Resident #05 at Stellar Care Center was supposed to have his suprapubic catheter changed on March 25 by Physician Assistant #300, who works for general surgery at a local hospital. The catheter connects directly through the abdomen to the bladder, bypassing normal urination.
But nursing notes contain no record of the catheter being placed during that visit.
Three months later, on June 17, the resident attended a follow-up appointment with PA #300 because the catheter was leaking. The facility's Director of Nursing said PA #300 told them they switched the catheter out during this visit. Again, no documentation exists confirming the change occurred.
The resident never attended another appointment about the catheter.
When inspectors interviewed LPN #84 on September 25, the nurse admitted never personally changing Resident #05's suprapubic catheter. The LPN said he had received no training on the procedure and wouldn't know how to do it. To his knowledge, the resident never had a physician order for catheter changes.
The Director of Nursing revealed the truth during her interview that same morning. She had spoken with LPN #84 and LPN #69, who both admitted they had signed off on catheter changes because "they thought it was just for the catheter bag itself, not the actual catheter."
The nurses confused changing a simple collection bag with replacing the actual catheter inserted into the resident's body.
The DON blamed the mix-up on facility practices. She said staff weren't used to changing indwelling Foley catheters because of infection risks, creating confusion about the suprapubic catheter maintenance.
Medical Intensive Care Unit Physician #803 explained the consequences during his interview on September 25. Resident #05 remained under his care in the ICU, where the physician said the resident's condition resulted directly from the catheter neglect.
"Resident #05's suprapubic catheter not being changed as ordered and catheter care not being completed as it should, led to the development of a UTI causing Resident #05 to become septic," Physician #803 told inspectors.
The facility's own catheter care policy, reviewed on April 28, required staff to document care completion and notify supervisors of any problems or resident complaints. The policy demanded reporting "in accordance with facility policy and standards of practice."
Instead, nurses documented procedures they never performed on equipment they didn't understand.
Suprapubic catheters require specialized knowledge because they create a direct pathway into the bladder through surgical insertion. Unlike external catheter bags that can be changed by nursing assistants, the catheter itself must be maintained by trained medical professionals to prevent exactly the type of infection that hospitalized Resident #05.
The falsified documentation meant no one tracked the actual condition of the resident's catheter for months. While PA #300 may have performed maintenance during the March and June visits, the facility kept no records proving the work occurred.
Federal inspectors classified the violation as "immediate jeopardy," their most serious finding, affecting few residents but posing life-threatening risks.
The case emerged through multiple complaints filed with state regulators, indicating concerns extended beyond this single resident's care.
Resident #05's progression from a leaking catheter to life-threatening sepsis illustrates how documentation failures can mask medical neglect. The nurses' confusion about basic medical equipment suggests broader training deficiencies that could affect other residents requiring specialized care.
The resident remains hospitalized in intensive care, his condition a direct result of staff who signed their names to procedures they never performed and didn't understand.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stellar Care Center from 2025-09-30 including all violations, facility responses, and corrective action plans.