Inspection·February 28, 2019

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on resident personal needs accounts reviews and staff interview, the facility failed to ensure the authorization to maintain funds was completed. This affected one (#35) of five residents reviewed for new funds accounts opened in the past year. The facility census was 47. Residents Affected - Few Findings include: Review of the resident personal needs accounts (PNA) revealed Resident #35 was identified as newly established PNA accounts in the past 12 months. Review of the facilities resident personal funds authorization papers identified Resident #35 did not have written authorization to maintain her funds. Interview with the Business Office Manager #200 on 02/28/19 at 10:39 A.M. confirmed there was a lack of written authorization for Resident #35. The interview confirmed upon admission the family/resident did not want their funds managed and then later changed their minds, but did not complete an authorization to care for the resident funds. 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: 365676 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 365676 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delaware Court Health Care Center 4 New Market Dr 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)