Health inspection·May 1, 2025

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. Page 1 of 2 145651 145651 05/01/2025 LA Bella of Alton 3490 Humbert Road Alton, IL 62002

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. 145651 Page 2 of 2