F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and interview, the facility failed to prepare food in a clean environment. This had the
potential to affect all residents of the facility. The facility census was 102 at the time of survey.Findings
include:During initial tour of the facility kitchen on 09/25/25, two ceiling vents were observed to have a
brown, fuzzy build up on them. One vent was positioned directly over the meal prep area.Interview with
Dietary Director #203 on 09/29/25 at 11:10 A.M. confirmed that the vents were dirty and had the potential
to blow debris onto the food prep area and contaminate the food.Interview with the Administrator on
09/29/25 revealed that the vents were removed and thoroughly cleaned.This was an incidental finding
discovered during the course of the complaint investigation.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
365530
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365530
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Delhi Post-Acute
5999 Bender Road
Cincinnati, OH 45233
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to maintain clinical records, including medication
administration, in accordance with accepted professional standards and practices that are complete,
accurately documented, and readily accessible. This affected two residents (#2 and #4) of four residents
reviewed. The facility census was 102 at the time of survey.Findings include:1.Review of the medical record
revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive
Pulmonary Disease (COPD), Chronic Kidney Disease (CKD), Schizophrenia, and Type II Diabetes
Mellitus.Resident #2 had an order for oxycodone-acetaminophen oral tablet 5-325 mg Give 1 tablet by
mouth every 6 hours as needed for pain.Review of the July sign-out sheet and medication administration
record (MAR) for Resident #2's oxycodone-acetaminophen revealed that the medication was signed out for
administration on 07/05/25 at 05:30, 12:15, 08:30, and 15:11 with administration documented at 05:32 and
12:18. On 07/06/25 the medication was signed out for administration at 21:30 with no documentation for
administration. On 07/07/25 the medication was signed out for administration at 07:00 and 13:00 with no
documentation for administration. 2.Review of the medical record revealed Resident #4 was admitted to the
facility on [DATE]. Diagnoses included Acquired Absence of Left Leg Above the Knee, COPD, and
Peripheral Vascular Disease.Resident #4 had an order for oxycodone HCl Oral Capsule 5 mg by mouth
every 6 hours as needed for pain.Review of the August sign-out sheet and MAR for Resident #4's
oxycodone revealed that the medication was signed out for administration on 08/26/25 at 15:15 and 9:30
P.M. with administration documented at 23:14. On 08/27/25 the medication was signed out at 00:00, 06:00,
14:30, and 8:30 with no documentation of administration. On 08/28/25 the medication was signed out at
14:00, 18:00, and 00:28 with documentation of administration at 18:00.Interview with Director of Nursing on
09/29/25 at 9:12 A.M. revealed that the facility was unaware of medications being signed out and not
documented as being given. Interview with Administrator on 09/29/25 revealed that an investigation was
initiated and an Self Reported Incident (SRI) was filed regarding the matter. Facility policy titled
Administering Medications dated April 2019 states As required or indicated for a medication, the individual
administering the medication records resident's medical record the date and time the medication was
administered.This deficiency represents non-compliance investigated under Complaint Number 2603422
Event ID:
Facility ID:
365530
If continuation sheet
Page 2 of 2
