The 29-year-old woman, identified in records as Resident 33, has lived at the facility since August with diagnoses including cerebral palsy, neurological bladder dysfunction, and lack of coordination. She requires a suprapubic catheter due to urinary retention and is always incontinent of bowel and bladder.
On January 6 at noon, inspectors observed the resident in bed watching television. Her catheter bag was full of urine and lying on the floor with no privacy cover.
The next day at 4:30 PM, inspectors found her sitting in her wheelchair in her room. Again, the catheter bag was on the floor behind her wheelchair without any privacy covering.
When confronted 14 minutes later, the facility's Unit Manager acknowledged the problems immediately. The catheter bag should not be on the floor because that could cause infection, she told inspectors. The covering is a dignity issue for the patient.
"She is aware that the catheter bag should not be on the floor," inspectors wrote in their report. The Unit Manager said she would take care of the matter right away.
The facility's own policy, revised in October, requires employees to treat all residents with kindness, respect and dignity. The policy states the facility "will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity."
Resident 33's care plan, developed in August, specifically addresses her catheter management. It calls for staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. Staff are instructed to check tubing for kinks during rounds each shift.
The resident prefers Catholic activities and some activities outside her room, according to her care plan. Her cognitive assessment in December showed a score of 10 out of 15, indicating moderate impairment but retained mental capacity.
Medical records show she completed antibiotic treatment for a urinary tract infection in early November. A progress note from November 5 indicated no adverse reactions and no concerns or complaints at the time.
During an interview on January 8, the facility's Director of Nursing told inspectors that staff uses locks to keep catheter tubing from kinking. She said staff visually observe catheters to check for kinking as well.
The Director of Nursing acknowledged that catheter bags should never be on the floor and should have privacy bag coverings to protect patients and prevent infection. She stated she had never witnessed the catheter bag being on the floor in Resident 33's room.
The violation represents what federal regulators classify as "minimal harm or potential for actual harm" affecting "few" residents. However, the case highlights basic dignity and infection control failures for a vulnerable resident who depends entirely on staff for personal care.
Catheter-associated urinary tract infections are among the most common healthcare-associated infections in nursing homes. Proper catheter management requires keeping drainage bags below bladder level and maintaining sterile technique during handling.
For Resident 33, who has already experienced at least one urinary tract infection requiring antibiotic treatment, improper catheter care poses ongoing health risks. The lack of privacy covering also violates basic dignity standards for a young woman living with permanent disabilities.
The facility operates under the corporate name Resorts at Beaufort and is located on Todd Drive in Beaufort. Federal inspection records show this represents the facility's most recent documented violation of resident rights and dignity standards.
Resident 33 continues to live at the facility, dependent on staff who failed twice in two days to provide basic catheter care that meets both medical and dignity standards. Her wheelchair sits in a room where inspectors found her catheter bag on the floor, full of urine, without the privacy covering that facility managers acknowledged she deserved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Resorts At Beaufort from 2025-01-08 including all violations, facility responses, and corrective action plans.
