Premier Care Center: Catheter Removed Without Order - CA
The incident occurred on July 19, 2025, when LVN 2 removed Resident 1's catheter at 8:50 p.m. after RN 1 asked her to do it. During a July 22 interview, LVN 2 admitted she never checked for a physician's order before removing the catheter.
"There should be a physician's order to remove an urinary catheter before removing the catheter, document the procedure conducted, and monitor the resident's urine output, presence of pain, or distention, after the urinary catheter was removed," LVN 2 told inspectors.
The Director of Nursing confirmed no physician's order existed to remove the catheter. He also revealed that LVN 1, not LVN 2, actually removed the catheter, and that nurse admitted she never documented the removal.
"He would expect the nurse who removed Resident 1's foley catheter to document the procedure, including, results, such as, any trauma and/or blood in urine," according to the inspection report. The DON emphasized that staff are required to document every procedure.
Resident 1 had returned from Garfield Community Adult Center Hospital on July 7, 2025, with a new diagnosis of a urinary tract infection. The physician wrote new medication orders on July 11 for Rocephin, an antibiotic used to treat UTIs.
But nursing staff failed to complete required monitoring protocols. The DON confirmed that when residents receive foley catheters due to urinary retention complaints, nursing staff should complete a Change of Condition form and monitor residents for adverse effects every shift for 72 hours.
The monitoring should track urinary output, pain, discomfort, and bladder distention. Urinary output gets documented in the Medication Administration Record, while other symptoms should be recorded in monitoring notes each shift.
None of this happened.
The DON verified that nursing staff never completed a Change of Condition form for the UTI, despite facility policy requiring it. They also failed to develop a care plan for urinary retention or foley catheter placement, which should have been initiated when the catheter was first placed.
The facility's own policies, revised as recently as February 2025, state clearly that indwelling foley catheters should only be removed per doctor's order. The procedures require staff to "document all appropriate information in medical record" and "document procedure."
The facility's Significant Change of Condition policy, revised in January 2022, requires licensed nurses to perform and document assessments when residents' conditions change. It mandates "no less than three days of observation, documentation, and response to any interventions."
The violation represents a breakdown in basic nursing protocols. Urinary catheters carry infection risks and removing them without medical authorization or proper monitoring could mask complications or worsen existing conditions.
Resident 1's case illustrates how multiple safety nets failed simultaneously. The resident returned from the hospital with a UTI requiring antibiotic treatment, yet staff removed the catheter without checking for orders, failed to document the procedure, and skipped required monitoring protocols.
The DON's interviews revealed confusion about which nurse actually performed the removal, suggesting poor communication and accountability systems. LVN 2 initially took responsibility but the DON later confirmed LVN 1 actually removed the catheter.
Federal inspectors cited the facility for failing to ensure residents receive proper treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The violation affected few residents but posed minimal harm or potential for actual harm.
The incident occurred at Premier Care Center for Palm Springs on East Ramon Road. State inspectors completed their investigation on August 20, 2025, following a complaint that triggered the inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Premier Care Center For Palm Springs from 2025-08-20 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: June 20, 2026 · Our methodology
PREMIER CARE CENTER FOR PALM SPRINGS in PALM SPRINGS, CA was cited for violations during a health inspection on August 20, 2025.
The incident occurred on July 19, 2025, when LVN 2 removed Resident 1's catheter at 8:50 p.m.
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.