Health inspection·May 22, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's had updated care plans reflecting catheter care for Resident #12 and care of a tracheostomy stoma site for Resident #7. This affected two residents (Resident #7 and Resident #12) of 12 residents who were reviewed for accurate care plans. The facility census was 40. Findings Include: 1. Record review for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, neuromuscular dysfunction of the bladder and chronic kidney disease. The resident was admitted with a urinary catheter in place. Review of the quarterly Minimum Data Set Assessment (MDS) assessment, dated 03/31/19, revealed Resident #12 was cognitively intact and had a urinary catheter in place. Review of the physician orders, dated 06/26/18, revealed the physician ordered for urinary catheter care to be done every shift. Review of the resident's plan of care dated 06/18/18 showed that this resident had an indwelling urinary catheter related to a neurogenic bladder (bladder is flaccid and does not contract to empty). Interventions for this plan of care included positioning of the catheter, changing the catheter as needed including the urinary catheter bag and monitoring for signs and symptoms of a urinary tract infection. There was no inclusion in this plan of care for urinary catheter care to be provided daily on every shift. Interview with the Director of Nursing (DON) on 05/20/19 at 1:40 P.M. verified that the care plan did not include urinary catheter care. 2. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, cancer of the larynx, tracheostomy stoma and quadriplegia. Review of the quarterly MDS assessment, dated 03/07/19, revealed Resident #7 was cognitively intact and required extensive assistance for transfers, dressing and personal hygiene. This resident had a stoma sight from a tracheostomy. Review of the physician order, dated 06/26/18, revealed an order for the area around the stoma site (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: 366012 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 366012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Meadow Rehabilitation and Nursing Center 4910 Algire Rd Bellville, OH 44813 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)