Arbors At Delaware

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, observation, resident interview, staff interview, and policy review, the facility failed to maintain

a clean, safe, comfortable homelike environment. This affected one (#68) of three residents reviewed for environment. The facility census was 89. Review of Resident #68 ' s medical record revealed an admission date of 12/28/22. Diagnoses included heart failure, type two diabetes mellitus, hypertension, and bipolar disorder.

Review of Resident #68 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #68 had intact cognition.

Observation on 11/24/25 at 11:44 A.M. of Resident #68 ' s room revealed an air conditioner that was not functioning, a large puddle of water on the bathroom floor under the sink, and a hole in the tile near the bathroom door.

Interview on 11/24/25 at 11:45 A.M. with Resident #68 revealed her air conditioner did not function at all and her room would become hot, and it would make her uncomfortable. Resident #68 also reported in her bathroom the sink was leaking and had been leaking for a long time which resulted in a large puddle of water on her floor. Furthermore, Resident #68 stated there was a hole in the tile in her bathroom near the door that had also been there for a long time. Resident #68 stated she had reported all three of her concerns to maintenance and to administration and no one had done anything about it.

Interview on 11/24/25 at 12:19 P.M. with the Activities Director (AD) #146 verified that the air conditioner was not functioning at all, the large puddle of water on the floor in the bathroom, and the hole in the tile near the bathroom door.

Review of policy titled Safe and Homelike Environment dated 07/28/20 revealed in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

This deficiency represents noncompliance investigated under Complaint Number 2622146, Complaint Number 2591474, and Complaint Number 2580514.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

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)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for

a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, pharmacy delivery slips, pharmacy return slips, staff interviews, and policy review the facility failed to ensure residents were discharged with adequate amount of medications. This affected one (#93) of two residents reviewed for discharge. The facility census was 89. Review of medical record for Resident #93 revealed an admission date of 01/04/25 and discharge date of 02/27/25 with diagnoses including but not limited to epilepsy intractable with status epilepticus, severe intellectual disabilities, post-traumatic stress disorder, bipolar disorder, and conversion disorder with seizures or convulsions.Review of discharge Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident was cognitively intact with no behaviors.Review of care plan dated 01/05/25 revealed the resident plans to discharge to home with family

after completion of stay. Interventions included encourage resident/family to participate in the discharge planning process, involve specialized home care agencies and appropriate community support services as needed for safe discharge, and provide resident/family with written instructions upon discharge to ensure a safe return to the community.Review of physician orders for February 2025 revealed the resident was to take zonisamide (seizure medication) 100 milligrams (mg) two capsules twice daily and midodrine (for hypotension) 10 mg three times daily.Review of Discharge to Home documents setting dated 02/27/25 revealed follow up appointment with primary physician was scheduled for 03/05/25 at 8:45 A.M. Review of pharmacy delivery sheets revealed the following medications were delivered: on 01/05/25, 120 capsules of zonisamide 100 mg; on 02/23/25, 56 capsules of zonisamide 100 mg; on 02/21/25, 120 capsules of zonisamide 100 mg; on 01/05/25, 30 tablets of midodrine 10 mg; on 01/23/25, 90 tablets of midodrine 10 mg 90; and on 02/16/25, 90 tablets of midodrine 10 mg. Review of Medication Administration Record (MAR) for January 2025 revealed the total amount of medication administered to Resident #93 in the month of January was 84 capsules of zonisamide 100 mg, and 24 tablets of midodrine 10 mg. Review of MAR for February 2025 revealed Resident #93 received 102 capsules of zonisamide 100 mg and 76 tablets of midodrine 10 mg.Review of Medication Release for split bill dated 02/27/25 revealed the following medications were sent home with Resident #93: zonisamide 100 mg, nine tablets and midodrine 10 mg, two tablets.Review of pharmacy return slip revealed Resident #93 had 120 capsules of both zonisamide 100 mg and midodrine 10 mg returned on 03/10/25.Interview on 11/26/25 at 9:48 A.M. with Licensed Practical Nurse Unit Manager (LPN UM #183) revealed they removed all the medications from Resident #93's slot in the medication cart and sent them home with the resident. LPN UM #183 stated there may have been more medications in the overflow area in the cart and she overlooked them. LPN UM #183 verified she did not call any medications into Resident #93's pharmacy. LPN UM #183 verified they only sent nine capsules of zonisamide 100 mg, and two tablets of midodrine 10 home with the resident.Review of policy titled Discharge Summary and Plan of Care dated 10/30/20 revealed upon discharge of a resident (other than to hospital or death) a discharge summary will be provided to the receiving care provider. The discharge summary should include reconciliation of all pre-discharge medications with the resident's post discharge medication to include prescription and over the counter medications.This deficiency represents noncompliance investigated under Complaint Number 1369970.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

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)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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 policy review the facility failed to ensure a complete and thorough resident assessment was completed for a resident with a change in condition. This affected one (#92) of five residents reviewed for change in condition. The facility census was 89.Review of medical record for Resident #92 revealed an admission date of 03/29/25 and discharge date of 04/23/25 with diagnoses including but not limited to wedge compression fracture of second lumbar vertebra, nondisplaced fracture of lateral end of right clavicle, rotator cuff tear or rupture of right shoulder, Alzheimer's disease, and age-related osteoporosis with current pathological fracture vertebrae.Review of Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had moderately impaired cognition with no behaviors.Review of Situation, Background, Assessment, and Recommendation (SBAR) dated 04/23/25 at 10:34 P.M. revealed Resident #92 had uncontrolled pain in right foot starting on 04/23/35, the physician was notified and an order was received for an x-ray and to send the resident the emergency room (ER) for evaluation. Family was notified. Vital signs documented on the SBAR included a blood pressure of 124/76

on 04/20/25 at 10:30 A.M., a pulse of 76 on 04/20/25 at 10:31 A.M., respirations of 18 on 04/20/25 at 10:31 A.M., and a temperature of 98.0 on 04/20/25 at 10:31 A.M. Further review of the SBAR form directed the nurse that before calling the physician the nurse should evaluate the resident, check vital signs, review the medical record, and have relevant information available when reporting concerns to the physician. Review of vitals tab in the electronic charting revealed the last vitals for Resident #92 were obtained was on 04/20/25 at 10:31 A.M.Interview on 11/26/25 at 2:45 P.M. with the Director of Nursing (DON) verified no vital signs were obtained on 04/23/25 for Resident #92 when the resident experienced a change in condition and should have been. The DON verified the last set of vital signs for Resident #92 were obtained

on 04/20/25. Review of the facility policy titled Notification of Changes dated 10/30/20 stated the facility must inform the resident, consult with the resident's physician, and notify the resident's family member when there is a change in condition. Use the SBAR process for documentation and reporting to the provider. This deficiency represents noncompliance investigated under Complaint Number 1369972.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to maintain a clean, safe, comfortable homelike environment. This affected 25 (#5, #6, #8, #13, #14, #15, #16, #19, #22, #23, #25 #28, #29, #30, #34, #46, #50, #54, #55, #56, #70, #72, #82, #83 and #91) residents residing on hall 300 and 16 (#2, #12, #20, #21, #24, #31, #32, #37, #39, #40, #42, #48, #62, #71, #76 and #78) residents residing on the on the Memory Care Unit. The facility census was 89. Observation

during the initial tour on 11/24/25 from 8:51 A.M. to 9:07 A.M. revealed a black substance on the ceiling in

the shower room on the hall 300. Observation also revealed loose plaster in the left corner of the shower room over the tub, a grate in the ceiling that was loose with cracked plaster around it., a black/brown substance on the ceiling on opposite side of the room near a sprinkler head that was by the door of the shower room. The black substance by the door appeared to have been painted over and was now showing through.Observation on 11/25/25 at 10:12 A.M. of shower room in the Memory Care Unit revealed a blackish brown substance on the ceiling that appeared to be mold. The shower room presented with a musty smell.Interview on 11/25/25 at 10:14 A.M. with Certified Nursing Assistant (CNA #156) revealed they verified the blackish brown substance on the ceiling of the shower room. CNA #156 stated she did not think

the room was musty smelling at the time of the interview but, stated when she first entered the shower room upon starting her shift there was a musty smell in the shower room.Interview on 11/25/26 at 10:17 A.M. with CNA #189 revealed they verified the black substances and loose plaster in the 300 hall shower room.Review of policy titled Safe and Homelike Environment dated 07/28/20 revealed in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.This deficiency represents noncompliance investigated under Complaint Number 2622146, Complaint Number 2591474, and Complaint Number 2580514.

Event ID:

Facility ID:

If continuation sheet