Health inspection·February 6, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their change in condition policy by not notifying the provider about a resident's urinary retention and being unable to drain urine through catheterization. This failure has caused 1 of 3 residents (R1) in a sample of 3 reviewed for catheter care to be admitted to the intensive care unit (ICU) for aggressive treatment for sepsis secondary to urinary tract infection (UTI).The findings include:R1 is a [AGE] year-old female originally admitted on [DATE], having a slight cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. A further review of the MDS also documents that R1 was admitted with an admitting diagnosis including urinary retention and Urinary Tract Infection (UTI).A review of the admission progress note dated 12/26/25 documented that R1 was admitted with a Foley catheter in place.A review of the Physician Order Sheet (POS) and Medication Administration Record (MAR) documented a physician order in place dated 1/21/26 to start voiding trial after removing the Foley catheter and then do post void residual (PVR) every shift for five days. If PVR is greater than 300 milliliter (ml), straight catheter reinsertion, and third time reinsert foley catheter, and need to follow up with the Urologist.A review of R1's MAR documented that the bladder scan on 1/25/26: morning shift, 450; afternoon shift, 700; and night shift, 654. A review of the administration note dated 1/25/26 at 2:57 PM, V6 (Licensed Practical Nurse / LPN), documented a straight catheter (cath) draining approximately 500 ml of urine. A review of the general note dated 1/25/26 at 8:58 PM documented a bladder scan result of 716 ml urine, and V5 (LPN) straight cathed R1 and drained 650 ml urine out. A review of the administration note dated 1/26/26 at 4:54 AM documented that V6 (LPN) reinserted a 16 French Foley.On 2/5/26 at 6:15 AM, V6 (LPN) stated, I did the bladder scan for R1 on 1/25/26 night shift, and it was over 300. I reinserted foley, but it was not draining. Another nurse (V8) also tried and was still not draining. After the morning report, I removed the Foley as it was not draining. I know I should have reached out to the urologist or physician on call to let them know that R1 was retaining urine and was unable drain with a catheter.On 2/5/26 at 8:15 AM, V8 (LPN) stated, V6 was the nurse for R1 on 1/25/36 night shift, and she told me she tried twice to insert foley on R1 as the bladder scan was over 700. She asked for my help, and I inserted foley and it was not draining. V6 told me to leave the Foley in place and wait for a while to see if it drains. I believe the foley was not in place, and that's why it wasn't draining.On 2/5/26 at 8:25 AM, V7 (Morning Nurse/LPN on 1/26/26) stated, When I got the report from V6 on 1/26/26 morning shift, the foley was still there. I removed it as it wasn't draining, reinserted a new one, and the Foley still wasn't draining. I didn't notify the physician (MD) or nurse practitioner that the indwelling catheter was not draining.On 2/4/26 at 4:45 PM, V10 (hospital social worker) reported that R1 was sent from the urology appointment to the emergency room on 1/28/26 due to low blood pressure and lethargy, diagnosed with urinary retention and sepsis caused by a UTI, and was admitted to the ICU for intensive treatment.On 2/5/26 at 9:10 AM, V2 (Director of Nursing/DON) stated, If the Residents Affected - Few Page 1 of 2 145994 145994 02/06/2026 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067

F 0684 Level of Harm - Actual harm Residents Affected - Few foley is not draining, it may not have been in place. If multiple staff members couldn't reinsert the Foley in the right place to drain urine, my staff should notify the physician and follow their order.On 2/4/26 at 3:43 PM, V12 (Nurse Practitioner / NP) stated, I was on call, and nobody called me to report on R1's urinary retention or inability to drain urine through a Foley catheter. The voiding trial order clearly states to reinsert the Foley a third time if the post-void residual is greater than 300 ml and to follow up with a urologist. Urinary retention can cause discomfort and UTI to residents.The facility presented an acute change of condition policy (dated 1/5/25) statement document: It is the policy of this facility to promptly identify, evaluate, address, and report a resident's change in condition.Procedure:4. Phone calls to attending or on-call physicians should be made by the nurse who has collected pertinent information, including the resident's current symptoms and status, onset, duration, severity of the change in condition, and available strategies to manage the change of condition in the facility if appropriate. 145994 Page 2 of 2