Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Delhi Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to properly label and store medications, with issues such as missing open and expiration dates on medications, pre-poured medication cups, and personal items stored with controlled substances. LPNs were unaware of the requirements for dating medications with shortened expiration dates, and the DON lacked knowledge about the location of a safe for residents' valuables.
The facility failed to provide palatable and appropriately tempered meals for residents, with numerous complaints about cold, unappetizing food. Observations confirmed meals were served at incorrect temperatures and lacked flavor, violating the facility's policy.
The facility failed to maintain food service safety standards, with a malfunctioning dishwashing machine and soiled equipment across multiple units. Observations revealed zero ppm sanitizing chemical in the dishwashing machine's final rinse and unclean conditions in the main kitchen and serveries, including food debris, black residue, and dead insects.
The facility did not ensure adequate ventilation in the Family Conference Room due to a malfunctioning heating and air conditioning system. The air quality was observed to be humid and stuffy, and the Director of Maintenance noted a clogged water line and failing heat pumps as contributing factors. Temporary window air conditioning units were used in affected areas.
The facility failed to maintain a pest-free environment in the main kitchen and two resident unit serveries, with evidence of insect infestation such as small flies and dead cockroaches. Observations revealed soiled floor drains, missing door sweeps, and vegetation overgrowth. The pest control vendor's recommendations were not fully implemented, and there was a gap in pest control services due to a canceled contract.
A facility failed to conduct comprehensive and accurate assessments for a resident with dementia, hemiplegia, and gastro-esophageal reflux disease. The MDS did not reflect changes in the resident's condition, and assessments were conducted telephonically without the coordinator being physically present in the facility.
The facility failed to update comprehensive care plans for two residents, neglecting to include necessary medical conditions and medication use. One resident had orders for congestion and fungal infection treatments, while another had five medications prescribed for various conditions. Interviews with staff revealed that care plans were not consistently updated to reflect changes in residents' conditions or medications.
The facility did not update Comprehensive Care Plans for two residents, failing to reflect changes in their conditions. One resident's care plan was not revised after a resident-to-resident altercation, while another's care plan did not document the completion of antibiotic therapies. Staff interviews confirmed that care plans should be updated to reflect current conditions and treatments.
Two residents experienced deficiencies in care due to missed specialist appointments and lack of wound care supplies during a Leave of Absence. One resident, with multiple co-morbid conditions, missed appointments due to transportation issues, leading to toe amputations. Another resident went on leave without necessary wound care supplies, resulting in unchanged and soiled dressings. Staff interviews revealed lapses in policy adherence and communication.
A resident with multiple health conditions was left with unattended medication in their room, despite facility policies against such practices. The resident was not assessed for self-administration capability, and no physician's order was documented. Interviews with staff confirmed the inappropriateness of the action, highlighting a lapse in supervision and adherence to safety protocols.
The facility failed to ensure gradual dose reductions for psychotropic medications for two residents, as required by policy. One resident was prescribed Seroquel, Mirtazapine, and Zoloft, while another was prescribed Trileptal, Olanzapine, and Clonazepam, with no documented attempts at dose reduction. Both residents had significant cognitive impairments and psychiatric diagnoses. The facility had recently started using telehealth psychiatric services, and the Nurse Practitioner had only recently received psychiatric certification.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. During the recertification survey, it was observed that medication carts and storage rooms on the Elm and Aspen units contained medications without open and expiration dates, and some labels were illegible. Specifically, opened medications such as insulin pens, inhalers, and eye drops lacked proper dating, and a pre-poured medication cup was found in a medication cart. Additionally, a narcotic was not signed out correctly, leading to discrepancies in the narcotic count. Personal items were improperly stored in a double-locked cabinet with controlled substances, and a wallet and cash were found in a narcotic lock box. Interviews with nursing staff revealed a lack of awareness regarding the requirement to date medications with shortened expiration dates. The Director of Nursing acknowledged that medications should be dated upon opening and checked for expiration during each medication pass, and that nurses should not pre-pour medications. However, there was a lack of knowledge about the location of a safe for residents' valuables.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for 19 out of 32 residents reviewed. Residents expressed dissatisfaction with the quality of food during a resident council meeting, citing issues such as cold, unattractive, and unpalatable meals. Specific complaints included food being consistently cold, lacking flavor, and not meeting dietary needs, particularly for those on specialized diets. Residents reported having to order food from outside due to the unappetizing meals provided by the facility. Observations during test trays on multiple units revealed that meals were served at inappropriate temperatures and lacked flavor. For instance, a lunch meal on the Chestnut unit had items served at temperatures below the recommended levels, and the food was described as bland and lacking condiments. Similar issues were noted on the Fir and Aspen units, where meals were not only served at incorrect temperatures but also missing items as per the meal ticket. These deficiencies were in violation of the facility's policy to provide nourishing and palatable meals that meet residents' dietary needs and preferences.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations, it was noted that the automatic dishwashing machine was not in good repair, as the thermometer was not functioning, and the concentration of sanitizing chemical in the final rinse was zero parts per million, contrary to the required 50 to 100 ppm. Additionally, various equipment in the nourishment rooms and servery kitchens across multiple units were found soiled with food particles or drips, including microwave ovens, refrigerators, and cabinetry. Further observations revealed significant cleanliness issues in the main kitchen and serveries. The main kitchen had soiled floor drains with food debris and black residue, and the area below and behind the dishwashing machine was heavily soiled with a black build-up. Dead insects were found above the suspended ceiling and in ceiling light fixtures. Similar conditions were observed in the Aspen/Birch and Chestnut/Dogwood Serveries, where dead insects and food debris were found on the floors, and a black build-up was noted along the walls and under various kitchen equipment.
Inadequate Ventilation in Family Conference Room
Penalty
Summary
The facility failed to provide adequate outside ventilation in the Family Conference Room due to issues with the heating and air conditioning system. Observations revealed that the air quality in the room was humid and stuffy over two consecutive days. The Director of Maintenance reported that a clogged water line in the closed loop air handler had been affecting the system's performance for about a year. Additionally, several air conditioning heat pumps were failing, with only three replacements available on-site, leading to the temporary use of window air conditioning units in affected rooms.
Pest Control Deficiency in Kitchen and Serveries
Penalty
Summary
The facility failed to maintain a pest-free environment and implement an effective pest control program in the main kitchen and two resident unit serveries. During observations, surveyors found evidence of insect infestation, including swarms of small flies around floor drains and dead cockroaches above suspended ceilings and in ceiling light fixtures. The kitchen and serveries had soiled floor drains with food debris and black residue, and the floors were caked with black build-up and food debris. Additionally, door sweeps were missing on pantry doors, and there was vegetation overgrowth and waste around the building perimeter. The facility's pest control sighting log documented sightings of cockroaches and drain flies over the past year, and the pest control vendor had advised the facility to clean floor drains and kitchen floors daily, install door sweeps, and clear vegetation. However, there was no evidence of pest control services from November 2023 through March 2024, as the vendor canceled their contract. The Director of Maintenance confirmed the sightings and treatment gaps, while the Administrator acknowledged ongoing efforts to address the vendor's recommendations.
Deficiency in Comprehensive Resident Assessment
Penalty
Summary
The facility failed to conduct comprehensive, accurate, and standardized assessments of a resident's functional capacity as required. Specifically, the facility did not complete a comprehensive resident assessment for a resident with multiple diagnoses, including unspecified dementia, hemiplegia, and gastro-esophageal reflux disease with esophagitis and bleeding. The Minimum Data Set (MDS) for this resident did not reflect changes in the resident's physical and medical conditions, such as the need for medication to treat gastrointestinal bleeding. The MDS Coordinator conducted assessments telephonically and relied on information provided by the facility staff through emails and phone calls. The coordinator had never been physically present in the nursing home, which may have contributed to the incomplete and inaccurate assessments. The facility's policy required that assessments accurately reflect the resident's status at the time of assessment, but this was not adhered to in the case of the resident in question.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to address their medical, nursing, and psychosocial needs. Resident #124, who was admitted with diagnoses including unspecified dementia and type 2 diabetes, had orders for medications to treat congestion and a fungal infection. However, the care plan did not document these medical conditions, the use of the medications, or any signs and symptoms of adverse reactions. Similarly, Resident #150, diagnosed with schizoaffective disorder and hypertension, had orders for five medications, but the care plan lacked documentation regarding the medical conditions requiring these medications and their potential adverse effects. Interviews with facility staff revealed that care plans were expected to be updated quarterly and whenever there were changes in a resident's condition or medication regimen. However, the Assistant Director of Nursing acknowledged that care plans sometimes were only updated during care reviews every three months, and the Director of Nursing indicated that the facility focused more on diagnoses rather than specific medications. This oversight led to the deficiency, as the care plans did not reflect the current medical needs and treatments of the residents.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised to reflect the current conditions of two residents. Resident #33, who was admitted with sensorineural hearing loss, chronic obstructive pulmonary disease, and major depressive disorder, experienced a resident-to-resident altercation resulting in injury. Despite this incident, the Comprehensive Care Plan for Behavior and Aggressive tendencies, last updated prior to the altercation, was not revised to address the new circumstances. Interviews with facility staff confirmed that the care plans should have been updated to reflect the resident's changing needs and conditions. Resident #108, admitted with unspecified dementia, hemiplegia, hemiparesis, and gastrointestinal hemorrhage, had a Comprehensive Care Plan for infections that was not updated to document the completion of antibiotic therapies and resolution of infections. The care plan included outdated information regarding cellulitis and urinary tract infections, with no updates after the completion of prescribed antibiotic courses. Interviews with the Assistant Director of Nursing revealed that care plans should be updated as conditions change, and outdated therapies should not remain on the care plan.
Deficiencies in Resident Care Due to Missed Appointments and Inadequate Supplies
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards for two residents, leading to significant health issues. Resident #24, who had multiple co-morbid conditions including diabetes, diabetic foot ulcers, and peripheral vascular disease, missed two scheduled specialist appointments due to transportation issues. This resident subsequently underwent amputation of five toes. The facility's transportation policy required alternative arrangements or rescheduling in case of cancellations, but these were not effectively implemented, contributing to the resident's deteriorating condition. Resident #87, who had intact cognition and was admitted with cervical radiculopathy and other conditions, went on a 3-day Leave of Absence without receiving necessary supplies for daily wound care. Upon return, the resident's dressings were unchanged and observed to be soiled and sliding down both legs. The facility's Out on Pass policy required that residents be provided with medications and supplies for their leave, but this was not adhered to, resulting in inadequate wound care for the resident. Interviews with facility staff revealed lapses in communication and adherence to policies. The Transportation Scheduler prioritized another resident's appointment over Resident #24's, and the Director of Nursing admitted that rescheduling decisions were made without notifying the facility physician or Nurse Practitioner. Similarly, the LPN responsible for Resident #87's care failed to provide dressing supplies due to a last-minute request, and no nurse note was entered. These actions and inactions led to deficiencies in the quality of care provided to the residents.
Unattended Medication Poses Hazard in Resident's Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident. Specifically, medications were left unattended in the resident's room without an assessment to determine if the resident could independently self-administer their medication. The resident, who was diagnosed with multiple sclerosis, bipolar disorder, and failure to thrive, was in the bathroom when the medication was left unattended on their lunch tray. The Minimum Data Set did not document that the resident was capable or desired to self-administer their medications. Facility policies clearly stated that medications should not be left unattended and must be secured in a locked area or under visible control. Observations and interviews with nursing staff confirmed that it was inappropriate to leave medications at the bedside unless the resident had been assessed and deemed capable of self-administration. However, there was no documented evidence of a physician's order or care plan indicating that the resident could self-administer their medications. The nursing staff responsible for leaving the medication unattended was not available for an interview.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents who were prescribed psychotropic medications received gradual dose reductions (GDR), unless clinically contraindicated, as part of an effort to discontinue these drugs. This deficiency was identified during a recertification survey for two residents. Resident #108 was prescribed Seroquel, Mirtazapine, and Zoloft, while Resident #150 was prescribed Trileptal, Olanzapine, and Clonazepam. In both cases, there was no documented evidence that a GDR was attempted, despite the facility's policy requiring routine evaluation and monitoring of psychotropic medications to ensure they are free from unnecessary use. Resident #108 had significant cognitive impairment and was diagnosed with heart failure, unspecified dementia, post-traumatic stress disorder, and depression. Resident #150 had a fluctuating cognitive pattern with disorganized thinking and was diagnosed with schizoaffective disorder, depression, and disruptive mood disorder. Observations and interviews revealed that the facility had recently started using telehealth psychiatric services, and the Nurse Practitioner had only recently received psychiatric certification. The psychiatric provider had never been physically present in the facility, which may have contributed to the oversight in medication management.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Delhi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chestnut Park Rehabilitation And Nursing Center | 15.3 mi | ★★★★★ | 4 | 1 |
| Aurelia Osborn Fox Memorial Hospital | 16.7 mi | ★★★★★ | 0 | 0 |
| Mountainside Residential Care Center | 17.4 mi | ★★★★★ | 0 | 0 |
| Robinson Terrace | 19.5 mi | ★★★★★ | 6 | 0 |
| Roscoe Regional Rehab & Residential H C F | 20.9 mi | ★★★★★ | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.