Inspection·March 7, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review, the facility failed to ensure a resident's dignity was maintained by appropriately covering a urinary catheter collection bag for one (#153) of one resident reviewed for urinary catheters. The facility census was 50. Findings include Medical record review revealed Resident #153 was admitted to the facility on [DATE]. Diagnoses included dysphagia, Parkinson's disease, vascular disease, obstructive and reflux uropathy, Barrett's esophagus, depressive disorder, type two diabetes mellitus, hypothyroidism, hypertension, duodenal ulcer, and pneumonitis due to inhalation of food and vomit. Review of a physician order dated 02/20/19 revealed Resident #153 was ordered a urinary catheter for obstructive and reflux uropathy. Observation on 03/04/19 at 2:42 P.M. revealed Resident #153 had an uncovered urinary catheter bag. Observation on 03/05/19 at 12:48 P.M. also revealed Resident #153 had an uncovered urinary catheter drainage bag. Interview on 03/05/19 at 12:50 P.M., Licensed Practical Nurse (LPN) #17 verified Resident #153's urinary catheter bag was uncovered and should be covered. LPN #17 revealed she would provide Resident #153 with a new urinary catheter bag with a cover. Review of the policy titled Catheter Care, revised 12/2013, revealed no guidelines for staff to cover a urinary catheter bag. 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: 366118 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 366118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elms Retirement Village Inc 136 S Main St Wellington, OH 44090 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)