Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
DELHI REHABILITATION AND NURSING CENTER
DELHI, NY · 176 certified beds · Last Life Safety survey July 30, 2024
CMS Certification Number 335876 · first certified March 2018
Ownership
Operated by PERSONAL HEALTHCARE MANAGEMENT · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
8 citations — more than 20% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 2. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (January 2026 to September 2026). Most NY facilities have been surveyed by February 2027. This facility’s last Life Safety survey was July 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 8 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 8 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 8 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 18, 2019 | 3 |
| February 2, 2022 | 1 |
| July 30, 2024 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 3 | 2024-07-30 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-07-30 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 1 | 2019-09-18 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2024-07-30 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2024-07-30 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Smoke Deficiencies 2
- Emergency Preparedness Deficiencies 2
- Egress Deficiencies 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Smoke Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 30, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (September 23, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 23, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 26, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (September 26, 2024) |
February 2, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (March 31, 2022) |
September 18, 2019 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (November 11, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 11, 2019) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (November 13, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.