Inspection·October 23, 2023

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 medical record review, and staff interview, the facility failed to ensure urinary intermittent straight catheterization was provided in accordance with physician orders. This affected one (#01) of three sampled residents reviewed for urinary catheterization. Facility census 52. Findings include: Review of the medical record for Resident #01, revealed the resident was admitted to the facility on [DATE] with the diagnosis including, non-pressure chronic ulcer to back, paraplegia, type 2 diabetes mellitus, osteomyelitis, pressure ulcer of sacral region, varicose veins with ulcer to lower extremity, and hypertension. Review of the Minimum Data Set (MDS) assessment 3.0 dated 08/27/23 for Resident #01, revealed the resident was assessed with intact cognition, able to make needs known, dependent on staff for activities of daily living, utilized an ostomy and required intermittent catheterization. Review of the physician orders dated 08/14/23 for Resident #01, revealed the resident was ordered to be catheterized via a straight catheter (device used to empty the bladder) every six hours and as needed (PRN) due to paralysis and urinary retention. The orders dated 08/15/23 revealed the staff would document urinary output every shift. Review of the August 2023 treatment administration records (TARs) for Resident #01 revealed no documented evidence the facility provided the resident with a straight catheterization (cath) every six hours as ordered. The TARs indicated the resident did not receive a straight cath every six hours as ordered on the following dates: 08/15/23, 08/16/23, 08/18/23 08/19/23 08/21/23, 08/22/23, 08/24/23, 08/26/23, 08/27/23, 08/28/23 and 08/31/23. The TARs on those dates were marked with an x for the missed procedures. The TARs indicated no straight cath was performed for the entire day on 08/17/23 and no documented evidence a straight cath was performed on 08/20/23 (day shift), 08/23/23 (night shift), and 08/30/23 (night shift). The TARs also indicated no urinary output was recorded on 08/17/23 (day and night shifts), 08/23/23 (day and night shifts) and 08/30/23 (night shift) Review of the September 2023 TARs for Resident #01, revealed the resident was only scheduled for straight cath once during the day shift and once during the night instead of the ordered every six hours. The TARs indicated the resident did not receive a straight cath every six hours as ordered from 09/01/23 through 09/22/23 when the orders were discontinued. The TARs revealed no documented evidence the resident received a straight cath on 09/10/23 (night shift), 09/15/23 (day shift), 09/18/23 (night shift), and 09/21/23 (day shift). The TARs also indicated no urinary output was recorded for (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: 366097 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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)