Health inspection·November 25, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, interviews and policy reviews the facility failed to ensure urinary catheter care was provided in a dignified manner. This affected one (#19) out of three residents reviewed for resident rights. The facility census was 63. Findings include Review of medical record for Resident #19 revealed an admission date of 12/11/23. Diagnoses included neuromuscular dysfunction of bladder, inflammatory disorder of male genital organ, cystitis without hematuria, tracheostomy, and obstructive and reflux uropathy. Review of Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed an resident was cognitively intact. Resident #19 was substantial maximal assistance for toileting, and bathing. Resident #19 was coded with placement if an indwelling urinary catheter. Review of plan of care dated 09/19/24 revealed that Resident #19 was at risk for potential for complications related to the use of suprapubic catheter related to neurogenic bladder. Interventions included change Foley collection bag per facility policy and as needed, encourage adequate fluid intake daily, notify the physician of abnormal lab values, obtain vital signs if resident becomes symptomatic, position catheter bad, and tubing below the level of the bladder to ensure no tubing, make sure tubing was not under resident legs, and provide Foley catheter care per facility policy and as needed. Review of the physician orders for Resident #19 revealed an order dated 12/11/23 catheter care every day shift and night shift. Observation on 11/18/24 at 2:20 P.M. with Certified Nursing Assistant (CNA) #20 revealed staff knocked on the door of Resident #19, donned personal protective equipment and advised Resident #19 that she would be providing catheter care. CNA #20 donned gloves and gown, entered residents room, gathered equipment, laid paper towel on the floor and set the urinal on the paper towel under the urinary drainage bag. CNA #20 removed the blanket and sheet exposing the superpublic cath. CNA #20 explained what she was going to be doing and then stabilizing the tubing using soap and water the CNA cleaned the tubing to the drainage bag. CNA #20 using an alcohol pad cleaned the tubing on the drainage bag and emptying the urine into the urinal without touching the sides of the urinal. Once completed the tubing was again wiped with alcohol and inserted into the storage tube on the drainage bag. CNA #20 then measured the urine and disposed the urine in the commode. (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 9 Event ID: 365920 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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)