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
interview and record review the facility failed to change an indwelling urinary catheter per Physician order
and failed to perform urinary catheter care per Physician order for 2 of 3 (R1, R3) residents reviewed for
quality of care.
Findings include:
1.R1's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility
on [DATE].
R1's EMR dated 12/31/24 documents a diagnosis of unspecified injury at unspecified level of cervical
spinal cord, subsequent encounter and pressure ulcer of sacral region, stage 4.
R1's Care Plan dated 2/05/25 documents The resident has Indwelling Catheter r/t (related to) Urinary
Retention related to neurogenic bladder secondary to Cervical spine injury and Pressure Injury.
R1's MDS (Minimum Data Set) dated 3/4/25 documents a BIMS (Brief Interview for Mental Status) score of
15 out of 15. The MDS documents that the resident requires partial/moderate assistance for roll left and
right. The MDS documents that the resident requires substantial/maximal assistance for sit to lying and
lying to sitting on side of bed. The MDS documents that the resident is dependent for sit to stand, chair/bed
to chair transfer, and tub/shower transfer. The MDS documents that the resident has an indwelling catheter.
R1's Physician Order dated 2/22/25 documents (Urinary) Catheter care and securement device q (every)
shift and PRN (as needed) Please change (urinary) catheter monthly starting 2/22/25; every 1 month(s)
starting on the 22nd for 28 day(s) for Prophylaxis.
On 4/30/25 at 11:09 AM, R1 stated that he has not had his catheter changed since he was admitted . He
stated that it should be changed every month.
On 4/30/25 at 1:14 PM, V3, Wound Nurse/Licensed Practical Nurse (LPN) stated that she missed the order
to change (R1's) catheter because it was combined with another order. She stated that she would change
his catheter now and separate the order, so it does not happen again.
2.R3's EMR undated documents that the resident was admitted to the facility on [DATE].
R3's EMR dated 8/3/24 documents a diagnosis of acute kidney failure, unspecified.
(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:
145651
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
145651
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
LA Bella of Alton
3490 Humbert Road
Alton, IL 62002
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
R3's EMR dated 3/18/24 documents a diagnosis of neuromuscular dysfunction of bladder, unspecified.
Level of Harm - Minimal harm
or potential for actual harm
R3's EMR dated 4/11/25 documents a diagnosis of retention of urine, unspecified.
Residents Affected - Few
R3's Care Plan dated 4/11/25 documents The resident has an Indwelling (urinary) Catheter r/t diagnosis of
Neurogenic bladder and urinary retention.
R3's MDS dated [DATE] documents a BIMS score of 15 out of 15. The MDS documents that the resident
has an indwelling catheter. The MDS documents that the resident requires supervision or touching
assistance for roll left and right. The MDS documents that the resident requires partial/moderate assistance
for sit to lying. The MDS documents that the resident requires substantial/maximal assistance for lying to
sitting on side of bed and sit to stand. The MDS documents that the resident is dependent for chair/bed to
chair transfer and toilet transfer.
R3's Physician Order dated 3/9/25 documents (Urinary) Catheter Care; every shift AND as needed for
soiling or leakage.
On 4/30/25 at 11:20 AM, R3 stated . the (facility) staff do not clean it every shift.
On 4/30/25 at 1:35 PM, V8, CNA (Certified Nursing Assistant) stated that urinary catheter care should be
done every shift. She stated that she has not completed catheter care for (R3) yet today.
On 4/30/25 at 1:41 PM, V9, CNA stated that she does catheter care every time she changes a resident.
She stated that she has not done catheter care on (R3).
On 4/30/25 at 2:09 PM, V8 was questioned about urinary catheter care for (R3). She stated that the
midnight shift switched (R3's) leg bag to the regular bag. She stated that she did not complete catheter care
for (R3).
Facility's Policy Catheter Care, Urinary dated August 2022 documents The purpose of this procedure is to
prevent urinary catheter-associated complications, including urinary tract infections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145651
If continuation sheet
Page 2 of 2
