The September inspection at Camino Healthcare found that Resident 1, who was cognitively intact and capable of making decisions, lacked the comprehensive care plan required by federal regulations. The resident had been admitted with diagnoses including vertebra fracture, paraplegia, and urinary retention.
Medical records showed the resident understood instructions and could communicate clearly with others. He used a wheelchair for mobility but had no impairment to his arms and legs, according to his July assessment.
The facility's Minimum Data Set Nurse discovered the gap during the inspection. When inspectors reviewed the resident's Order Summary Report on September 9, they found active orders allowing the resident to perform in-and-out self-catheterization. The procedure involves temporarily inserting a thin tube into the bladder to drain urine, then immediately removing it.
But no care plan existed to address this critical need.
"Resident 1 should have a care plan to reflect that," the nurse told inspectors after reviewing the orders. She acknowledged the resident "did not have a care plan for in and out self-catheterization and was important to have one to identify the needs of Resident 1 and to guide their care."
The missing care plan violated federal requirements that nursing homes develop comprehensive, person-centered plans for each resident. According to the facility's own policy, dated January 2021, the interdisciplinary team must create plans with "measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs."
Self-catheterization requires specific protocols, timing, and monitoring to prevent complications. Without a formal care plan, staff lacked guidance on frequency, technique verification, supplies needed, or how to respond to problems.
The resident's medical history made proper catheter care particularly crucial. His urinary retention and spinal injuries created elevated risks for infection, bladder complications, and other serious medical issues if the procedure wasn't performed correctly or consistently.
Federal inspectors classified the violation as causing minimal harm with potential for actual harm. The deficiency affected few residents, but represented a fundamental breakdown in care planning that could have led to serious medical consequences.
The inspection occurred following a complaint, though the report doesn't specify what prompted the investigation. Complaint-driven inspections typically focus on specific allegations of poor care or safety violations.
Camino Healthcare operates at 13922 Cerise Avenue in Hawthorne. The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs.
The case illustrates how administrative failures can directly impact resident safety. Even when residents have the cognitive ability and physical capacity to manage aspects of their own care, nursing homes remain responsible for creating formal plans that ensure proper oversight and support.
For Resident 1, the absence of a catheterization care plan meant potential gaps in monitoring, supply provision, technique verification, and emergency response protocols. The resident's paraplegia and history of urinary retention made these oversights particularly concerning from a medical standpoint.
The violation occurred despite clear documentation of the resident's needs and capabilities. His assessment showed he was mentally sharp, could communicate effectively, and had full use of his arms for performing the catheterization procedure. Yet staff failed to translate these facts into the required care plan.
Federal regulations require nursing homes to assess residents comprehensively and develop individualized care plans within specific timeframes. These plans must address all identified needs and include measurable goals with target dates for achievement.
The facility's own policy emphasized the importance of person-centered planning that respects resident rights while ensuring appropriate medical oversight. The interdisciplinary team approach is designed to bring together multiple perspectives to create comprehensive care strategies.
Without proper care planning, even capable residents like Resident 1 can face unnecessary risks. Self-catheterization, while routine for many people with spinal injuries, still requires institutional support to ensure safety and prevent complications.
The inspection found that basic care coordination had broken down. A resident with complex medical needs was left without formal guidance for a critical daily procedure, despite having the mental capacity and physical ability to participate in his own care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Camino Healthcare from 2025-09-10 including all violations, facility responses, and corrective action plans.