Inspection·September 4, 2024

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. Based on observation, staff interview, and medical record review, the facility failed to provide resident dignity with use of an indwelling urinary catheter. This deficient practice affected two (#5 and #27) of four residents reviewed for indwelling urinary catheters. The facility census was 81. Findings Include: 1. Review of the medical record for Resident #5 revealed an admission date 05/14/19 with diagnoses including chronic obstructive pulmonary disease (COPD), muscle weakness, high blood pressure, and obstructive uropathy. Resident #5 required assistance from staff for activities of daily living (ADL) tasks, and was assessed as cognitively intact. Review of the physician orders for Resident #5 revealed an order dated 04/11/22 for a suprapubic catheter to straight drain due to chronic tubulointerstitial nephritis, and an order dated 01/28/23 for a dignity bag to cover the catheter drainage bag. Observation on 09/03/24 at 10:45 A.M. revealed Resident #5 was resting in bed with the urinary catheter drainage bag hung from the bed frame. The urinary catheter collection bag was facing the doorway with urine visible from the door and hallway. 2. Review of the medical record for Resident #27 revealed an admission date 08/30/24 with diagnoses including acute parametritis and pelvic cellulitis, muscle weakness, anxiety, and obstructive uropathy. Resident #27 required assistance from staff for ADL tasks including incontinence care and transfers. Review of the physician orders for Resident #27 revealed an order dated 08/31/24 for an indwelling urinary catheter, and an order dated 09/02/24 for a dignity bag to cover the drainage bag at all times. Observation on 09/03/24 at 10:55 A.M. revealed Resident #27 was resting in bed with the indwelling urinary catheter drainage bag hanging form the bed frame. The collection bag was facing the doorway with urine visible from the door and hallway. Interview on 09/03/24 at 11:30 A.M. with Licensed Practical Nurse (LPN) #148 confirmed the urinary catheter drainage collection bags for Resident #5 and Resident #27 were uncovered and in view of the hallway and doorway. This deficiency represents non-compliance investigated under Complaint Number OH00156817. 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: 365410 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 365410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mayfair Village Nursing Care C 3000 Bethel Rd Columbus, OH 43230 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)