F 0657
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Few
Based on observation, interview, and record review, the facility failed to ensure that a resident with an
indwelling urinary catheter had care plan that reflected current status for one sampled resident (R2) in a
sample of three residents reviewed for bowel and bladder care.
Findings include:
R2 is a [AGE] year-old female admitted to the facility on [DATE], was transferred to the hospital on 4/20/23
and returned on 4/25/2023. R2's medical history includes but not limited to: Hypertension, Diabetes
Mellitus, Congestive heart failure, breast cancer, Spinal stenosis lumbar, DVT, Urinary retention, Right
lumpectomy, Hysterectomy and Right axillary lymph node dissection.
R2's Minimum Data Set with Assessment Reference date of 4/06/2023 Section C: Brief Interview for Mental
Status documents a score of 14 which indicates some cognitive impairments.
R2's Progress Notes dated 4/25/2023 20:18 PM documents:
Note Text: admitted patient via stretcher accompanied by the EMT (Emergency Medical Technician) staff
(sic). No oxygen support noted, no DOB (difficulty of breathing) or SOB (shortness of breath). Alert and
oriented x3-4. No pain verbalizes. With indwelling urinary catheter (fr.16) connected to urine bag and
draining. No wound or pressure injury noted except blanchable redness at the sacral area. Initial vital signs
are within normal limit. Able to verbalize concerns. Instructed to use call light. Informed MD regarding
admission with orders made and carried out. will continue to monitor.
On 4/28/2023 at 11:13 AM, R2 was observed sitting in a wheelchair watching TV, with indwelling urinary
catheter attached to a leg bag with clear amber colored urine, no odor noted. R2 stated I have been here
for a month. They drain my catheter regularly. They change it regularly. When I came here, I was not able to
urinate, then I had a blood clot and went to the hospital. The urologist saw me at the hospital, and they put
in my catheter. I've only had the (brand) urinary catheter for a week after I came back from the hospital. Per
the urologist, Urinary Tract Infection they believe is why I couldn't urinate, and they believe it would come
back.
R2's Daily Skilled assessment dated [DATE] under Section 13 Genitourinary -last 24 hours Bladder
Elimination Question Incontinent is checked Catheter is not checked.
R2's Care Plan, with a revision date of 4/7/2023 documents:
(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:
145637
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
145637
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Joseph Village of Chicago
4021 West Belmont
Chicago, IL 60641
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 0657
R2 receives intermittent urinary catheterization d/t urinary retention.
Level of Harm - Minimal harm
or potential for actual harm
On 4/28/2023 at 1:00 PM, V6 (Care Plan Coordinator) via telephone conversation stated, There is no care
plan for R2's indwelling foley catheter. On admission, the doctor on the History & Physical on 4/26/23 still
stated bladder scan every shift, straight catheter every shift, and as needed. I am not aware that R2 now
has an indwelling urinary catheter, that's why there is no care plan for an indwelling urinary catheter. I am in
charge of updating care plans. Had I known that R2 had an indwelling urinary catheter, I would have
updated her care plan right away. I review the doctor's notes and progress notes only for the skilled unit
pretty much every single time. I didn't see any documentation that she had an indwelling urinary catheter or
that it was inserted after she came back from the hospital stay. I will update her care plan right away.
Residents Affected - Few
On 4/28/2023 at 1:24 PM, V2 (Assistant Director of Nursing/ADON) stated, For R2, she was admitted with a
16 Fr. indwelling urinary catheter on 4/25/2023. V6, Care Plan Coordinator, is also supposed to review the
hospital records of R2 when she came back from the hospital. She should have a care plan for R2's
indwelling urinary catheter. For the Daily Skilled assessment dated [DATE], it documents under Bowel
Elimination that R2 is incontinent of bladder elimination and Catheter is not checked, V2 states, That is not
correct. We had agency nurse yesterday and it must have been an error. The agency nurses are oriented
when they come in, they go from room to room with another nurse for a report, they read communication
dashboard to know everything about their residents. We also let them know that there are assessments that
need to be done on that day. For somebody with an indwelling urinary catheter, under the first question: the
answer should have been always because they are continent with a (brand) urinary catheter, and catheter
should have been checked. For R2, she should also have a care plan for urinary catheter in her
comprehensive care plan and also in her baseline care plan.
Facility provided a document with a reviewed date of May 19, 2022, titled Care Plan Preparation, long-term
care which documents in part: The interdisciplinary team then collaborates with the resident and reviews
and revises the care plan, as necessary, to meet the resident's needs throughout the stay in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145637
If continuation sheet
Page 2 of 2
