Grove of Elmhurst: Catheter Care Failures Found - IL
The resident, identified in inspection records only as R5, uses an indwelling urinary catheter because of a neuromuscular dysfunction of his bladder. He also has contractures, the kind of muscle stiffening that can make basic care complicated, that can make positioning difficult, that can make the difference between a routine procedure and one that gets skipped or done halfway. When inspectors examined R5 during an August 2025 complaint investigation at the facility, they found bowel residue present in the area around his catheter.
The nursing assistant, identified as V7, told inspectors directly that R5's contractures made it hard to position his catheter tube correctly and to clean around it. That acknowledgment was notable for what it confirmed: the difficulty was known. Staff had encountered it before. The problem was not a surprise.
R5's care plan, reviewed by inspectors on August 9, spelled out the stakes plainly. He was at risk for infections. He required catheter care every shift and as needed. Staff were responsible for his toileting hygiene. The plan did not leave room for interpretation about how often care should happen or who was responsible for providing it.
The facility's own catheter care policy, dated July 3, 2025, describes a specific sequence of steps. Staff are supposed to put on gloves, wash the resident's genitalia and perineum thoroughly with soap and water, rinse and dry the area, retract the foreskin for uncircumcised male residents, assess the urethral opening, cleanse around it using circular strokes that move outward from the insertion site, and change the position of the washcloth with each stroke. The catheter itself is to be cleaned from the insertion point outward for approximately four inches. Gloves come off, hands get washed. The policy lists observation for complications as a separate obligation: check the urine for unusual color or blood, watch for signs of urinary tract infection or urinary retention, and report anything abnormal to a physician or supervisor immediately.
The bowel residue inspectors found suggested those steps were not being completed as written.
The Director of Nursing, identified as V2, met with inspectors at 1:30 in the afternoon on August 9. She said she expected nursing staff to monitor catheter patients for complications, including obstructions. She said nurses were supposed to notify the physician of any abnormalities. She said documentation of catheter procedures belonged in the resident's electronic medical record. She described the standard that should have been in place.
What she described and what inspectors found around R5's catheter were not the same thing.
Catheter-associated urinary tract infections are among the more preventable complications in long-term care. They are also among the more serious ones for residents whose overall health is already compromised. The facility's own policy opens by stating that its purpose is to prevent exactly that outcome. For a resident like R5, whose care plan already flagged infection risk as a specific concern, the margin for incomplete care is narrow.
The violation was cited at a level of minimal harm or potential for actual harm, meaning inspectors determined that R5 had not yet suffered a documented injury from the lapse but that the conditions created real risk. That distinction matters in how federal regulators categorize and respond to findings, but it does not change what was present when inspectors arrived: a man with known vulnerabilities, a care plan that required consistent attention, and bowel residue where there should have been none.
V7's explanation, that the contractures made proper care difficult, is the kind of answer that points toward a need for a different approach, a care conference, a revised technique, a second staff member, some adaptation to the specific reality of this resident's body. There is no indication in the inspection record that any such adaptation had been made.
R5 remained at the facility as of the inspection date.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grove of Elmhurst, The from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
GROVE OF ELMHURST, THE in ELMHURST, IL was cited for violations during a health inspection on August 11, 2025.
The resident, identified in inspection records only as R5, uses an indwelling urinary catheter because of a neuromuscular dysfunction of his bladder.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.