Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview, and review of the facility policy, the facility failed to ensure advanced
directives for the code status were signed by the physician. This affected two (#7 and #20) residents
reviewed for code status in a total facility census of 47.
Findings include:
1. Review of the record for Resident #20 revealed the resident was admitted on [DATE]. Diagnosis included
atherosclerotic heart disease, dementia with behavioral disturbance, major depressive disorder, anxiety
disorder, hypertension, macular degeneration and glaucoma.
Review of the admission minimum data set (MDS) assessment dated [DATE], revealed a brief interview of
mental status score of three, indicating impaired cognition.
Review of undated document titled, DNR (Do Not Resuscitate) Comfort Care DNR Identification Form,
revealed an unsigned copy of an advanced directive for code status by the physician. The document was
signed by the Power of Attorney (POA).
Review of document titled, DNR Comfort Care DNR Identification Form, revealed the advanced directive
was signed by the Clinical Nurse Practitioner (CNP)/Medical Doctor (MD) on 08/02/21 for DNRCC-A. The
facsimile was time stamped on 08/02/21 at 5:28 P.M., and an additional time stamp on 08/02/21 at 6:13
P.M., revealed CNP/Medical Doctor signed and returned the form.
Interview on 08/02/21 at 5:25 P.M. with Minimum Data Set (MDS) Nurse #115, revealed there was an
unsigned copy of the advanced directive for the code status in Resident #20's chart. No other physician
signed forms for the code status were located in the chart at that time. After searching through the physical
chart and the electronic medical record for evidence of a physician signed advanced directive, no signed
copy of the advance directive for code status was found.
Interview on 08/02/21 at 5:47 P.M. with Admissions Coordinator #132, verified there were no physician
signed copies of the advanced directive for code status since this resident's admission to the facility.
Interview on 08/02/21 at 5:47 P.M. of MDS Nurse #115 and Admissions Coordinator #132, revealed the
employees searched in medical records for the overflow files for advanced directives for Resident #20 and
found an old copy from 05/19/21, which was prior to admission to this nursing home indicating DNRCCA,
however, there were no physician signed copies of the advanced directives for code status
(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 8
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
08/05/2021
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)
F 0578
since admission to this nursing facility.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 08/02/21 at 6:00 P.M. with MDS nurse #115, verified there was no physician signed advanced
directives for Resident #20.
Residents Affected - Few
Interview on 08/03/21 at 8:33 A.M. with MDS Nurse #115, verified Clinical Nurse Practitioner (CNP) #200
signed the Advanced Directive for code status last night.
2. Review of the record for Resident #7 revealed the resident was admitted to the facility on [DATE].
Diagnoses included rheumatoid arthritis, severe protein-calorie malnutrition, dementia without behavioral
disturbance, generalized intra-abdominal and pelvic swelling, mass and adult failure to thrive.
Review of the MDS dated [DATE], revealed the resident as having extensive cognitive impairment. Her
functional status was listed as extensive one to two person assist for all activities of daily living.
Review of the care plan dated 05/04/21, revealed the resident as having a Do Not Resuscitate Comfort
Care (DNRCC) status.
Further review of the record revealed the electronic record and the paper record matched for a DNRCC.
However, the record did not contain a physician signature on the DNRCC and the resident had been in the
facility since 05/2020.
Interview with MDS Nurse #115 on 08/02/21 at 6:00 P.M., verified there was no physician signature on the
DNRCC form.
Review of undated facility policy titled, Advance Directives, revealed Advance Directives were legal
documents which can protect the right of the resident to refuse medical care in the event the resident was
no longer able to mentally or physically communicate this right. The policy addressed to check with the
resident or resident's sponsor about Advance Directives at the time of admission. The plans for Advance
Directives were placed in the resident's medical chart and a copy of same in the financial chart. These
include choice for resuscitation, choice for transport, living will, or POA (Power of Attorney) for health care.
The front of the resident's chart will have labels indicating code status, (DNRCC, DNR-Arrest or Full Code)
and if Advance Directives (living will, POA for health care) were in the file. It was the responsibility of the
admissions coordinator, social services, and nursing to assure Directives were in place for each resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365676
If continuation sheet
Page 2 of 8
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
08/05/2021
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)
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and review of an undated form titled, Form Instructions for the Notice of
Medicare Non-Coverage (NOMNC) CMS-10123, the facility failed to ensure appropriate beneficiary notices
were provided to residents. This affected one (#295) of three residents reviewed for provision of beneficiary
notices. The facility census was 47.
Residents Affected - Few
Findings include:
Review of the record for Resident #295 revealed an admission on [DATE] and discharged to the hospital on
[DATE]. Resident #285 did not return to the facility. Diagnosis included orthopedic aftercare, discitis lumbar
region, fusion of spine, urinary tract infection, history transient ischemic heart attack, cerebral infarction due
to unspecified occlusion or stenosis of right middle cerebral artery and history of COVID-19.
Review of the discharge return not anticipated minimum data set (MDS) assessment dated [DATE],
revealed a planned discharge to the community with a discharge date of 04/28/21. Resident #295 had a
Medicare-covered stay since the most recent entry and the most recent Medicare stay end date was
04/28/21.
Review of a document titled, Skilled Nursing Facility (SNF)) Beneficiary Protection Notification Review,
dated 01/2018, revealed Resident #295's Medicare Part A skilled services episode start date of 03/02/21.
The facility/provider initiated the discharge from Medicare Part A services when benefit days were not
exhausted. The required NOMNC (Notice of Medicare Non-coverage) form CMS-10123 was not provided to
the resident with an explanation documented with the following, I was busy and slipped my mind.
Interview on 08/04/21 at 9:45 A.M. with Admissions Coordinator #132, verified the required NOMNC notice
for Resident #295 was not completed.
Review of an undated form titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC)
CMS-10123, revealed a Medicare provider or health plan must deliver a completed copy of the Notice of
Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home
health, comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be
delivered at least two calendar days before Medicare covered services end or the second to last day of
service if care was not being provided daily.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365676
If continuation sheet
Page 3 of 8
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
08/05/2021
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interviews with staff and residents, and review of the facility policy's, the facility failed to
ensure care plans were revised to include an accurate code status, updated fall interventions, and updated
dental concerns. This affected three (#9, #16 and #37) of sixteen residents reviewed for revision of care
plans. Additionally, the facility failed to ensure care conferences were conducted. This affected one (#10) of
one resident reviewed for care conferences. The facility census was 47.
Findings include:
1. Review of medical record for Resident #9 revealed an admission date of 04/21/21. Diagnosis included
encephalopathy, anemia, heart disease, hypertension, Type II diabetes, major depression disorder single
episode, retention of urine, hemorrhoids, history of malignant neoplasm of prostate, unsteadiness on feet
and pain in right shoulder.
Review of the Admission/Medicare 5-day Minimum Data Assessment (MDS) dated [DATE], revealed a brief
interview for mental status score (BIMS) of five, indicating severely impaired cognition. Resident #9
required extensive assistance of two or more persons physical assist for bed mobility, transfers and toilet
use. Resident #9 required supervision of two or more persons physical assistance for walking in room.
Resident #9 had one fall since admission/entry or reentry or the prior assessment, whichever was more
recent. Resident #9 did not exhibit rejection of care.
Review of fall risk screens dated 07/21/21 and 08/04/21, revealed Resident #9 was a high risk for falls.
Review of the current physician orders revealed orders were in place for a mat to the floor with a start date
of 07/23/21.
Review of the care plan dated 04/26/21, revealed an editable care plan. No other care plans were available
for review. The care plan revealed Resident #9 had an alteration in self-mobility and was at risk for a
fall-related injury related to impaired cognition, impaired balance, weakness, unsteady gait, use of
medications that put him at risk for falls and a recent fall while trying to go to the bathroom. Interventions on
the care plan did not include the physician ordered mat to the floor beside the bed for safety that was
initiated on 07/23/21.
Interview on 08/05/21 at 8:53 A.M. with the Director of Nursing (DON), verified the 07/23/21 telephone
order for the mat on the floor beside bed for safety was a current order.
Interview on 08/05/21 at 9:22 A.M. with the DON verified Resident #9's current care plan was not updated
for the mat on the floor beside the bed for safety.
2. Review of medical record for Resident #37 revealed an admission date of 12/24/21. Diagnosis included
hypotension, chronic obstructive pulmonary disease, chronic respiratory failure, atrial fibrillation,
hyperlipidemia, chronic kidney disease, encephalopathy, gastrointestinal bleed and history of COVID-19.
Review of the quarterly Minimum Data Set assessment dated [DATE], revealed a brief interview for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365676
If continuation sheet
Page 4 of 8
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
08/05/2021
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)
F 0657
mental status (BIMS) score of ten, indicating moderately impaired cognition.
Level of Harm - Minimal harm
or potential for actual harm
Review of document titled, Do Not Resuscitate (DNR) Order Form, dated 01/13/21, revealed a signed copy
of an advanced directive for DNRCCA.
Residents Affected - Few
Review of care plan dated 07/13/21, revealed an advanced directive for a status of full code.
Interview on 08/03/21 at 2:32 P.M. with Minimum Data Set (MDS) Nurse #115, confirmed the electronic
medical record care plan indicated Resident #37 was a full code.
Interview on 08/03/21 at 3:03 P.M. with Licensed Practical Nurse (LPN) #149, revealed Resident #37 had a
history of full code status that was changed to DNRCCA on 01/13/21.
Interview on 08/03/21 at 3:11 P.M. with MDS Nurse #115, confirmed she updated the code status for
Resident #37 and now reflected the DNRCCA status. MDS Nurse #115 reviewed the electronic medical
record and confirmed the 07/13/21 care plan, reflected full code when Resident #37 should have been
DNRCCA.
3. Review of medical record for Resident #16 revealed admission date of 05/04/16 with cognitive deficits.
The resident was admitted with diagnoses including Alzheimer's disease , unspecified dementia anxiety,
aphasia and dental caries . The minimum data set (MDS) revealed Resident #16 has her own teeth.
Review of Resident #16's medical record revealed on 11/6/19 to 02/2/21, the resident had a tooth infection
with antibiotic treatment on 11/06/2019. Arrangements had been made for the root of the tooth to be
removed, however, family declined the appointment.
On 06/25/20, Resident #16 was seen by the dentist and recorded several broken down teeth were
observed.
On 02/02/21, Resident #16 was seen by the dentist. Review of the dentist visit note revealed a hospital
referral was to be made if Resident #16 becomes symptomatic of pain or any sign of mouth infection.
On 08/04/21 at 8:30 A.M., interview with LPN #151, revealed they were aware of Resident #16's teeth, and
dental services had been scheduled in the past, however, the residents spouse declined.
On 08/05/21 at 10:45 A.M., MDS Coordinator #115 verified Resident #16's care plan does not include
interventions for tooth pain.
4. Review of the medical record for Resident #10 revealed an admission date of 04/15/21. Diagnoses
included cerebral infarction, diabetes mellitus Type II, and end stage renal disease. Review of the quarterly
minimum data set assessment dated [DATE], revealed Resident #10 was cognitively intact. Review of the
medical record revealed no evidence Resident #10 had a care conference since admission to the facility on
[DATE].
Interview with Resident #10 on 08/02/21 at 9:43 A.M., revealed she has not had a care conference since
she admitted to the facility on [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365676
If continuation sheet
Page 5 of 8
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
08/05/2021
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview with MDS Coordinator #115 on 08/04/21 at 9:58 A.M., revealed care conferences were held upon
admission, quarterly, and as needed. The interview revealed Resident #10 was missed and had no care
conferences since admission to the facility on [DATE].
Review of the undated policy titled, Plan of Care Policy, revealed plan of care meetings will be held and the
plan of care reviewed and updated on a quarterly basis and if a significant change occurs in the resident's
condition. The plan of care will be revised as identified by the medical record. Changes to the plan of care
will be indicated by using a highlighter, dating, and initialing the entry. Family conferences with the resident
and their representatives will be held the week following the assessment completion date. Reasonable
efforts will be made to accomodate those who were unable to attend the scheduled day. A plan of care
conference summary will be signed by those attending and kept with the plan of care to be used by nursing
staff as a communication tool to implement care.
Review of facility policy titled, Fall Prevention and Management Policy and Procedure, revision date
02/2018, revealed a plan of care based on identified risk factors will be implemented. The purpose was to
identify those residents at risk for falls and the creation of an individualized plan of care to reduce the risk of
injuries from falls. Procedures included the fall risk assessment which indicated a total score of ten or
greater was considered at high risk for potential falls and preventative interventions should be initiated and
documented on the plan of care. Procedures for fall management when a fall occurs included to plan and
initiate new fall prevention intervention. The interdisciplinary team would review the investigation of the fall
and the preventative intervention that was put into place. The result of the review will be documented on the
post incident evaluation and the approved intervention will be placed on the resident's comprehensive plan
of care and added to the tasks on the resident's point of care [NAME].
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365676
If continuation sheet
Page 6 of 8
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
08/05/2021
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations, staff interview, and review of the facility policy, the facility failed to ensure fall
interventions were implemented. This affected one (#9) of two residents reviewed for implementation of fall
interventions. The facility census was 47.
Findings include:
Review of medical record for Resident #9 revealed an admission date of 04/21/21. Diagnosis included
encephalopathy, anemia, heart disease, hypertension, Type Two diabetes, major depression disorder single
episode, retention of urine, hemorrhoids, history of malignant neoplasm of prostate, unsteadiness on feet
and pain in right shoulder.
Review of Admission/Medicare 5-day Minimum Data Assessment (MDS) dated [DATE], revealed a brief
interview for mental status score (BIMS) of five, indicating severely impaired cognition. Resident #9
required extensive assistance of two or more persons physical assist for bed mobility, transfers and toilet
use. Resident #9 required supervision of two or more persons physical assistance for walking in room.
Resident #9 had one fall since admission/entry or reentry or the prior assessment whichever was more
recent. Resident #9 did not exhibit rejection of care.
Review of current physician orders revealed orders were in place for a mat to the floor with a start date of
07/23/21.
Review of the treatment administration record (TAR) for 08/2021, revealed the mat on the floor was not on
the record.
Review of the current care plan dated 04/26/21, revealed an editable care plan. No previous care plans
were available. The care plan revealed Resident #9 had an alteration in self-mobility and was at risk for a
fall-related injury related to impaired cognition, impaired balance, weakness, unsteady gait, use of
medications that put him at risk for falls and a recent fall while trying to go to the bathroom. Interventions
did not include the intervention for a mat to the floor beside the bed for safety that was initiated on the
physician orders on 07/23/21. Review of the full care plan revealed mats to the floor beside the bed were
not on the care plan.
Review of fall risk screens dated 07/21/21 and 08/04/21, revealed Resident #9 was a high risk for falls.
Review of nursing progress notes revealed Resident #9 had a fall on 07/23/21 and 08/04/21, with no major
injuries. On 07/23/21, Resident #9 was found lying on his right side in front of his dresser. On 08/04/21,
Resident #9 was found on the floor, sitting on buttocks on the right side of the bed at 1:18 A.M., with no
apparent injuries.
Observations on 08/03/21 from 3:50 P.M. through 08/05/21 at 8:55 A.M. of Resident #9, revealed Resident
#9 was in his room with no mat on the floor beside the bed, including when Resident #9 was in the bed.
Interview on 08/05/21 at 8:53 A.M. with the Director of Nursing (DON) revealed the mat on the floor
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365676
If continuation sheet
Page 7 of 8
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
08/05/2021
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
beside the bed for safety would be documented on the TAR. The DON verified the 07/23/21 telephone order
for the mat on the floor beside the bed for safety was a current order.
Interview on 08/05/21 at 9:05 A.M. with admission Coordinator #132, verified there were no mats on the
floor of any kind in Resident #9's room.
Residents Affected - Few
Interview on 08/05/21 at 9:07 A.M. with Minimum Data Set (MDS) Nurse #115, verified there were no mats
on the floor and no mats present in Resident #9's room.
Interview on 08/05/21 at 9:22 A.M. with the DON verified Resident #9's current care plan was not updated
for the mat on the floor beside the bed for safety. The DON revealed she was going to go put a mat on the
floor now.
Interview on 08/05/21 at 1:52 P.M. with Licensed Practical Nurse (LPN) #149, revealed Resident #9 has
had some falls and most recently a couple days ago he slid on the edge of the bed.
Review of facility policy titled, Fall Prevention and Management Policy and Procedure, revision date
02/2018 revealed each resident will be assessed for fall risk during the admission process. A plan of care
based on identified risk factors will be implemented. The purpose was to identify those residents at risk for
falls and the creation of an individualized plan of care to reduce the risk of injuries from falls. Procedures
included the fall risk assessment which indicated a total score of ten or greater was considered at high risk
for potential falls and preventative interventions should be initiated and documented on the plan of care.
Procedures for fall management when a fall occurs included to plan and initiate new fall prevention
intervention. The interdisciplinary team would review the investigation of the fall and the preventative
intervention hat was put into place. The result of the review will be documented on the post incident
evaluation and the approved intervention will be placed on the resident's comprehensive plan of care and
added to the tasks on the resident's point of care [NAME].
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365676
If continuation sheet
Page 8 of 8
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Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0753GeneralS&S Epotential for harm
Have restrictions on the use of highly flammable decorations.
FAQ · About this visit
Common questions about this visit
What happened during the August 5, 2021 survey of DELAWARE COURT HEALTH CARE CENTER?
This was a inspection survey of DELAWARE COURT HEALTH CARE CENTER on August 5, 2021. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DELAWARE COURT HEALTH CARE CENTER on August 5, 2021?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arra..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.