Health inspection·March 5, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review revealed Resident #43 was admitted to the facility 09/07/16 with diagnoses including dementia without behavioral disturbance. Review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Observations on 03/02/20 at 10:16 A.M., on 03/03/20 at 8:37 A.M., and on 03/04/20 at 8:38 A.M. revealed Resident #43 in her wheelchair in the dining room. Her wheelchair had two strips of pink tape and one strip of blue tape with her first initial of her first name, and full last name taped to the back of her chair. Interview on 03/04/20 at 11:35 A.M. with State Tested Nursing Assistant (STNA) #211 confirmed Resident #43 had two strips of pink duct tape and one strip of blue painter's tape with her first initial of her first name, and full last name on her wheelchair. The STNA confirmed it was not dignified to have tape on the back of Resident #43's wheelchair with her name on it. Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to promote dignity by not providing privacy during one Resident (#42) of one observed during wound care and incontinence care. The facility also failed to provide privacy for one Resident (#43) of one observed with their name taped to a wheelchair. The facility census was 45. Findings include: 1. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including dementia without behavior disturbances, and Parkinson's disease. Review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was significantly cognitively impaired. The resident required extensive assistance of two people Activities of Daily Living (ADLs). Observation of incontinence care and pressure ulcer wound care for Resident #42 with Licensed Practical Nurse (LPN) # 223 and assisted by LPN #312 on 03/04/20 at 11:24 A.M., revealed LPN #223 removed the resident's clothing. Resident #42's window had blinds, which were opened. There was a person observed walking around outside near the window. The wound was cleansed and care provided as ordered. LPN #223 then put a new brief and clothes on the resident. Interview with LPN #223 on 03/04/20 at 11:37 A.M. confirmed the window blind was up and the (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 3 Event ID: 365047 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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)