Nurses staffing: 16
Licensed Practical Nurses staffing: 14
Licensed Practical Nurses staffing: 18.5
Licensed Practical Nurses staffing: 12
Registered Nurses staffing: 3
Registered Nurses staffing: 3
Registered Nurses staffing: 3
Registered Nurses staffing: 3
Registered Nurses staffing: 2
Registered Nurses staffing: 1
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 20
Date: Feb 2, 2022
Visit Reason
Complaint Survey with 19 health and 1 life safety citations, mostly Level 2 severity, covering ADL care, care plans, discharge planning, drug regimen, food sanitation, infection control, notification of changes, nutrition, pain management, privacy, physical environment, staffing, transfer requirements, dementia treatment, and pressure ulcer care, all corrected by March 29-31, 2022.
Findings
Complaint Survey with 19 health and 1 life safety citations, mostly Level 2 severity, covering ADL care, care plans, discharge planning, drug regimen, food sanitation, infection control, notification of changes, nutrition, pain management, privacy, physical environment, staffing, transfer requirements, dementia treatment, and pressure ulcer care, all corrected by March 29-31, 2022.
Deficiencies (20)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Discharge planning process
Drug regimen review, report irregular, act on
Food procurement, store/prepare/serve-sanitary
Infection control
Notify of changes (injury/decline/room, etc. )
Nutrition/hydration status maintenance
Nutritive value/appear, palatable/prefer temp
Pain management
Personal privacy/confidentiality of records
Physical environment
Reporting of alleged violations
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Sufficient/competent staff-behav health needs
Transfer and discharge requirements
Treatment/service for dementia
Treatment/svcs to prevent/heal pressure ulcer
Electrical equipment - testing and maintenanc
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Jan 7, 2022
Visit Reason
Complaint Survey with 4 health citations (Level 2 severity) related to meal frequency, infection prevention, resident rights, and nursing staff sufficiency, all corrected by March 2, 2022.
Findings
Complaint Survey with 4 health citations (Level 2 severity) related to meal frequency, infection prevention, resident rights, and nursing staff sufficiency, all corrected by March 2, 2022.
Deficiencies (4)
Frequency of meals/snacks at bedtime
Infection prevention & control
Resident rights/exercise of rights
Sufficient nursing staff
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Sep 18, 2019
Visit Reason
Recertification survey and abbreviated survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare Part A notices, privacy violations with resident mail, improper use of physical restraints, failure to provide written bed hold notices, late and incomplete resident assessments, incomplete care plans, inadequate activity programming, pressure ulcer prevention deficiencies, nutritional care issues including failure to monitor weight and meal refusals, lack of psychological evaluation for behavioral health needs, medication administration errors, gluten-free diet noncompliance, food safety violations, and lack of policy for foods brought by visitors.
Deficiencies (17)
F 0582: Facility failed to provide residents or representatives with required Medicare Part A termination notices including SNFABN and NOMNC forms.
F 0583: Facility did not ensure residents' mail was delivered unopened, violating privacy rights.
F 0604: Facility used physical restraints by locking a resident's geri chair to tables or counters without assessment, care plan, or physician order.
F 0625: Facility failed to provide written notice of bed hold policy to resident or representative upon hospital transfer.
F 0636: Facility did not complete initial and periodic comprehensive resident assessments within 14 days of admission for multiple residents.
F 0637: Facility failed to complete significant change Minimum Data Set assessment for a resident admitted to hospice services.
F 0638: Facility did not complete required quarterly resident assessments for multiple residents within required timeframes.
F 0640: Facility failed to timely transmit Minimum Data Set assessments to CMS; 171 of 210 assessments were not transmitted within 14 days.
F 0656: Facility failed to develop and implement comprehensive care plans addressing medical, nursing, and psychosocial needs for multiple residents.
F 0679: Facility did not provide adequate activities tailored to resident's mental and physical abilities, limiting engagement for a cognitively impaired resident.
F 0686: Facility failed to provide appropriate pressure ulcer prevention care including initial skin assessment and care planning for a resident at moderate risk.
F 0692: Facility failed to ensure adequate nutritional care including dental consult, care planning, intake monitoring, weight monitoring, and notification of meal refusals for a resident.
F 0740: Facility did not provide necessary behavioral health care and services including failure to complete ordered psychological evaluation for a resident with dementia and behavioral issues.
F 0760: Facility failed to ensure residents were free from significant medication errors; a resident did not receive ordered medications on admission evening.
F 0806: Facility did not ensure gluten free diet was free from gluten-containing foods, failed to provide appropriate gluten free alternatives, and did not prevent cross contamination of gluten free toast.
F 0812: Facility lacked a policy addressing safe use and storage of foods brought by family or visitors including safe food handling and assistance for dependent residents.
F 0813: Facility failed to store, prepare, distribute, and serve food in accordance with professional standards; dented cans, uncalibrated thermometer, and improper sanitizer concentration were observed.
Report Facts
MDS not transmitted timely: 171
Weight loss: 10.29
Meal refusals: 30
Weekly weights obtained: 7
Gluten containing foods on gluten free menu: 5
Dented cans: 2
Sanitizer chemical residual: 0
Out of calibration thermometer: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse MDS Coordinator #2 | Registered Nurse MDS Coordinator | Named in relation to late and incomplete MDS assessments and submissions |
| Director of Nursing | Director of Nursing | Named in relation to restraint findings and pressure ulcer prevention |
| Licensed Practical Nurse Manager (LPNM) #3 | Licensed Practical Nurse Manager | Named in relation to restraint findings and nutritional monitoring |
| Certified Nursing Assistant (CNA) #4 | Certified Nursing Assistant | Named in relation to restraint and activity findings |
| Activity Director | Activity Director | Named in relation to activity program deficiencies |
| Registered Dietitian (RD) #7 | Registered Dietitian | Named in relation to nutritional monitoring |
| Food Service Director (FSD) | Food Service Director | Named in relation to food service and gluten free diet deficiencies |
| Diet Technician (DT) | Diet Technician | Named in relation to nutritional monitoring and gluten free diet |
| Physician | Physician | Named in relation to behavioral health and nutritional care |
| Social Worker | Social Worker | Named in relation to behavioral health and nutritional care |
| Director of Food Service | Director of Food Service | Named in relation to food safety deficiencies |
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