Health inspection·June 23, 2022

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, interview, record review, and review of the facility policy, the facility failed to ensure an indwelling urinary catheter was stabilized and maintained in a manner to prevent urinary tract infection (UTI). This affected one resident (#17) out of three residents reviewed for an indwelling urinary catheter. The facility census was 45. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/25/22 with diagnoses including type II diabetes mellitus, chronic kidney disease, and calculus of kidney. Review of Resident #17's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/22, revealed Resident #17 was cognitively intact. Resident #17 required the extensive assistance of two staff members for bed mobility and transfers. Resident #17 had an indwelling catheter for urine and was always continent of bowel. Review of the plan of care, dated 04/26/22, revealed the resident had an indwelling urinary catheter due to urinary retention. Interventions included positioning catheter bag below level of bladder, manipulating tubing as little as possible during care, reporting UTIs, and changing the catheter per physician order. Review of physician orders, dated 04/26/22, revealed an order for catheter care every shift for indwelling 16 French with 10 cubic centimeter (CC) balloon due to urinary retention. Observation on 06/21/22 at 11:16 A.M. revealed Resident #17 sitting in her wheelchair with her urinary catheter drainage bag sitting next to her on the wheelchair seat. The urinary catheter drainage bag was not secured to the chair and the drainage tube was looping upward and stationary in a position above the resident's bladder. Interview and observation on 06/21/22 at 11:21 A.M. with Licensed practical Nurse (LPN) #905 verified the aforementioned findings. LPN #905 further verified the drainage tube was kinked which prevented urine from flowing through the drainage tube, and the Foley catheter stabilization device/lock normally located on Resident #17's inner thigh had become unattached and unsecured. LPN #905 retrieved and replaced the stabilization device. Review of the facility policy titled Infection Control Program, reviewed January 2022, revealed an important facet of infection prevention includes educating staff and ensuring they adhere to proper techniques and procedures. 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 3 Event ID: 366342 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 366342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary of the Woods 35755 Detroit Road Avon, OH 44011 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)