Health inspection·June 2, 2025

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to assess the urinary status of a resident with an indwelling urinary catheter. This failure resulted in the resident experiencing urinary retention and being hospitalized with a diagnosis of UTI (Urinary Tract Infection). Note: The nursing home is disputing this citation. This applies to 1 of 3 residents (R1) reviewed for catheters in a sample of 3. The findings include: R1's face sheet shows an admission date to the facility on 2/24/25. R1's face sheet showed his diagnoses chronic kidney disease, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of bladder. R1's 4/30/2025 MDS (Minimum Data Set) showed he was severely cognitively impaired and had an indwelling urinary catheter. R1's progress note from 5/17/25 at 12:21 PM showed [R1] being discharged to another nursing home .Ambulance here to transfer [R1] during transport with paramedic staff informed writer that due to vital signs and resident's mentality status, they were diverting [R1] to [local hospital] . R1's 5/17/2025 History of Present Illness ER note from 2:07 PM showed he had his [indwelling urinary catheter] changed out with doing this there was frank pus in the [catheter] and he had about 1.9 liters of brisk urine output with replacement of the [catheter]. On 5/28/25 at 9:52 AM, V3 LPN (Licensed Practical Nurse) stated she was R1's nurse on 5/17/2025 and she couldn't remember anything about his catheter. V3 stated the CNA (Certified Nursing Assistant) most probably emptied it out and the CNAs performed catheter care on R1. V3 stated if something was wrong with his catheter, I would attempt to irrigate it. If that doesn't work, I will change it. R1's 5/17/2025 emergency room (ER) notes showed Diagnosis: Urinary Tract Infection associated with indwelling urethral catheter. On 5/17/25 at 12:26 PM, Bladder exceptionally full unable to fully measure on bedside ultrasound. He does have chronic indwelling Foley catheter . however it is dry, there is no urine in the bag. Suspect, [it] has been displaced. At this point, high suspicion for urosepsis due to urinary retention, likely [acute kidney injury] and electrolyte disturbance present .will reassess .once his bladder is decompressed . Imaging studies: CT (Computerized Tomography) abdomen pelvis with IV Contrast-Final Result . Bilateral urothelial thickening suspicious for ascending urinary tract infection . R1's Electronic Medical Record (EMAR) showed the order Catheter: Record output from urinary catheter every shift. R1's last recorded output was 300 cc at 10:30 PM on 5/16/2025, with nothing (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: 145761 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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)