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 Post-acute during CMS and state inspections, most recent first.
A cognitively intact resident with COPD, vascular dementia, and major depressive disorder reported that an LPN sent explicit photos of her exposed breasts, allowed the resident to have sexual contact with her breasts, and touched the resident’s genitals. The resident stated that the LPN recorded a video of this sexual contact using the resident’s personal phone, and facility leadership and surveyors later viewed video evidence clearly showing the LPN’s face and exposed breasts during the encounter. Law enforcement was notified and reported that the LPN confessed to sexual contact with the resident, despite a facility policy stating residents must be free from abuse, including sexual abuse.
The facility failed to report an allegation of staff-to-resident sexual abuse to the state agency within required federal timeframes. A resident with COPD, vascular dementia with behavioral disturbance, and major depressive disorder, who had intact cognition and required staff assistance for bathing, was the subject of the allegation. The facility became aware of the alleged abuse but did not submit the Self-Reported Investigation to the state agency until more than 24 hours after discovery, despite a written abuse policy requiring allegations to be reported within federally mandated timeframes.
A resident with COPD, anxiety disorder, and osteoporosis, who had intact cognition but was dependent on staff for all ADLs, used a power wheelchair with a seatbelt for mobility. However, the resident’s care plan did not address the use of the power wheelchair or seatbelt, and the medical record contained no assessment of the appropriateness of the seatbelt. The DON and DOR confirmed both the resident’s use of the device and the absence of any related assessment or care plan, resulting in a deficiency in comprehensive care planning for device use.
Surveyors observed two ceiling vents with brown, fuzzy buildup in the kitchen, including one directly above the meal prep area. The Dietary Director confirmed the vents were dirty and could blow debris onto food, creating a risk of contamination for all residents.
Two residents with complex medical conditions had incomplete and inaccurate documentation of PRN pain medication administration, with multiple instances where medications were signed out but not properly recorded on the MAR, contrary to facility policy.
A facility failed to obtain and implement hospital recommendations for BiPAP use for a resident with COPD and heart failure, resulting in the resident using the device without physician orders. The resident had a BiPAP machine in her room, which was initially unused due to staff unfamiliarity. The DON confirmed the resident used the machine without orders, and an LPN was observed adjusting the device without knowing the correct settings. Facility policy required checking medical records and physician orders before using such devices, which was not adhered to.
A resident with chronic pain conditions did not receive nine doses of Lyrica as ordered due to the medication being unavailable in the facility and emergency supply. The facility's policy required timely administration of medications, which was not adhered to, leading to a deficiency finding.
The facility's Dietary Director, in position since January 2024, lacked the required food service manager certification, potentially affecting 94 of 95 residents receiving meals. Despite working towards certification, the DD had not scheduled the exam, as confirmed by interviews with the DD, Administrator, and RD. The job description required completion of an approved dietary manager's course.
The facility did not follow the approved menu, affecting 94 residents. The planned lunch included Polish sausage, sauerkraut, mashed potatoes, green beans, and cake, but the served trays lacked green beans and cake. Instead, an orange was provided, which was not an appropriate substitute. The Dietary Director cited staffing issues, and the RD confirmed the menu should be followed.
The facility failed to maintain cleanliness in the kitchen, affecting 94 residents. Observations showed a dirty ice machine, a dusty fan blowing towards clean dishes, and a dusty dish rack. Interviews confirmed the lack of cleaning logs and inadequate cleaning schedules. Facility documents lacked guidelines for cleaning, and the existing schedule did not meet manufacturer's recommendations.
A resident with an anxiety disorder missed four doses of Ativan due to the facility's failure to reorder the medication in a timely manner. Despite having a physician's order for Ativan every six hours, the medication supply was exhausted, and the resident confirmed the lack of medication. Interviews with nursing staff revealed that the normal process for reordering was not followed, and the facility's policy on ensuring a sufficient supply of medications was not adhered to.
A resident with an anxiety disorder missed four doses of Ativan due to the facility's failure to reorder the medication in a timely manner. Despite the facility's policy to reorder medications at least two days before the last dose, the staff did not follow this procedure, leading to a significant medication error. Interviews confirmed the oversight and the resulting missed doses.
A resident with an anxiety disorder did not receive prescribed doses of Ativan due to an exhausted supply, yet the medication was inaccurately documented as administered by an RN. The error was confirmed by the RN and acknowledged by the DON, highlighting a documentation deficiency in the facility.
Failure to Protect Resident From Sexual Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member. A cognitively intact resident with COPD, vascular dementia, and major depressive disorder, who required setup or cleanup assistance for mobility and transfers, reported that an LPN sent him pictures of her exposed breasts and allowed him to have sexual contact with her breasts. The resident stated that the LPN also touched his genitals on at least one occasion, though he could not recall the date. The resident reported that the LPN videotaped him sucking on her breasts using his personal cell phone, and he later showed a portion of this video to surveyors, which clearly depicted the LPN’s face and exposed breasts. The DON and Administrator viewed a video on the resident’s phone showing approximately 45 seconds of sexual contact between the resident and the LPN, with both clearly visible. The facility’s self-reported incident documentation and subsequent investigation concluded that the allegation of sexual abuse by the LPN toward the resident was substantiated. Law enforcement became involved, and detectives confirmed that the LPN confessed to having sexual contact with the resident and that they were pursuing a sexual battery charge. These events occurred despite a facility policy stating that residents have the right to be free from abuse, including sexual abuse.
Failure to Timely Report Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident sexual abuse to the Ohio Department of Health (ODH) within required federal timeframes. A resident admitted with COPD, vascular dementia with behavioral disturbance, and major depressive disorder, who had intact cognition per a recent MDS and was dependent on staff for bathing, was the subject of the allegation. The facility’s Self-Reported Investigation (SRI) for this resident showed the allegation was discovered on 02/01/26, but the SRI was not created until 02/02/26 at 12:06 p.m. The DON confirmed that the facility received notification of the alleged staff-to-resident sexual abuse on 02/01/26 at 11:00 a.m. and did not report the incident to the state agency until more than 24 hours later, despite a facility policy requiring allegations to be reported within federal timeframes. This deficiency was identified through medical record review, review of the facility’s SRI, staff interview with the DON, and review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy dated April 2021, which states that any allegations must be reported within timeframes required by federal requirements.
Failure to Care Plan and Assess Seatbelt Use with Power Wheelchair
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of a power wheelchair with a seatbelt for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and osteoporosis, and had intact cognition but was dependent on staff for all ADLs. Review of the resident’s care plan dated 12/12/25 showed no inclusion of the power wheelchair or seatbelt use, and the medical record lacked any assessment of the appropriateness of the seatbelt in the power wheelchair. During interviews, the DON and DOR confirmed that the resident used a power wheelchair with a seatbelt for mobility, that no assessment regarding seatbelt use had been conducted, and that the resident’s plan of care should have reflected the use of the seatbelt. These findings demonstrate that the facility did not develop and implement a complete, measurable care plan that addressed all of the resident’s needs related to the use of the power wheelchair and seatbelt, nor did it perform an assessment to determine the appropriateness of the device, resulting in a deficiency in comprehensive care planning for device use.
Unclean Kitchen Vents Observed Over Food Prep Area
Penalty
Summary
During an initial tour of the facility kitchen, surveyors observed two ceiling vents with a brown, fuzzy buildup, with one vent located directly above the meal preparation area. The Dietary Director confirmed that the vents were dirty and acknowledged the potential for debris to be blown onto the food preparation area, which could contaminate food. This deficiency was identified during the course of a complaint investigation and had the potential to affect all residents in the facility, which had a census of 102 at the time of the survey.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, specifically regarding the documentation of medication administration. For one resident with diagnoses including COPD, CKD, schizophrenia, and diabetes, there were multiple instances where oxycodone-acetaminophen was signed out for administration, but the corresponding medication administration record (MAR) either lacked documentation of administration or had discrepancies in timing. On several occasions, the medication was signed out at specific times, but there was no documentation to confirm that the medication was actually administered. Similarly, for another resident with diagnoses including above-the-knee amputation, COPD, and peripheral vascular disease, the MAR and sign-out sheets for oxycodone showed that the medication was signed out at various times, but documentation of administration was either missing or did not correspond with the sign-out times. Interviews with the DON and Administrator confirmed that the facility was unaware of these documentation lapses until the issue was identified during the survey. Facility policy requires that the date and time of medication administration be recorded in the resident's medical record, which was not consistently followed in these cases.
Failure to Implement and Document BiPAP Use
Penalty
Summary
The facility failed to timely obtain and implement hospital recommendations for the use of positive airway pressure devices for a resident, and there were no physician orders for these devices. Resident #72, who had chronic obstructive pulmonary disease (COPD) and diastolic heart failure, was admitted to the facility and later discharged to the hospital due to shortness of breath and other complications. Upon returning to the facility, the hospital discharge summary recommended the use of BiPAP while sleeping, but there were no specifications for the settings, and no follow-up was conducted to clarify these settings. The medical record for Resident #72 showed no progress notes regarding follow-up with the hospital for BiPAP settings, and there were no physician orders for its use. The resident had a BiPAP machine in her room, which was unused for several nights because the staff did not know how to apply it. An unidentified nurse eventually set up the device, and the resident used it herself at bedtime without any physician orders. The Director of Nursing (DON) confirmed that the resident used the machine without orders and was unsure how it was delivered without an order. During an observation, a Licensed Practical Nurse (LPN) was seen adjusting the BiPAP mask for the resident, who was using the machine without a physician order. The LPN was unaware of the correct settings and had to check the order, which did not exist. The facility's policy required nurses to check the medical record for baseline oxygen saturation levels and review the physician's order for settings before using positive air pressure devices, which was not followed in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide medications as ordered for a resident, identified as Resident #72, who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. The resident's care plan indicated a risk for pain due to shingles neuropathy, chronic back pain, and toe fractures, with interventions to administer medications as ordered. However, the Medication Administration Record for August 2024 showed that the resident did not receive nine doses of Lyrica 75 mg on specific dates because the medication was unavailable. The deficiency was confirmed during an interview with a registered nurse who verified the unavailability of the medication in both the facility and the emergency supply. The facility's policy on administering medications, dated April 2019, required medications to be administered in a safe and timely manner, within one hour of their prescribed time. This deficiency was investigated under Complaint Number OH00158245.
Dietary Director Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Director of Food and Nutrition Services met the necessary qualifications for a dietary supervisor position. The Dietary Director (DD), who had been in the role since January 2024, was in the process of completing her certified dietary manager course but had not yet obtained the required food service manager certification. Interviews with the DD, the facility's Administrator, and the Registered Dietitian (RD) confirmed that the DD was working towards certification but had not scheduled the exam. The Administrator acknowledged that the DD did not meet the qualifications for her position, as outlined in the job description, which required completion of an approved dietary manager's course. This deficiency had the potential to affect 94 of the 95 residents receiving meals from the kitchen.
Failure to Follow Approved Menu
Penalty
Summary
The facility failed to adhere to the planned menu as approved by the dietitian, which had the potential to affect 94 of 95 residents receiving meals from the kitchen. On the specified date, the planned lunch menu included Polish sausage on a bun, sauerkraut, garlic mashed potatoes, green beans, and Jello rainbow cake. However, observations revealed that the lunch trays served included Polish sausage on a bun, mashed potatoes, and sauerkraut, but lacked green beans and cake. Instead, an orange was provided for residents with a regular diet order, canned fruit for those with a mechanical soft diet order, and apple slices for residents with a renal diet order. Interviews with the Dietary Director and Registered Dietitian confirmed that the menu was not followed as planned. The Dietary Director acknowledged the absence of green beans and cake, citing a lack of staff to bake the cake. The Registered Dietitian, who had not reviewed the menus since they were approved by a previous dietitian, stated that the facility should follow the menus and that an orange was not an appropriate substitute for cake. The Director of Nursing and the Administrator also confirmed that the kitchen staff should adhere to the menus and obtain approval from the dietitian for any changes. The facility's policy, revised in October 2008, mandates that menus meet residents' nutritional needs, be prepared in advance, and be followed, with all menus reviewed and approved by the dietitian.
Deficiencies in Kitchen Sanitation and Equipment Cleaning
Penalty
Summary
The facility was found to have deficiencies in maintaining cleanliness and sanitation in the kitchen, which had the potential to affect 94 of 95 residents receiving meals. Observations revealed a black and pink substance on the interior ice shield of the ice machine, which remained uncleaned over two days. Additionally, a fan in the dish room had dust and dirt buildup, with dust visibly blowing towards clean dishes. A metal dish rack used for storing clean water pitchers also had dust buildup. Interviews with facility staff, including the Administrator, Maintenance Director (MD), Registered Dietitian (RD), and Director of Nursing (DON), confirmed the lack of cleanliness and the absence of a cleaning log for the fans. The ice machine was scheduled for cleaning every six months, but the MD suggested a quarterly schedule might be necessary. The RD noted general cleaning needs and emphasized the importance of keeping equipment clean to prevent contamination. Facility documents lacked guidelines for cleaning the ice machine, fan, and dish racks, and the existing cleaning schedule did not align with the manufacturer's recommendations for more frequent cleanings.
Medication Reordering Failure Leads to Missed Doses
Penalty
Summary
The facility failed to ensure that medications were ordered and available for administration as prescribed by the physician for a resident diagnosed with an anxiety disorder. The resident had a physician's order for Ativan, an antianxiety medication, to be administered every six hours. However, the facility ran out of the medication, resulting in the resident missing four doses over two days. The medication error report confirmed that the Ativan supply was exhausted, and the resident confirmed the lack of medication. Interviews with nursing staff revealed that the normal process for reordering medications was not followed. The staff did not reorder the Ativan in a timely manner, despite the facility's policy requiring medications to be reordered at least two days before the last available dose. The Regional Nurse Consultant and the Director of Nursing confirmed that the staff should have reordered the medication earlier, and the failure to do so led to the missed doses. The facility's policy emphasized the importance of ensuring a sufficient supply of medications and timely administration, which was not adhered to in this case.
Failure to Administer Ativan Due to Reordering Lapse
Penalty
Summary
The facility failed to ensure that Resident #40 was free from significant medication errors, specifically regarding the administration of Ativan, an antianxiety medication. Resident #40, who was cognitively intact and diagnosed with an anxiety disorder, had a physician's order for Ativan to be administered every six hours. However, the facility ran out of the medication, resulting in the resident missing four doses between May 19 and May 20, 2024. The medication error was confirmed through interviews with the resident and nursing staff, who acknowledged the lack of medication and the failure to reorder it in a timely manner. The facility's policy required that medications be reordered at least two days before the last available dose, or when there were ten doses left. Despite this, the staff did not reorder the Ativan in time, leading to the medication error. Interviews with the nursing staff and the Director of Nursing confirmed that the facility did not follow its policy, resulting in the resident missing the prescribed doses. The Director of Nursing acknowledged the significant medication error and the failure to administer the medication as ordered.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident diagnosed with an anxiety disorder. The resident was prescribed Ativan, an antianxiety medication, to be administered every six hours. However, the Medication Administration Record (MAR) indicated that the medication was documented as administered by a registered nurse, despite the medication supply being exhausted, resulting in missed doses. The registered nurse confirmed that the medication was not administered due to the inability to access the emergency box, and the documentation was made in error. The Director of Nursing acknowledged that medication should not be documented as administered unless it has actually been given. This deficiency affected one resident out of a sample of 19, within a facility census of 95 residents.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayley Place | 0.5 mi | ★★★★★ | 11 | 0 |
| Western Hills Retirement Village | 1.2 mi | ★★★★★ | 0 | 0 |
| Aventura At West Park | 3.3 mi | ★★★★★ | 5 | 0 |
| Brookside Healthcare Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Edith Lane Of Cincinnati | 3.8 mi | ★★★★★ | 4 | 0 |
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