Based on interview and record review, it was determined that: R #1 1) R #1 was identified as possibly having a urinary tract infection 2) subsequently had 2 days, 09/10/17 and 09/11/17 where the urine output was not recorded. R #2 3) R #2 was on a bladder retraining program after the facility removed his Foley catheter. Due to the removal of the foley R #2 required monitoring of urine output. 4) R #2 did not have an order to d/c (discontinue) his Foley catheter. 5) R #2 was also at risk for complications (dehydration, low urine output) from being on fluid restrictions. 6) The facility did not revise R #2's care plan to d/c his Foley catheter/start bladder retraining program, and did not follow R #2's care plan for monitoring low urine output from being on fluid restrictions. …
F315
Quality of Life and Care Deficiencies
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The harm level
How severely F315 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D5100.0% | E— | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
What an F315 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility failed to have a physician order to discontinue an indwelling urinary catheter (a flexible tube that passes through the urethra (a tube by which urine is conveyed out of the body from the bladder) and into the bladder to drain urine), accurately monitor the fluid intake and output (I & O) according to facility's policy and procedure, and monitor the weekly weights as ordered by the physician for one of three sampled resident (Resident 1). These deficient practices resulted inaccurate assessment and monitoring of Resident 1's fluid intake and output and weight loss. …
Based on observation, interview, and document review, the facility failed to provide necessary cares/services to prevent urinary tract infections [MEDICAL CONDITION] for 1 of 6 residents, R1, reviewed for an indwelling urinary catheter care who had a history of [REDACTED]. Findings include: R1's annual Minimum Data Set ((MDS) dated [DATE], indicated the resident had no cognitive impairment, had an indwelling urinary catheter, and required extensive assistance from staff with all activities of daily living. R1's physician progress notes [REDACTED]. R1's hospital admission [DIAGNOSES REDACTED]. R1 had a video camera placed in her room at the facility by a family member. Review of a video taken in R1's room on 10/27/17, at approximately 7:40 a.m. …
Surveyor: Hudson, Edwina F. Based on observation, interview and record review, the facility failed to ensure one (Resident #4) of three residents reviewed for indwelling catheters received appropriate care and services to prevent urinary tract infections [MEDICAL CONDITION] and as much normal bladder function as possible. The facility failed to ensure Resident #4's indwelling urinary catheter was secured to prevent movement and urethral traction. This failure could place four residents with urinary catheters at risk for discomfort, urethral trauma and urinary tract infections [MEDICAL CONDITION]. …
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