North Crest Living Center: Catheter Monitoring Failure - IA
The August 2025 complaint inspection at the facility, located at 34 Northcrest Drive, centered on a single resident identified in inspection records as Resident 1. That resident had a urinary catheter. At some point, the catheter recorded no output.
Zero output from a urinary catheter is not a paperwork problem. It can mean the catheter is clogged. It can mean the catheter has stopped functioning. The director of nursing acknowledged both possibilities to inspectors during the survey. She said if there was a decrease in output, the nurse should have been notified. In this case, the nurse was not notified.
The director of nursing, whose name does not appear in the inspection report, did not dispute the core finding. She acknowledged that no output could indicate dysfunction or a clog. She said she felt the concern was a documentation issue.
That framing, documentation rather than care, is the tension at the center of what inspectors found. A catheter that stops draining urine is a clinical event. It carries infection risk. It requires a nurse's attention. The facility's own policy, updated in October 2024, described catheters as part of the overall infection control program and committed the facility to providing a safe and healthy environment for residents to minimize or prevent the spread of infection.
The gap between that written commitment and what happened with Resident 1 is what brought inspectors to North Crest in the first place. The inspection was complaint-driven, meaning someone, a resident, a family member, or a staff member, reported a concern significant enough to trigger a federal review.
Inspectors rated the deficiency at the minimal harm or potential for actual harm level, meaning they did not find that Resident 1 suffered a documented serious injury as a result. A small number of residents were identified as affected. But the distinction between minimal harm and no harm is not the same as the distinction between a paperwork gap and a care failure, and inspectors treated this as the latter.
Urinary catheters are among the most common sources of infection in long-term care settings. Catheter-associated urinary tract infections can move fast in elderly residents, escalating from a localized problem to a systemic one. Monitoring output is one of the basic tools for catching early warning signs. When output drops or stops, it is a signal the system is not working as it should.
The facility's October 2024 policy on catheters was not vague on this point. Catheters are to be changed per orders, the policy stated, and the broader framework was infection control. The policy existed. The monitoring did not happen. The nurse was not called.
What the director of nursing's response reveals is a question about how the facility interprets its own obligations. If the answer to a missed clinical observation is that it was a documentation issue, the facility may be measuring the wrong thing. The record not being updated is a symptom. The nurse not being called is the event.
Inspectors completed their review on August 26, 2025. The plan of correction, if one has been submitted, is available through the facility or the Iowa state survey agency. Resident 1's catheter, and whether it was functioning properly by the time inspectors left, is not addressed in the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Crest Living Center from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 2026 · Our methodology
North Crest Living Center in Council Bluffs, IA was cited for violations during a health inspection on August 26, 2025.
That resident had a urinary catheter.
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.