Health inspection·September 17, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure nurse aids had the skills and competencies to care for 1 of 3 residents with urinary catheters (R2) in the sample of 3.Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including paraplegia and neuromuscular dysfunction of bladder.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was independent with cognitive skills for daily decision making, required partial assistance with rolling from side to side, was dependent for transfer, and had indwelling catheter.R2's Physician Order dated 8/27/25 documents R2 has indwelling urinary catheter with diagnosis of neurogenic bladder.R2's Care Plan initiated 6/3/24 documents R2 has a catheter related to neuromuscular dysfunction of the bladder and will remain free from catheter-related trauma.R2's Progress Note by V7, Registered Nurse, on 9/10/25 at 5:31 PM documents R2 stated V4 Certified Nursing Assistant (CNA) pulled on his catheter. The catheter is leaking urine, and R2 requested to go to the emergency room (ER).R2's Hospital After Visit Summary dated 9/10/25 documents R2 was seen for displacement of indwelling urinary catheter.R2's Progress Note by V8, Medical Doctor (MD), on 9/12/25 documents R2 was seen for catheter pain and reported forceful tugging on the catheter on behalf of his nurse aid. There was no evidence of significant trauma at that time. R2's Grievance Form dated 9/10/25 documents, CNA was being rough and pull(ed) on catheter. (R2) stated that he does not want that CNA in his room.On 9/17/25 at 8:48 AM, R2 was lying in bed in his room with catheter tubing running into a dignity bag hanging off the side of his bed. R2 stated V4 (always takes the catheter bag off the bed to empty his urine, whereas the other nurses just open the clamp and let it drain out into the urinal. One morning V4 was emptying his catheter, and the tubing just went snap. He had to catch the line higher up (toward his body) to keep it from pulling more. He stated if he had not grabbed the tubing the catheter would have come completely out. R2 added, I don't wish this on nobody, but I know what it felt like, and it wasn't good. It's another trip to the hospital my insurance shouldn't have to pay for.On 9/17/25 at 8:45 AM, V6, Licensed Practical Nurse (LPN), stated R2 complained that V4 pulled on his catheter and is generally not very careful with it.On 9/17/25 at 11:51 PM, V4 stated she was providing care to R2 last week when he told her his catheter hurt. The catheter bag had been placed on the bed frame, so she tried to lift the mattress off the bed frame to remove the bag. When R2 said it hurt, she pulled up his bed sheet. The leg strap that connects to the tube to keep it from pulling was in the middle of his thigh. V4 stated that probably should have been further up on his leg or not be worn at all, as he usually does not.On 9/17/25 at 1:35 PM, V2, Director of Nursing (DON), stated it is not procedure to lift the mattress on residents' beds while emptying catheter bags. Staff should open the clamp on the bag and allow the urine to drain into a urinal. The leg bands that secure catheter placement should always be worn. It was a competency issue when V4 pulled on R2's catheter, and staff were in serviced regarding the Facility's catheter care policy and Page 1 of 2 146122 146122 09/17/2025 St Paul's Senior Community 1021 West E Street Belleville, IL 62220

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few procedure after this happened.V4's Employee Suspension Form dated 9/10/25 documents, The allegation occurred on 9/10/25. Resident states staff pulled his catheter by not following correct procedures which caused issues with his catheter, leaking and pain. The incident was described as poor work quality and was classified as a category II offense where employee is not entitled to back pay while on suspension.The Facility's Catheter Care, Urinary Policy reviewed 4/20 documents, Ensure resident is not lying on the catheter and keep the catheter and tubing free of kinks. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh. 146122 Page 2 of 2