Inspection·November 18, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, the facility failed to ensure that the shower rooms were maintained in a clean and sanitary condition. This was noted in all four of the facility's shower rooms and impacted all residents who used them (Residents #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #39, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, and #54). The facility census was 54. Findings include: Observation on 11/14/24 at 8:55 A.M. revealed the 300's shower room contained black-spotted substances along the grout lines and tile, specifically at the bottom of the wall beneath the shower head and in the corners. Observation on 11/14/24 at 8:58 A.M. revealed the 100's shower room showed black-spotted substances along the grout lines and tile at the bottom of the wall under the shower head and in the corners. The shower chair had deteriorating fabric, with black-spotted substances and long, twisted hairs between the legs and base of the chair. Observation on 11/14/24 at 9:01 A.M. revealed the 200's hallway shower room had a black-spotted substance along the grout lines and tile, particularly at the bottom of the wall under the shower head and in the corners. Observation on 11/14/24 at 9:04 A.M. revealed the 400's hallway shower room had a black-spotted substance along the grout lines and tile, particularly at the bottom of the wall under the shower head and in the corners. Observation on 11/14/24 at 11:47 A.M. revealed the 300's hallway shower room had not been cleaned, with black-spotted substances along the grout lines and tile, and unknown black substances and hair on the shower chair. Observation on 11/14/24 at 11:54 A.M. revealed the 100's hallway shower room had not been cleaned, with black-spotted substances along the grout lines and tile. Observation on 11/14/24 at 12:01 P.M. revealed the 200's hallway shower room had not been cleaned, with black-spotted substances along the grout lines and tile. Observation on 11/14/24 at 12:04 P.M. revealed the 400's hallway shower room had not been cleaned, (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 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 11/18/2024 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)