A resident with obstructive uropathy, urinary retention, and a suprapubic catheter had the urinary collection bag placed in a canvas dignity bag under the wheelchair seat, but the tubing repeatedly dragged on the floor and the bag was visibly dirty with lint and debris. Staff said the bag was heavy fabric and there was no schedule to change it, while the DON and RCM stated the tubing and dignity bag should not be on the floor.
Failure to assess and care for residents with bowel and bladder incontinence: Three residents had incomplete or absent bowel/bladder program evaluations, inconsistent incontinent care, and poor documentation of toileting and brief changes. One resident newly developed bowel incontinence after surgery and reported long waits for changes, another had continent/incontinent episodes with a diuretic order and family reports of urine odor and delayed care, and a third with severe dementia had no incontinent care plan, infrequent check-and-change documentation, and moisture-related skin breakdown.
A resident with an indwelling catheter for urinary retention and prostatitis had catheter tubing observed on the floor and on a wheelchair wheel, and the catheter bag was repeatedly placed on the floor during emptying. The resident reported the bag had often been left on the floor and described urine spilling during emptying. An NA was observed emptying the catheter bag on the floor without disinfecting the spout, while an LPN/NM stated catheter care should be done every shift, with the spout disinfected and tubing and bag kept off the ground.
Urinary catheter care was not maintained for two residents with indwelling catheters. One resident’s care plan and Kardex did not direct staff to empty the bag or keep it off the floor, and observations showed the bag repeatedly full and resting on the floor. Another resident had an order to empty the bag every shift due to high UTI risk, but the bag was observed half full and later full on the floor without a privacy cover, and staff confirmed it had not been emptied or properly positioned.
A resident with urinary incontinence and a recent UTI history developed burning and frequent urge with urination, but staff only placed the resident on alert and encouraged fluids rather than promptly documenting provider notification and treatment actions. Nursing staff gave inconsistent accounts of when to notify the provider for UTI symptoms, and the record contained no note to the provider about the resident’s symptoms. The resident’s briefs were reportedly not changed often, and the resident was later discharged with a UTI.
Failure to restore continence and provide appropriate toileting support. A resident who had been continent before admission was placed in a brief and documented as frequently incontinent, while records showed no voiding pattern was completed and a toileting program was not attempted. The care plan included prompted and routine toileting, but documentation lacked detail, and observations showed the resident was sometimes assisted to the bathroom only when they indicated a need, while at other times they remained at the nurse’s station without toileting.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Leaking Catheter Not Reported or Addressed: A resident with MS, neurogenic bladder, and functional quadriplegia had an indwelling catheter that was documented as leaking over multiple months. The record showed no documented provider notification of the leak, the care plan had no interventions for the issue, and physician notes continued to reference the need for a urology referral that had not been scheduled. During catheter care, staff observed the catheter still leaking, and an RN stated the leak should have been reported to the provider.
Two residents with indwelling urinary catheters were not properly assessed for continued catheter use or monitored according to provider orders. One resident with BPH and urinary obstruction had a catheter documented on admission and in the care plan, but there was no assessment of the need for ongoing use, no discussion of infection risk at care conference, and no documented provider decision to continue the catheter; the resident attempted to pull out the catheter, an outside provider later recommended removal due to high infection risk, and a voiding trial was only initiated at the receiving facility on the day of discharge. Another resident with urinary retention and prior UTI had a catheter care plan with no stated reason, incomplete documentation of ordered PVR scans and straight catheterization after catheter removal, and reinsertion of the catheter after failed voiding trials; later catheter removal occurred without a documented order or PVR monitoring, and the resident subsequently had difficulty voiding with high PVR before discharge, without documented urology referral or clear post-catheterization care planning.
A resident with an indwelling catheter, moderate cognitive impairment, and diagnoses including CHF, diabetes, BPH, and UTI was observed during mechanical lift transfers with the catheter drainage bag hung above bladder level. On two occasions, NAs placed the bag on the sling during transfers, and urine was seen flowing back into the bladder; the DON stated the bag should be kept at or below bladder level to avoid UTI risk.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
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.