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 residents who were incontinent of
bladder received appropriate treatment and services to prevent urinary tract infections and to restore
continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinent care.
The facility failed to ensure Resident #1's catheter bag was not maintained below the bladder.
This failure could place residents at risk for pain, infection, injury, and hospitalization.
Findings included:
Record review of Resident #1's face sheet dated 7/12/24 revealed a [AGE] year-old female admitted to the
facility on [DATE]. Resident #1 had diagnoses included: urinary tract infection, neuromuscular dysfunction
of bladder (lacks bladder control due to brain, spinal cord or nerve problems), functional quadriplegic and
hypertension (high blood pressure).
Record review of Resident#1's admission quarterly assessment dated [DATE] revealed: Resident #1 had a
BIMS score of 13 out of 15 indicating her cognition was intact. Further review revealed Resident #1 had an
indwelling catheter.
Record review of Resident #1's care plan dated 7/12/2024 revealed the following in part:
Focus: [Resident #1 has a indwelling Catheter Neurogenic bladder (a condition that affects bladder function
due to nervous system damage or disease) Date initiated 6/29/2021.
Goal: Reduce the risk from catheter related trauma through review date. Date initiated 6/29/2021.
Interventions: .Catheter: .Position catheter bag and tubing below the level of the bladder
An observation on 7/12/2024 at 12:15 p.m. revealed Resident #1 was lying down in her bed. Resident #1's
catheter bag and tubing was not visible on either side of her bed.
During an interview on 7/12/2024 at 12:16 p.m., Resident #1 said she had a catheter. She said it should be
hung on the side of her bed so it could drain. She called for assistance.
During an observation 7/12/2024 at 12:17 p.m. revealed Manager A came into the room, lifted the blankets
that covered Resident #1 and discovered the catheter bag and tubing was in the bed. The
(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:
676423
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
676423
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Hallmark
4718 Hallmark Dr
Houston, TX 77056
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
catheter bag was half full without urine draining from the tubing.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 7/12/2024 at 12:20 p.m., Manager A said Resident #1's catheter was not draining.
She said the catheter bag and tubing should have been hanging below her bladder to aid in the drainage
and prevent backing up in the tube that could cause infection. She said Resident #1 returned from a sister
facility earlier that day and the assigned nurse should have ensured the catheter was in the correct position.
Residents Affected - Few
During an interview on 7/12/2024 R 12:33 p.m., Agency LPN A said she had worked with Resident #1 once
approximately a month ago. She said she started her shift this morning (7/12/2024) at the sister facility. She
said she did not remember if Resident #1 had a catheter. Agency LPN A said, after arriving to the facility,
she went into Resident #1's room approximately an hour ago and to adjust Resident #1's oxygen and
provide her with a snack. She said she did not check for a catheter. She said the catheter should have been
positioned below her bladder so it could drain. She said if the urine did not drain, then the Resident was at
risk for developing an infection. Agency LPN A said she was trained to receive report from staff before
providing care each shift. She said she did not recall if she received report on Resident #1's catheter status
or care.
During an interview on 7/12/2024 at 12:44 p.m., CNA A said she saw Resident #1 at the sister facility
earlier today (7/12/2024) and the resident had the catheter on. She said after she arrived at the facility
today (7/12/2024), she had not checked on Resident #1. She said Agency LPN A should have ensured the
catheter was in place. CNA A said if the catheter was not draining, the urine could back up in the tubing and
could cause an infection.
During an interview on 7/12/2024 at 12:49 p.m., the DON said the nurse should have made sure the
catheter was draining. She said Resident #1 was at risk for infection when the catheter was not draining
properly or positioned below her bladder. She said the nurses should have given report to each other so the
nurse coming on shift was aware of resident needs. She said catheter care was a basic nursing skill that
was within a nurse's scope of practice.
Record review of facility policy Catheter Care, Urinary (not dated) revealed the following in part:
Purpose
The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary
tract infections .
Maintaining Unobstructed Urine Flow
.3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the
urinary bladder.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676423
If continuation sheet
Page 2 of 2
