Inspection·August 28, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy review, the facility failed to maintain and monitor a resident's urinary catheter system. This affected one (#1) of two residents reviewed for a urinary catheter. The facility identified two residents (#1 and #3) with an indwelling urinary catheter. The facility census was 61. Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses including, quadriplegia, seizure disorder, mood disorder, neuromuscular dysfunction of bladder, protein calorie malnutrition, tracheostomy, gastrostomy, supra pubic catheter, urinary tract infection, and a tibia fracture. Review of the most current minimum data set assessment dated [DATE] revealed Resident #1 was cognitively intact and had no behaviors, had impaired range of motion to bilateral upper and lower extremities, was dependent on staff for the completion of activities of daily living including bed mobility, was incontinent of bowel, had a suprapubic catheter, received regular diet, and was at risk for pressure ulcer with no skin break down. Review of the nursing plan of care revealed the care plan was revised 04/11/25 to address Resident #1's use of a suprapubic urinary catheter due to neurogenic bladder. Interventions included positioning the catheter bag and tubing below the bladder, when providing assistance, check the tubing to ensure there is urine present and collecting in the catheter bag, empty the catheter drainage bag and as needed, notify the nurse if there is only a small amount or urine or none present in the drainage bag, or if the urine appears cloudy or dark yellow/brown. The care plan did not contain interventions to monitor the suprapubic stoma (catheter insertion site) or to record the amount of urine collected in the catheter drainage bag. Review of physician orders noted on 08/03/25 an order was initiated to cleanse suprapubic catheter with wound cleanser and apply dry dressing every day. According to the medical record no documentation indicated the suprapubic catheter site was cleansed with a dressing applied on 08/04/25, 08/05/25, 08/06/25, 08/19/25, 08/23/25, 08/24/25. The medical record also lacked assessment of the suprapubic catheter stoma site. Observation on 08/27/25 at 9:47 A.M. with Licensed Practical Nurse (LPN) #300 and Certified Nurse Aide (CNA) #200 noted Resident #1 in bed. CNA #200 exposed Resident #1 suprapubic insertion site (stoma) and verified no dressing was in place as ordered by the physician. Review of electronic task documentation lacked urinary output recorded each shift or for a 24-hour period on the following days; 07/30/25- None, 08/04/25 recorded once at 12:55 P.M.400 cubic centimeters (cc), 08/06/25- None, 08/16/25 at 6:29 A.M.- 1300 cc, 08/18/25 at 6:11 A.M.- 50 cc, 08/20/25- None, 08/21/25- None, 08/22/25 at 6:29 A.M.- 500 cc, 08/24/25- None, 08/26/25 at 9:38 P.M.-200 cc. On 08/27/25 at 2:40 P.M. interview with the Director of Nursing (DON) during a review of the medical record confirmed the lack of documentation regarding Resident #1 suprapubic catheter stoma condition, stoma site treatment application, and urinary output. Review of the facilities undated Catheter Care policy stated catheter care will be performed every shift and as needed by nursing personnel. (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 2 Event ID: 365488 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 365488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Healthcare of Toledo 4420 South Avenue Toledo, OH 43615 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)