Edgewater Woods: Catheter Delay Left Resident Without Relief - IN
The inspection, completed August 29, 2025, at Edgewater Woods on North Madison Avenue, found that a resident's urinary catheter had been removed and was not successfully reanchored for over nine hours. The physician's order had been clear: if the resident did not void within six hours, the catheter should be reanchored. Nine hours passed before that happened.
The sequence began on July 29. The catheter was removed, and when the time came to reinsert it, the nurse did not have the correct size available. The facility stocked an 18 French catheter. What had been ordered was a 16 French. The nurse had to contact the nurse practitioner for a new order authorizing the different size. Only after that new order was received, at approximately 8:45 p.m., was the catheter placed. When it finally went in, there was an immediate return of urine.
That gap, between removal and successful reinsertion, ran longer than nine hours.
Every nurse interviewed during the inspection described the same standard. RN 5 said a resident should go no longer than eight hours without voiding after a catheter is removed. The Unit Manager said she would expect a catheter to be reanchored within eight hours if the resident hadn't voided. The Director of Nursing said the same thing, adding that the resident had declined the catheter earlier in the day, which required the nurse to obtain a new order. She said she was uncertain whether the correct size catheter couldn't be found or simply wasn't available.
The Scheduler, who was responsible for ordering and maintaining medical supplies at the facility, told inspectors she tried to keep one of every catheter size in stock. She said new admissions were discussed in morning meetings, including what sizes of catheters, feeding tubes, and tracheostomy supplies they would need.
One of every size. Except, on July 29, the size that was needed wasn't there.
The Director of Nursing told inspectors the facility had procedures for catheter care and draining a urinary drainage bag. It had nothing else. No additional policies governing urinary catheters, no written protocol for what to do when a required size was unavailable.
The inspection report cited guidance from the National Library of Medicine, drawn from the National Institutes of Health, which states that after an indwelling catheter is removed, the time of removal and the time of the first void should be documented and communicated during handoff. If a patient cannot void within four to six hours, or reports bladder fullness, a nurse should assess for incomplete bladder emptying. The American Nurses Association recommends prompting the patient to urinate, and if the volume is under 180 milliliters, performing a bladder scan to check how much fluid remains. If a bladder scanner isn't available, a straight catheterization should be performed.
The resident received pain medication before the catheterization, had a fentanyl patch in place, and was also receiving routine acetaminophen. He voiced no concerns. The inspection classified the violation as minimal harm or potential for actual harm.
But the standard the facility's own nurses described, eight hours, was itself already longer than the four-to-six-hour window in the clinical guidance. The resident waited past both.
The nursing progress note documenting what happened wasn't written in real time. It was entered on July 30 at 3:04 a.m., timestamped to the events of July 29. A late entry, written in the early morning hours, accounting for the night before.
When the catheter finally went in, urine returned immediately.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edgewater Woods from 2025-08-29 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: August 4, 2026 · Our methodology
EDGEWATER WOODS in ANDERSON, IN was cited for violations during a health inspection on August 29, 2025.
The physician's order had been clear: if the resident did not void within six hours, the catheter should be reanchored.
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.