Countryside Meadows: Catheter Care Failures Cited - IN
The resident at the center of the complaint inspection, identified in records only as Resident D, had a nephrostomy tube — a catheter inserted through the back directly into the kidney to drain urine when normal urinary function is compromised. On September 29, 2025, when inspectors arrived, that tube had no drainage bag connected to it.
The Director of Nursing told inspectors at 1:27 p.m. that the tube was currently dislodged and would need to be replaced at the hospital. She said the tube had no bag attached because it wasn't draining, a consequence of the dislodgment. She added she needed to review the current orders for the tube.
Nine minutes later, at 1:36 p.m., the same Director of Nursing told inspectors she planned to "clean up" Resident D's orders, because the correct order should have been to change the dressing only when soiled and to flush the tube as needed.
Then the unit manager spoke with inspectors at 2:31 p.m. Her account was different. She told inspectors the nephrostomy tube currently in place was a new tube and was working properly, as far as she knew. She said she was about to change the dressing because, to her knowledge, the tube was supposed to be flushed and the dressing changed daily. She explained there was no drainage bag because Resident D's other kidney was functioning and the resident was urinating normally, so the tube simply wasn't draining at the moment. If it started draining, she said, staff would connect a bag and track the output.
Twenty-nine minutes after that, the administrator stepped in to correct the record. The unit manager had misspoken, the administrator told inspectors. The current order was to change the dressing only as needed. And the tube, the administrator confirmed, was still dislodged.
Three staff members. Three accounts. The tube's basic status — was it a new tube working properly, or a dislodged tube awaiting hospital replacement — remained unsettled until the administrator's interview closed out the afternoon.
The inspection was triggered by a complaint. Inspectors also reviewed Resident D's care records related to incontinence. Because the resident could not sense when she needed to void, only after she already had, she was placed on a two-hour check and change schedule. The unit manager described this arrangement to inspectors, noting the resident was not on a formal bowel and bladder program for this reason.
What inspectors did not find in Resident D's chart was any care plan or documentation addressing the resident's behaviors around incontinence care, including any record of refusals of toileting assistance, personal hygiene, or what the report describes as false accusations. The absence of that documentation was part of what drew scrutiny.
The facility's own bowel and bladder policy, dated May 2019 and provided to inspectors by the administrator on the day of the inspection, stated that residents who are totally incontinent and cannot be placed on a toilet or bedpan should be checked and changed every two hours. Resident D was on that schedule. The gap wasn't the schedule itself. It was the missing documentation around why certain care approaches were or weren't in place, and the conflicting picture staff painted of her current medical status.
The violation was cited under F0690, covering urinary incontinence and catheter care. Inspectors classified the level of harm as minimal harm or potential for actual harm, affecting few residents.
What the inspection captured, in plain terms, was a nursing home where the people responsible for a resident's care could not give a consistent account of that care to federal inspectors on the same afternoon. The Director of Nursing said the tube was dislodged and non-functional. The unit manager said it was new and working. The administrator had to intervene to clarify what the actual orders were, and acknowledged the orders themselves needed to be cleaned up.
Resident D, meanwhile, was waiting for a hospital visit to have her nephrostomy tube replaced.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Countryside Meadows from 2025-09-29 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: June 26, 2026 · Our methodology
COUNTRYSIDE MEADOWS in AVON, IN was cited for violations during a health inspection on September 29, 2025.
On September 29, 2025, when inspectors arrived, that tube had no drainage bag connected to it.
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.