The September inspection at Ingleside Manor found staff had ignored clear written protocols about catheter care for a resident with a suprapubic catheter — a tube surgically inserted through the abdomen directly into the bladder.
The resident, identified as R6 in inspection records, told inspectors she has a history of urinary tract infections and was concerned about the care she receives for her catheter equipment. When inspectors interviewed her at 8:30 AM on September 11, they observed her catheter tubing and drainage bag sitting on the floor beside her recliner.
The facility's own catheter care policy, dated September 2014, states its purpose is "to prevent catheter-associated urinary tract infections." The policy specifically requires staff to "be sure the catheter tubing and drainage bag are kept off the floor."
R6's care plan, printed September 11, reinforced this requirement: "Do not allow tubing or any part of the drainage system to touch the floor." Her resident profile sheet used by nursing assistants contained identical instructions.
When inspectors questioned Certified Nursing Assistant D about the catheter placement nearly an hour later, the aide acknowledged the equipment should not be on the floor and moved it to proper position.
The Director of Nursing confirmed the violation when interviewed that afternoon. DON B told inspectors that catheter tubing and drainage bags should be hung below the level of the resident's bladder but never placed on the floor. When informed about the inspector's observation, the nursing director agreed R6's catheter equipment "should not have been on the floor."
The resident required the suprapubic catheter as part of her comprehensive care plan. Her physician's orders from September 11 directed daily cleansing of the catheter site with mild soap and water, followed by gentle drying with a soft towel.
The care plan established specific goals for catheter management: the resident should not exhibit obstruction, signs of infection, catheter dislodgement, bowel perforation, or trauma. The approach section emphasized keeping all drainage system components elevated off the floor.
Federal inspectors classified the violation as causing minimal harm with potential for actual harm, affecting few residents. The citation falls under regulations requiring facilities to provide appropriate care for residents with urinary catheters and appropriate care to prevent urinary tract infections.
Catheter-associated urinary tract infections represent a significant risk in nursing homes, particularly for residents with compromised immune systems or existing infection histories. Allowing drainage bags to rest on floors exposes the catheter system to bacteria and other pathogens that can travel up the tubing into the bladder.
The inspection occurred as part of a complaint investigation at the 407 N Eighth Street facility. Records show the nursing home had established comprehensive policies and training materials about proper catheter care, yet staff failed to follow these protocols in practice.
The resident's expressed concern about her catheter care suggests ongoing awareness of infection risks. Her history of urinary tract infections made proper catheter management particularly critical for preventing recurring complications.
The violation demonstrates a gap between written policies and actual care delivery at Ingleside Manor. Despite clear documentation requirements and staff training materials, the nursing assistant responsible for R6's care had not maintained proper catheter positioning.
The nursing director's acknowledgment that the equipment placement was inappropriate indicates facility leadership understood the infection control requirements. However, the violation occurred despite multiple layers of policy documentation and care plan instructions.
R6's suprapubic catheter requires specialized care due to its surgical placement through the abdominal wall. This type of catheter often serves residents who cannot use traditional urethral catheters due to medical complications or anatomical issues.
The inspection found that facility policies correctly identified infection prevention as the primary goal of catheter care protocols. The written procedures aligned with accepted medical standards for maintaining sterile catheter systems and preventing bacterial contamination.
The violation occurred during routine care activities when the resident was sitting in her room. The catheter bag's placement on the floor beside her recliner suggests staff had not properly secured the drainage system when positioning the resident in her chair.
The immediate correction by the nursing assistant after inspector questioning shows staff understood proper procedures once reminded. However, the initial violation indicates inconsistent application of established protocols during daily care routines.
R6 remains dependent on appropriate catheter management to prevent serious complications including recurring urinary tract infections, sepsis, and other potentially life-threatening conditions associated with improper catheter care in elderly residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ingleside Manor from 2025-09-15 including all violations, facility responses, and corrective action plans.