Health inspection·June 26, 2024

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, and policy review, the facility failed to provide comprehensive urostomy care for one (#40) of four residents reviewed for indwelling urinary drainage device. The facility identified one resident (#40) who had a urostomy used in his care. The facility census was 85. Findings Include: Review of the medical record for Resident # 40, revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified hydronephrosis, perinephric abscess and diabetes mellitus type two. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 was cognitively intact and was to have an indwelling catheter for his urinary elimination. Observation of Resident #40 on 06/24/24 at 2:40 P.M. revealed the resident had a bath basin lying on the floor on the left side of his bed that had a nephrostomy drainage bag lying on the bottom of the basin covered in liquid. The resident had a nephrostomy drainage bag anchored to the right side of his bed frame with a bath basin sitting on the floor under the drainage bag with a small amount of reddish liquid in the bath basin. Interview with Resident #40 at the same time, revealed his nephrostomy tubes were leaking and he had to go to an outside appointment to get them replaced. The resident stated the right bag had been leaking for a week and the left bag had been leaking for three weeks Observation and interview on 06/24/24 at 2:44 P.M. with the Director of Nursing (DON) in Resident #40's room confirmed the nephrostomy bags should not be leaking/draining into bath basins on the floor. The DON verified the left nephrostomy bag was lying in urine in the bath basin and should not be stored in that manner. The DON stated the facility had replacement nephrostomy bags that were delivered last week and available to use. The DON stated the right drainage bag did not have the stopper correctly in place and she corrected its placement and the bag stopped leaking. Review of the facility policy titled Nephrostomy and Cystostomy Tube Care and Maintenance revised on 01/01/22, revealed residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. The care and maintenance of nephrostomy/cystostomy tubes shall be in accordance with physician orders. (continued on next page) 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 4 Event ID: 365408 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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)