Inspection·February 23, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, staff interview, and record review, the facility failed to cover residents' catheter bags to promote privacy and dignity. This affected four (Residents #192, #33, #34, and #39) of four residents reviewed for dignity. The facility's census was 42. Findings include: 1. Review of the medical record revealed Resident #192 admitted to the facility on [DATE] and had diagnoses of type II diabetes, non-pressure chronic ulcer, unspecified major depressive disorder, and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident # 192 was a two-person assist, was independent with eating, and required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of the care plan dated 02/13/23 revealed Resident #192 had the potential for complications related to the use of a Foley catheter. Interventions included change catheter as needed, change Foley collection bag as per policy, position catheter bag and tubing below the level of the bladder, ensure tubing is not under the resident's legs, obtain output every shift, encourage fluids, observe/report signs of infection, report abnormal labs, and provide Foley catheter care per policy. Observation on 02/21/23 at 11:20 A.M. revealed Resident #192 had a urine collection bag in a clear trash liner attached to the right side of the bed and visible from the hallway. Interview on 02/21/23 at 11:52 A.M. Licensed Practical Nurse (LPN) #308 verified Resident #192's catheter bag was hanging from bed in a clear trash liner and should have been in a dignity bag (a bag used to cover the catheter bag showing any urine drainage). LPN #308 stated the aides had asked about dignity bags that morning and she had told them if they could not locate them in the storage room, they should use pillowcases to cover the urine collection bags. 2. Medical record review revealed Resident #33 admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, retention of urine, mononeuropathy, benign prostatic hyperplasia without lower urinary tract symptoms, heart failure, and diabetes mellitus. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, (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 5 Event ID: 366043 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 366043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Manor Health Care Inc 730 Hillcrest Drive Carlisle, OH 45005 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)