Health inspection·January 11, 2024

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 observation, interview, and record review, the facility failed to ensure urinary catheter bags were kept from resting on the floor and failed to secure the catheter tubing for 2 of 3 residents (R197 and R38) reviewed for catheters in the sample of 12. The findings include: On 1/8/24 at 11:22 AM, R197's urinary catheter bag was lying directly on the floor on the right side of her bed. On 1/8/24 at 11:41 AM, R38's urinary catheter bag was attached to her bed frame and her bed was low to the floor, therefore, resting directly on the floor, uncovered. On 1/8/24 at 2:03 PM, V6 and V7, Certified Nursing Assistants (CNAs) provided incontinence care to R38. R38's catheter tubing was not secured in any manner and was taut. After completing incontinence care, V6 and V7 positioned R38 on her back with the unsecured catheter tubing placed under her left leg. The drainage bag was hung on the bed frame, the bed was lowered and again the drainage bag was resting directly on the floor. On 1/8/24 at 2:31 PM, R197's urinary catheter bag was lying directly on the floor. On 1/10/24 at 2:25 PM, V6 said the first rule of catheter care is to not put the catheter on the floor. V6 said if the resident's bed needs to go low, we put the drainage bag in a dignity bag so it does not touch the floor directly and we hang it on the bed frame. V6 said we don't want it to touch the floor for infection control reasons; we don't want the patient to get a UTI (urinary tract infection). V6 said if the resident does not have the catheter secured, we tell the nurse, and they put the tubing in a secure holder on their leg so they don't pull it out and it's more comfortable. V6 said we position the tubing over the leg so it doesn't kink and to keep the urine from flowing back into the bladder. R38's Face Sheet printed 1/10/24 shows she is a [AGE] year old female admitted to the facility on [DATE]. R38's diagnoses include, but are not limited to acute and chronic kidney disease and urinary retention, heart disease, and heart failure. R38's Care Plan for 12/22/23 through 1/11/24 shows she is at risk for infection related to her indwelling urinary catheter status. R197's Face Sheet printed 1/11/24 shows she is an [AGE] year old female admitted to the facility on [DATE] after having a myocardial infarction (heart attack). R197's diagnoses include, but are not Page 1 of 2 145986 145986 01/11/2024 Lake Forest Place 1100 Pembridge Drive Lake Forest, IL 60045

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few limited to, heart failure, diabetes, urinary retention, hypertension, and protein malnutrition. R197's Care Plan for 1/4/24 through 1/11/24 shows she is at risk for infection related to her indwelling urinary catheter status. The facility's Bowel and Bladder Incontinence/Urinary Catheters/UTIs Policy (last reviewed 6/30/23) shows residents with urinary catheters will receive appropriate care and services to prevent UTIs. Care includes keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter and securing the catheter to facilitate the flow of urine. 145986 Page 2 of 2