Improper Positioning Technique Leads to Resident Fall and Injury
Summary
The facility failed to ensure proper positioning technique during incontinence care, resulting in a fall with a major injury for a resident. The incident occurred when a Certified Nursing Aide (CNA) was providing incontinence care to a cognitively intact resident who was at risk for falls and dependent on staff for turning, repositioning, and toileting. The CNA, while changing the resident's brief, reached for an incontinence pad with one hand while holding onto the pad the resident was lying on with the other hand, leading to the resident falling out of bed and fracturing her left femur. The resident, who had medical diagnoses including spinal cord compression, diabetes, malnutrition, and spinal stenosis, was assessed to be at moderate risk for falls. Her care plan indicated she required two-person assistance for repositioning and toileting, and assist bars were to be used for her bed. However, during the incident, the CNA was alone in the room and did not follow the care plan's requirement for two-person assistance, which contributed to the resident's fall. Interviews with the CNA and the Registered Nurse (RN) involved revealed that the CNA admitted to not holding the resident properly and acknowledged that the resident may have tried to grab the side rail or remote, leading to the fall. The RN confirmed that the CNA either left the room or left the resident unattended while reaching for linens, which was against the facility's procedures for safe resident handling. The incident resulted in the resident sustaining a left femoral neck fracture and multiple skin tears, requiring immediate medical attention and pain management.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Improper Foley Catheter Care During Incontinent Care: A resident with dementia and neurogenic bladder had an indwelling catheter, but a CNA did not secure the catheter tubing while providing incontinent/catheter care. The DON and ADM stated the tubing should be secured during care, and the CNA acknowledged she was not aware she had failed to do so despite prior training.
Indwelling catheter care was not provided as needed for a resident with Foley tubing that had cream-colored sediment along the length of the tubing on repeated observations. The resident had orders for Foley care every shift and irrigation for blockage, increased sediment, or decreased output, but staff and hospice interviews showed the tubing remained unchanged and there was no formal order for routine tubing changes, only PRN changes based on clinical findings.
A resident with an indwelling Foley catheter, dementia, and recent admission diagnoses including cancer and a pelvic fracture was observed without the ordered leg strap/securement device in place. The care plan did not reflect the need for securement, and staff interviews confirmed the tubing should have been secured and checked each shift; the ADM also stated there was no catheter care policy.
Failure to Document and Manage External Catheter Urinary Wicking System: A resident who used an external male catheter with a urine collection system had no physician order, no care plan details for setup or reapplication, and no documentation for changes. The resident said he needed help with the system and kept supplies in his room, while the DON stated the hospice nurse applied it weekly and acknowledged there was no policy or documentation for changes. Containers of urine were observed in the room, including one full of dark yellow urine, and the bag was later not found during brief care.
Delayed Incontinence Care: A resident with bowel and bladder incontinence, impaired mobility, and dependence on staff for ADLs was observed wet in bed and asking to be changed and cleaned up. An LPN checked the brief, confirmed it was wet, but left the room without providing care and was later observed at a med cart during another staff member’s med pass. The resident stated she had last been changed the night before and that it had been a long time.
Delayed Toileting and Incontinence Care: A resident with intact cognition, urinary and bowel incontinence, and max assist needs was left in a wet brief and later found sitting on a urine-soaked wheelchair cushion. Staff reported the resident had called for bathroom help during lunch, but assistance was delayed until after dining room duties, and the DON stated residents should be changed every 2 hours and assisted before meals when they request toileting.
Improper Foley Catheter Care During Incontinent Care
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate catheter care and services to prevent urinary tract infections and to restore continence to the extent possible. Resident #18 was an [AGE]-year-old male admitted with dementia, neuromuscular dysfunction of the bladder, heart failure, hypertension, and difficulty walking. His quarterly MDS identified that he had an indwelling catheter and a diagnosis of neurogenic bladder, and his care plan included a focus area for an indwelling catheter related to neurogenic bladder. During observation, CNA A provided incontinent care and catheter care to Resident #18 but held the tip of the penis with the left hand while cleaning the catheter tubing with the right hand and did not secure the tubing during the care. In interviews, the DON and ADM stated the tubing should be secured during catheter care and that staff had been trained in proper catheter care. CNA A stated she was not aware she had failed to secure the catheter tube and described the proper process as securing the tubing at the tip of the penis and wiping downward. The facility policy on catheter care stated the purpose was to prevent catheter-associated urinary tract infections and directed staff to maintain the position of the nondominant hand and cleanse the catheter from the insertion site outward.
Indwelling Catheter Care Not Provided as Needed
Penalty
Summary
Failure to provide treatment and services for the care of a resident with an indwelling urinary catheter was identified for one of five residents reviewed. During observation of the resident on 08/09/2026, Foley tubing had cream-colored sediment along the length of the tubing, and the same sediment was still present and unchanged during a second observation on 08/11/2026. The resident’s record showed physician orders for Foley care every shift and for irrigation with 60 cc normal saline for blockage, increased sediment, or decreased output every 6 hours as needed, with notification of the physician for any abnormal observation from baseline. Staff interviews showed that the CNA would notify the nurse if something was wrong with the Foley when emptying it, and the hospice director stated the hospice aide documented care and would notify the RN and floor nurse if there were new findings or resident complaints. The ADON/Infection Control Nurse stated the Foley catheter tubing should be changed based on how it looked, but there was no formal order for routine tubing changes and it was only PRN. The DON stated a PRN Foley change would be needed if there was leakage, blockage, or sediment that could not be flushed out. The facility policy stated routine fixed-interval catheter changes are not recommended and that residents should be observed routinely for complications and new complications reported to the provider as indicated.
Failure to Secure Foley Catheter Tubing
Penalty
Summary
Resident #58, an [AGE]-year-old female newly admitted with diagnoses including secondary malignant neoplasm, fracture of the superior rim of the left pubis, and dementia, had an indwelling Foley catheter ordered on 08/06/2026. Her care plan identified the indwelling Foley catheter as a problem and included a goal that she remain free from catheter-related trauma, but it did not reflect the need for a leg strap to secure the tubing. The order summary included an order to check the indwelling urinary catheter securement device every shift and to use a leg strap to secure the Foley in place. During observation of catheter care, Resident #58 had an indwelling urinary catheter and did not have a leg strap or securement device in place. CNA B stated the tubing should have been secured and that the purpose of securing it was to prevent pulling on the tubing, which could cause it to come out and require reinsertion. LVN D stated there was an order to check the securement device every shift but did not know why it was not in place. The ADM stated she did not have a policy for catheter care, and the DON stated it was her expectation that urinary catheter tubing be secured and that CNAs should notify the nurse if a securement device needs to be replaced.
Failure to Document and Manage External Catheter Urinary Wicking System
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for one resident who used an external male catheter with a urine collection system. The resident was admitted with diagnoses including anxiety disorder, chronic pain syndrome, scoliosis, and end stage heart failure. His admission telephone order and physician orders did not include any order or instructions for the external catheter urinary wicking system, and his comprehensive care plan did not address the system, including who would reapply it, empty the canister, or how often those tasks were needed. The care plan instead addressed bladder incontinence with incontinent care every 2 hours and moisture barrier application after each episode. During interview and observation, the resident stated he used the external catheter urinary wicking system, paid for the supplies himself, and needed assistance with setup and reapplication as needed. He pointed to boxes of supplies in his room, and two urine collection containers were observed on the floor next to the bed, with one container full of dark yellow urine. The DON stated the hospice nurse applied the system weekly on Mondays and acknowledged there was no documentation for it being changed and no policy for the external catheter urinary wicking system. Later observation showed the bag had been off since the prior day, and when the DON and Regional nurse were changing the resident's brief, the bag was not seen in the brief or in the bed.
Delayed Incontinence Care
Penalty
Summary
Timely incontinence care was not provided for Resident #13. The resident was admitted with diagnoses including acute kidney failure, acute chronic diastolic congestive heart failure, and peripheral vascular disease. Her care plan documented impaired mobility, bowel and bladder incontinence, dependence on staff for ADLs, and interventions to assist with toileting needs throughout the day and to check and change her as needed. The MDS showed a BIMS score of 15/15, and the resident was impaired in both upper and lower extremities and dependent on staff for ADLs. During an observation and interview on 07/22/26 at 7:37 A.M., Resident #13 was in bed pointing to her brief and stated she was wet and needed to be changed and cleaned up. She said she had last been changed the night before and that it had been a long time. At 7:39 A.M., an LPN observed in the room checked the brief, confirmed the resident was wet, fastened the brief back together, pulled up the covers, washed her hands, and left the room stating she would be back. The LPN was then observed standing next to a medication cart watching a medication pass by another surveyor and did not change the resident at that time. The facility policy titled Incontinence Care stated the facility had a policy to ensure residents who were incontinent of bowel and/or bladder received appropriate treatment and services.
Delayed Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide timely toileting assistance and incontinence care for Resident #6, who had a BIMS score of 13 indicating intact cognition and required maximum assistance for toileting hygiene and toileting transfers. Resident #6 had occasional urinary incontinence and frequent bowel incontinence, with diagnoses including a left femur fracture, COPD, bipolar disorder, anxiety, and dementia. The care plan identified bladder incontinence, self-care deficits, impaired balance during transitions, and incontinence, with interventions calling for two staff members for transfers. During observation, Resident #6 was found sitting on the edge of the bed while the resident representative and Staff A were present. The resident representative asked whether the wheelchair cushion was wet and removed it, showing urine wetness soaked through to the bottom of the cushion; the resident representative also stated the wheelchair felt wet and asked staff to clean it before Resident #6 was placed into it. Resident #6 stated staff had left them in a wet brief for 5 hours. Staff A stated residents were changed every 2 to 3 hours but reported that around lunchtime Resident #6 had activated the call light to use the bathroom, and Staff A told the resident about lunchtime and planned to return after assisting in the dining room. Staff C stated that if a resident requested bathroom assistance during lunch, staff helped only if sufficient staffing existed, and otherwise told the resident assistance would occur after dining room duties were completed. The DON stated residents should be changed every 2 hours upon rising, before and after meals, at bedtime, and as needed, and that if a resident requests bathroom assistance during a meal, staff must assist before going to the dining room.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.