Health inspection·September 12, 2019

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, staff interview, family interview, resident interview, medical record review, and facility policy review, the facility failed to have supporting documentation for the medical necessity for an indwelling urinary catheter for one (#181) of one resident reviewed for urinary catheters. The facility identified three residents with indwelling urinary catheters. The facility census was 81. Findings include: Review of the medical record of Resident #181 revealed an admission date of 08/28/19. Diagnoses included intrahepatic bile duct carcinoma, obstruction of bile duct and atherosclerotic heart disease. Review of the hospital discharge paperwork revealed Resident #181's daughter would like the urinary catheter to be placed for comfort reasons. Review of the physician orders for September 2019 contained no order for a urinary catheter. The record was silent for documentation on a valid diagnosis for a urinary catheter. Observation on 09/09/19 at 10:00 A.M. revealed Resident #181 with a urinary catheter hanging on the foot of the bed, in a privacy bag. Interview on 09/09/19 at 3:10 P.M. with Resident #181's daughter revealed the urinary catheter was placed, at the hospital, for convenience and comfort. Hospice was discussed and decided against at this time. The daughter felt Resident #181 was too weak and required physical therapy to strengthen him prior to removing catheter Interview on 09/10/19 at 1:30 P.M. with Resident #181 revealed she did not know why the urinary catheter was in place. Interview on 09/10/19 at 1:46 P.M. with Director of Nursing revealed she had spoken with Resident #181's daughter regarding the indwelling urinary catheter and the daughter would like to keep it for convenience. Interview on 09/10/19 at 2:41 P.M. with Corporate Nurse (CN) #405 revealed she had spoken last week with Certified Nurse Practitioner #410 who gave the diagnosis of urinary retention and CN #410 had not added it to the diagnosis list. Observation on 09/11/19 at 9:00 A.M. of Resident #181 revealed no indwelling urinary catheter. (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 4 Event ID: 365238 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 365238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wapakoneta Manor 1010 Lincoln Ave Wapakoneta, OH 45895 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)