Health inspection·August 11, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, and record review, the facility failed to provide residents with urinary catheter care. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for urinary catheters.The findings include:1. On 8/09/2025 at 10:45 AM, R1 was sitting in his wheelchair. R1's urinary catheter tube had amber urine with sediment. R1 said he had recurrent UTIs (urinary tract infections) and was receiving an oral antibiotic. R1 had an open urinary piston syringe with a bottle at bedside. R1 said the nurse would frequently irrigate his catheter because it would get clogged often. R1 said on 8/05/2025 by V11 (Licensed Practical Nurse/LPN) changed his catheter because there was no urine output. R1 said the nursing staff was emptying his catheter but not cleaning it frequently. R1 continued to say that he was dependent on the facility staff to care for his catheter. Then V4 (Certified Nurse Assistant/CNA) came to assess R1's urinary catheter. R1's catheter tube was underneath and over (in an upwards direction) in front of his incontinence brief, not secured. R1's catheter insertion site was soiled with a moderate amount of bowel residue. V4 said she had just provided R1 with catheter care approximately an hour prior. V4 proceeded to adjust R1's tube in a downward direction, and the urine then began to flow into the collection bag.On 8/09/2025 at 12:30 PM, V10 (Registered Nurse/RN) said CNAs were expected to provide routine and as-needed catheter care to prevent infections. V10 also said she was not aware of R1's catheter complications on 8/05/2025. V10 said she reviewed R1's EMR (Electronic Medical Record) and there was no documentation of R1's catheter obstruction complication and need for exchange on 8/05/2025. R1's care plan reviewed on 8/09/2025, said R1 was at risk for UTIs and required an indwelling catheter for obstructive and reflux uropathy. The care plan also said R1 required facility staff assistance with toileting hygiene. R1's interventions included checking catheter tubing for kinks, monitoring and reporting output, and monitoring for signs and symptoms of UTIs.R1's Order Summary Report dated 8/09/2025 did not have orders for routine catheter care, urine output recording, and catheter irrigation procedures.R1's Electronic Mediation Administration Record for August 2025 did not show any documentation of R1's catheter exchange procedure. 2. On 8/09/2025 at 11 AM, R2 was in bed. R2's urinary catheter bag with urine inside was hanging from the bed frame without a privacy bag, exposed. R2's urinary catheter tube had light-cloudy amber urine draining. V4 (CNA) said she had just provided R2 with catheter care approximately an hour prior. V4 assessed R2's catheter insertion site, and it had a build-up of yellowish discharge. V4 said she had noticed it prior and would now inform the nurse on duty. R2 said his catheter was being changed monthly by the nurses and was unsure why.R2's care plan reviewed on 8/09/2025, said R2 was at risk for infections and required an indwelling catheter for management of neurogenic bladder. The care plan also said R2 required facility staff assistance with toileting hygiene. R2's interventions included receiving catheter care every shift and as needed, changing foley catheter per facility protocol or MD order, and monitoring output.R2's Order Summary Report dated 8/09/2025 did not have orders for Page 1 of 3 145339 145339 08/11/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some routine catheter care and urine output recording.3. On 8/09/2025 at 11:20 AM, R3 was in bed. R3's urinary catheter bag with urine inside was hanging from the bed frame without a privacy bag, exposed. R3's urinary catheter tube had thick brown-greenish sediments. R3 said her catheter had been exchanged last week because it was clogged and leaking. R3 said she was also started on a probiotic and cranberry medication because she was having bladder discomfort and vaginal irritation. R3 said her catheter bag was last emptied around 5 AM, and she last had a bowel movement last night. V6 (Registered Nurse/RN) assessed R3's urine and said it was abnormal to have greenish-thick sediment in the urine. V6 said she was not notified prior of R3's abnormal urine and expected to be notified of any abnormal urine color or appearance. V6 said she would change the drainage bag and contact R3's provider for a urine culture. V6 then assessed R3's catheter insertion site. R3's catheter was soiled with bowel residue. R3 said agency CNAs frequently did not provide her proper catheter and incontinence care. V6 proceeded to clean R3's catheter with water, and no soap was added. R3's care plan reviewed on 8/09/2025, said R3 was at risk for UTIs and required an indwelling catheter for management of neuromuscular dysfunction of the bladder. The care plan also said R3 required facility staff assistance with toileting hygiene. R3's interventions included staff to monitor her urine, report any abnormalities for signs and symptoms of UTI, and routine catheter care.R3's Order Summary Report dated 8/09/2025 did not have an order for urine output recording. The report showed a new order dated 8/09/2025 for a urinalysis and culture collection. 4. On 8/09/2025 at 11:30 AM, R4 was in bed. R4 was nonverbal. R4's urinary catheter bag had a scant amount of urine inside and was hanging from the bed frame without a privacy bag, exposed. R4's catheter tube had urine sediments. V6 (RN) assessed R4's catheter insertion site. R4's catheter was soiled with bowel residue. V6 said R4's incontinence brief was not soiled, and V7 (CNA) had just provided R4 incontinence care. R4's catheter was wrapped around his scrotal area and unsecured. V6 proceeded to adjust R4's tube in a downward direction, and then the urine began to flow into the collection bag. At 12 PM, V7 (CNA) said she had provided R4 with catheter care at 10 AM after he had an incontinent bowel episode. R4's care plan reviewed on 8/09/2025, said R4 was at risk for UTIs and required an indwelling catheter for management of neuromuscular dysfunction of the bladder. The care plan said R4 required facility staff assistance with toileting hygiene. R4's interventions included checking catheter tubing for kinks and having staff to clean the peri-area.5. On 8/09/2025 at 11:45 AM, R6 was in bed. R6 was nonverbal. R6's urinary catheter bag with urine inside was hanging from the bed frame without a privacy bag, exposed. V9 (CNA) said she provided R6 with incontinence and catheter care at approximately 8 AM. V9 assessed R6's catheter insertion site. R6's catheter was soiled with bowel residue, and his foreskin of his penis had a yellow discharge buildup. R6's catheter tube was not secured. V9 proceeded to provide R6 with catheter care. V9 wiped R6's catheter with multiple upstrokes towards R6's urethra and then downstrokes using the same towel. V9 said R6's incontinent brief was not soiled and secured it back in place.R6's care plan reviewed on 8/09/2025, said R6 was at risk for UTIs and required an indwelling catheter for management of neurogenic bladder. The care plan said R6 required facility staff assistance with toileting hygiene. R6's interventions included catheter care every shift and as needed.R6's Order Summary Report dated 8/09/2025 did not show an order for routine catheter care and urine output recording. 6. On 8/09/2025 at 11:50 AM, R5 was in bed. R5 was nonverbal and severely contracted. R5's urinary catheter bag with a small amount of urine was hanging from the bed frame without a privacy bag, exposed. V7 said she had provided R5 with catheter care and incontinence care approximately a few hours prior. V7 assessed R5's catheter insertion site. R5's catheter was underneath his contracted legs and over his right thigh area, not secured. R5's catheter insertion site and penis area were soiled with dry 145339 Page 2 of 3 145339 08/11/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bowel residue. V7 said it was difficult to properly position R5's catheter tube and clean his catheter due to his contractures.R5's care plan reviewed on 8/09/2025, said R5 was at risk for infections and required an indwelling catheter for management of neuromuscular dysfunction of the bladder. The care plan said R5 required facility staff assistance with toileting hygiene. R5's interventions included catheter care every shift and as needed. On 8/09/2025 at 1:30 PM, V2 (Director of Nursing/DON) said she expected residents to be monitored for catheter complications such as obstructions. V2 said the nurse should be notifying the physician of any abnormalities and documenting any catheter procedures in the resident's EMR. V2 also said nursing staff were expected to follow physician urinary catheter management orders and the facility's urinary catheter care policy to prevent residents from having complications, such as UTIs. The facility's policy titled Urinary Catheter Care dated 7/03/2025, said The purpose of this procedure is to prevent catheter-associated urinary tract infections.General Guidelines.b. Maintain Unobstructed Urine Flow.Infection Control.Routine hygiene.Complications 1. Observe the resident for complications associated with urinary catheters.b. Check the urine for unusual appearances (i.e., color, blood, etc.).e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately.Steps in the Procedure.Put on gloves.Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry.retract the foreskin of the uncircumcised male resident.14. Assess the urethral meatus. 15. For a female resident: Use a washcloth with warm water and soap to cleanse the labia.For a male resident male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke.cleanse and rinse the catheter from the insertion site to approximately four inches outward.Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 145339 Page 3 of 3