Delhi Post-Acute

In the surveyor’s words

From the most serious findings on record at Delhi Post-Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801May 23, 2024

  Based on staff interview and facility document review, the facility failed to ensure that the designated director of food and nutrition services met the requirements for a dietary supervisor of a facility kitchen. This had the potential to affect 94 of 95 residents who received meals from the kitchen. Findings include: Interview on 05/20/24 at 9:01 A.M. with the Dietary Director (DD) confirmed she had been in the position since January 2024, and she was in the process of completing her certified dietary manager course. Interview on 05/23/24 at 9:02 A.M. with the Administrator confirmed the DD did not have a food service manager certification. […]

• No harm, potential for more than minimal, widespreadF803May 23, 2024

  Based on review of the facility menu, observation, staff interview, facility document review, and facility policy review, the facility failed to follow the planned menu as approved by the dietitian. This had the potential to affect 94 of 95 residents who received meals from the kitchen. Findings include: Review of the facility menu dated 05/21/24 revealed the planned lunch menu included Polish sausage on bun, sauerkraut, garlic mashed potatoes, green beans, and Jello rainbow cake. Observation on 05/21/24 at 11:22 A.M. revealed the lunch trays included a Polish sausage on a bun, mashed potatoes, and sauerkraut. […]

• No harm, potential for more than minimal, widespreadF812May 23, 2024

  Based on observation, staff interview, review of facility documents and policies, and review of the United States Food and Drug Administration (USFDA) Code, the facility to ensure kitchen equipment used in resident food preparation was kept clean and free of dust and debris. This had the potential to affect 94 of 95 residents who received meals from the kitchen. Findings include: Observation on 05/20/24 at 9:09 A.M. revealed there was a black and pink substance on the interior ice shield of the ice machine in the kitchen. Observation on 05/21/24 at 10:25 A.M. revealed the black and pink substance remained on the interior shield of the ice machine in the facility kitchen. Observation on 05/21/24 at 10:33 A.M. […]

• No harm, potential for more than minimal, widespreadF908Dec 19, 2022

  Based on resident and staff interviews, observations, and record reviews, the facility failed to maintain an operating telephone system. This had the potential to affect all 88 residents residing in the facility. Findings: Random observations throughout the survey n 12/15/22 revealed nursing staff making telephone calls on their cell phones related to facility business. An attempt to call the facility from an outside telephone number on 12/15/22 at 9:44 A.M. revealed the facility telephone rang four times and an option menu was offered. A selection was made for the nursing department and a message was received the voicemail was full. During an interview on 12/15/22 at 10:45 A.M. […]

• No harm, potential for more than minimal, patternF561Aug 27, 2026

  Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to honor a resident request to be transferred using a slide board. This affected one (Resident #100) of three residents reviewed for choices. Based on medical record review and staff interview, the facility also failed to honor resident choice in conjunction with completion of Advanced Beneficiary Notifications (ABNs.) This affected four (Residents #65, #94, #113, #115) of four residents reviewed for ABNs. The facility census was 104 residents. […]