Health inspection·December 18, 2019

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 medical record review, observation, and interview, the facility failed to ensure a resident's urinal was emptied on a regular basis which resulted in urine saturated clothing. This affected one (Resident #76) of one resident reviewed for dignity. Findings include: Review of Resident #76's medical record revealed an admission date of 11/23/19 with the diagnoses of chronic atrial fibrillation, muscle weakness, difficult walking and chronic pain. Review of Resident #76's annual Minimum Data Set (MDS) 3.0 dated for 11/18/19 revealed resident with intact cognition, adequate hearing and vision and able to make self understood and able to understand others. Resident #76 required extensive assistance from two staff members for bed mobility, transfers, and toilet use and dressing. Resident #76 was frequently incontinent of urine. Review of physician orders for Resident #76 revealed an order dated for 06/11/19 for Furosemide (a diuretic to help treat urine retention) 40 milligrams (mg) tablet, by mouth twice a day for congestive heart failure. Interview on 12/18/19 at 10:50 A.M. with Resident #76 revealed his concern that staff were not emptying his urinal after he uses it to urinate in. Resident #76 revealed he is currently taking Furosemide 40 mg twice a day and this makes him have to urinate frequently and not able to wait long periods of time. Resident #76 revealed the staff knows he has to urinate frequently and when he request for them to ensure his urinal is empty so he can use it, they do not do this. Resident #76 claimed he would empty the urinal himself but he is not able to walk into the bathroom and his hand was weak and he had dropped the urinal in the past. Observation on 12/18/19 at 11:40 A.M. revealed Resident #76 sitting in his wheelchair in his room with his call light on. Resident #76's urinal was placed on the side of his trash can, filled to the top with urine. Licensed Practical Nurse (LPN) #256 was observed applying gloves and entering Resident #76's room when the resident pulled on the top of his sweat pants to reveal a large wet area. Resident #76 informed LPN #256 that he has asked many times for his urinal to be emptied because when he has to use the bathroom he has to go and he ends up spilling it all over his pants and this happens all the time. Interview on 12/18/19 at 11:45 A.M. with LPN #256 confirmed Resident #76's urinal was filled to the top of the urinal and resulted in resident trying to use the urinal and spilling it on himself. LPN #256 also confirmed Resident #76 is not able to empty the urinal himself nor is he able to change (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 10 Event ID: 365585 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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)