Inspection·January 25, 2024

F 0690 maintained records of input/output that would demonstrate any ill-effects due to urine retention or presence of blood in urine. Level of Harm - Actual harm Residents Affected - Few emergency room hospital record dated 8/13/2023 authored by V8 (emergency room doctor) reads in part, (R1) is a [AGE] year-old with previous medical history of neurogenic bladder and quadriplegia presents with evaluation of hematuria after improperly inserted urinary catheter in the nursing care facility. The patient states that a urinary catheter was placed earlier in the day. The patient began having abdominal discomfort. When the nursing care staff removed the catheter, they noticed that the patient had bleeding from his urethra. R1 was transferred from the Emergency Department to the ICU with admitting diagnosis of 1. Septic Shock and 2. Injury of urethra. V8 (ED emergency room doctor) continued with ICU records which read in part, Total critical care time 60 minutes. Due to a high probability of clinically significant, life-threatening deterioration, the patient required my highest level of preparedness to intervene emergently, and I personally spent this critical care time directly and personally managing the patient. This critical time included urgent treatment with development of a management plan, evaluation of patient's response to treatment, and discussion with other providers. On 01/24/2024 at 10:10 AM Surveyor interviewed V3 (Licensed Practical Nurse) who related the following in summary: R1 had a chronic urinary catheter and pain medication pump due to the accident that he suffered before his admission to the facility. On 08/12/2024, R1's assigned nurse asked me if I could change his catheter per R1's request. I used a urinary catheter kit. There are different sizes of urinary catheters, I look at what the size that resident has inserted, and based on that, I reinsert the same size. If it is a first time that a resident is getting urinary catheter, I start with the smallest size and see if it works. If it too small, it's going to leak, so it needs to be observed for at least 24 hours. R1 wanted to change it due to catheter leakage. He was concerned about urine getting into his wounds and getting them infected. I heard R1 say that for a few days before I reinserted it on 08/12/2023. Urinary catheter insertion is a sterile procedure. I wash hands with soap and put on sterile gloves that are included in the kit. Clean the area, with iodine swabs, get a cup/tray to catch the initial urine return, put some lubricant, and insert it. When catheter is in the place, urine comes out right away. Next, I inject normal saline to inflate the balloon to secure the catheter in the bladder. I believe it takes 30 ml of saline to inflate the balloon. I connect the catheter to the collection bag and secure the tubing. In R1's case, there was a mist of urine in the tubing upon insertion, but then, I felt resistance, and couldn't insert the catheter any further. R1 didn't indicate any discomfort during the procedure. Later in the day, he started bleeding, and was sent out to the hospital. Progress note dated 08/12/2023 at 1:00 PM written by V3 (LPN) reads in part, Resident c/o (complaining of) (urinary catheter) was leaking urine, writer changed (urinary catheter) 16f without any difficulty with urine return, will continue to monitor. Progress note dated 08/12/2023 at 2:03 PM written by V10 (Licensed Practical Nurse) reads in part, Resident observed with new (urinary catheter) with no urine return. Per resident, voiced uncomfortable, writer checked the urine return and the bag was empty. NP (Nurse Practitioner) made aware, (urinary catheter) was removed and there was blood noted. On 01/24/2024 at 12:45 PM Surveyor interviewed V2 (Director of Nursing) who related the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145877 If continuation sheet Page 2 of 3 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 145877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Dolton 14325 South Blackstone Dolton, IL 60419 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 - Actual harm Residents Affected - Few in summary: There should always be an order for urinary catheter, it usually gets put in upon admission and readmissions. Order should include when to reinsert it, flushing intervals, bag change or when to do urinary catheter care. Urinary catheter order set includes accident dislodgement and there is no need for a new order for reinsertion; however, nurses should let the doctor know and follow their recommendations. The order is individual for each resident. When there is an issue with a urinary catheter, for example, when it is leaking, nurse should let the doctor know for further guidance. Urinary catheter balloon should be inflated with 10 ml of saline, that's what's included in the urinary catheter kit. Any licensed nurse is trained appropriately to insert the urinary catheter, for example Licensed Practical Nurse, Registered Nurse, or even Nurse Practitioner. Urinary catheter care is established between CNAs and nurses. CNAs render perineal care and empty the bag. CNAs should empty the bag at least once a shift and PRN, and need for perineal care should be checked at least every 2 hours and done at least once a shift. Urinary catheter care is charted in the MAR (Medical Administration Record) or TAR (Treatment Administration Record). If CNAs notice any changes of urine appearance, they should let the nurse know. On 01/24/2024 at 1:48 PM Surveyor interviewed V6 (Nurse Practitioner) who related the following in summary: I've been taking care of R1 since October 2023, so I was not part of the medical team during the time when he had traumatic urinary catheter insertion followed by the hospitalization. R1 had a chronic urinary catheter because he was quadriplegic. Every resident needs a complete physician order if they have a urinary catheter. There is an order set with urinary catheter maintenance that can be adjusted to resident's needs. Additionally, there should be an order for each time when urinary catheter is reinserted. If a urinary catheter is leaking, that means balloon might be deflated. In such case, I would suggest reinflating balloon and if that doesn't help, reinsertion of a urinary catheter. If a nurse feels resistance or any difficulty during reinsertion of a urinary catheter, doctor should be notified, and resident would be sent out immediately to the hospital for further evaluation. Often, residents with neurogenic bladders have spasm upon urinary catheter insertion, followed by lack of urine return, in that case, urinary catheter needs to be removed right away and doctor should be notified. Facility policy dated 02/14/2019 titled Urinary Catheter Care, reads in part, Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Guidelines: Urinary catheter and tubing may be removed or reinserted when any of the following are observed: Inability to observe urine contents in the urinary drainage bag or tubing; Upon physician's orders; The date of catheter insertion shall be documented in the nurses notes and Treatment Record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145877 If continuation sheet Page 3 of 3