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
record review and interview the facility failed to change an indwelling catheter as ordered and failed to
monitor urinary output for one resident (R6) of three residents reviewed for indwelling catheter in a total
sample of seven.
Findings Include:
R6's Physician Order Sheet dated October 2024 documents 16 fr (french) (indwelling) catheter for
neurogenic bladder. Change every month and PRN (As needed).
On 1/31/25 at 10:00 AM V2 (Registered Nurse/Director of Nursing) stated that all residents with catheters
should have I & O (Intakes and Outputs) done every shift. V2 stated that she was not aware of any issues
with R6's catheter.
R6's Electronic Medical Record did not contain any documentation of R6's urinary output from the time of
his admission [DATE]) until transfer to the hospital (1/23/25).
V1 (Administrator) provided hand written day sheet notes that did have urinary outputs documented on
10/27/24,10/31/24,11/25/24,11/26/24,11/29/24,11/30/24,12/1/24,12/5/24,12/9/24 and 12/11/24. V1 had
multiple other day sheet notes but the dates listed on those day sheets were duplicates of the days already
listed.
R6's Treatment Administration Records for October, November and December 2024 and January 2025
document 16 fr (indwelling catheter. Change every month and PRN (as needed). All months had an x
through every date. None of the Treatment Administration Records documented that R6 ever got his
catheter changed while at the facility.
On 2/4/25 at 10:00 AM V2 (Registered Nurse/Director of Nursing) confirmed that there was no
documentation of R6 getting his catheter changed while at the facility. V2 stated she believed that R6 got
his catheter changed at some point at the hospital but was unable to provide any documentation or further
details about that possible catheter change.
R6's Nurse's Notes dated 11/13/24 document that R6 had increased confusion and aggression so a
urinalysis was obtained and R6 had a urinary tract infection that was treated with antibiotics.
R6's Nurse's Notes dated 1/23/25 at 1:25 PM document that R6 was sent to the emergency room due to no
bowel movement in his colostomy bag.
(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:
145387
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
145387
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Anthony's Nsg & Rehab Ctr
767 30th Street
Rock Island, IL 61201
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 2/4/25 at 3:00 PM V15 (Registered Nurse) stated I am the nurse that sent (R6) to the hospital on
[DATE]). He was not acting right and he usually had some bowel movement every shift and his colostomy
bag was empty. His catheter did have output but I do not recall how much or what it looked like.
R6's emergency room Note dated 1/23/25 written by V2 (emergency room Doctor) documents that R6 was
being admitted to the hospital for IV (Intravenous) Antibiotics and further diagnostics with diagnosis of
hypoxia, Pneumonia of the right lower lobe due to infectious organism and urinary tract infection associated
with indwelling urethral catheter.
On 2/4/25 at 1:30 V17 (R6's Doctor) stated People with catheters are already a higher risk for urinary tract
infections because the catheter is in place. Changing the catheter every month is essential or urinary tract
infections will certainly start happening like they did with (R6).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145387
If continuation sheet
Page 2 of 2
