Health inspection·March 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 observation, medical record review, staff interview, and review of policy, the facility failed to ensure a resident's catheter tubing and collection bag were secured off of the floor to potentially prevent infections. This affected one (#22) of one residents reviewed for catheter care. The facility identified one resident with an indwelling catheter. The facility census was 65. Findings include: Review of Resident #22's medical record revealed an admission date of 11/11/22 and a readmission date of 12/15/22. Diagnoses included hypotension, hypertensive heart disease with heart failure, congestive heart failure (CHF), atherosclerotic heart disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact and required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. In addition, Resident #22 had an indwelling catheter. Review of the plan of care initiated 11/14/22 revealed Resident #22 used a Foley catheter for diagnoses of obstructive uropathy and BPH. Interventions included maintain a closed system with urinary bag below the resident's bladder and cover, observe for any signs of complications, observe tubing and avoid any obstructions, record urinary output, provide assistance with catheter care and change Foley catheter per physician orders. Review of current physician orders revealed catheter care each shift, three times daily. Observation on 03/20/23 at 12:07 P.M., of Resident #22 revealed Resident #22's catheter collection bag was hanging from the underside of the wheelchair, with approximately one to one and one half inch of the collection bag touching the floor. Observation on 03/21/23 at 2:00 P.M., revealed Resident #22 in the recliner in his room. Resident #22's catheter tubing was observed to be running down the Resident's left leg and onto the floor, with the catheter collection bag laying flat on the floor. Continued observation on 03/21/23 at 2:12 P.M., revealed two staff walked down the hall, stopped in front of Resident #22's room, looked inside the room, and continued down the hall. Resident #22's catheter tubing and collection bag remained on the floor. Additional observations on 03/21/23 at 2:20 P.M. and 2:33 P.M., revealed Resident #22's catheter tubing and collection bag remained on the floor. Interview on 03/21/23 at 2:33 P.M., of Licensed Practical Nurse (LPN) #490 verified Resident #22's catheter tubing and collection bag were laying on the floor. LPN #490 entered the room and secured the catheter collection bag to the recliner and adjusted the tubing. LPN #490 confirmed catheter tubing and collection bags should be secured off of the floor to assist in preventing infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366473 If continuation sheet Page 2 of 3 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 366473 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Willows at Tiffin 410 Fair Lane Tiffin, OH 44883 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)

F 0690 Review of the policy titled Urinary Catheter Care, reviewed 12/31/22, revealed steps to prevent infection of a resident's urinary tract, including to be sure the catheter bag and tubing were kept off the floor. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366473 If continuation sheet Page 3 of 3