Inspection·March 4, 2024

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to ensure colostomy care and services were in place for Resident #99. This affected one (Resident #99) of three residents reviewed for changes in condition. The facility identified no current residents with a colostomy and/or ileostomy. The facility census was 86. Findings include: Review of the medical record for Resident #99 revealed an initial admission date of 08/31/23. Resident #99 was hospitalized from [DATE] until he readmitted to the facility on [DATE]. The resident discharged to the hospital on [DATE] and did not return to the facility. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side and gastrostomy status. Review of Resident #99's care plan, initiated 08/31/23 and revised on 10/29/23, revealed the resident had an alteration in gastrointestinal status with an ostomy in place. The care plan stated to provide ostomy care as ordered. Review of the hospital records preceding Resident #99's re-admission to the facility, dated 12/02/23, revealed Resident #99 had a colostomy (a surgically created opening for bowel elimination) in place. Review of the nursing admission assessment, dated 12/02/23 revealed Resident #99 returned from a hospitalization on 12/02/23. The admission assessment did not indicate that Resident #99 had a colostomy. Review of Resident #99's physician orders from 12/02/23 to 01/14/24 revealed the resident had no orders for colostomy appliance changes, colostomy site care, or monitoring for complications at any point while a resident of the facility. Review of Resident #99's interdisciplinary progress notes from 12/02/23 to 01/14/24 revealed there was no mention of Resident #99 having a colostomy or having received any colostomy care or monitoring. An interview on 03/04/24 at 8:11 A.M. with the Director of Nursing (DON) verified there were no residents in the facility with a colostomy. The DON stated the standard of care for residents with a colostomy is to ensure they have orders for colostomy site care and appliance changes every three days (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: 365162 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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)