The resident, identified only as over 65 years old, had a doctor's order dating to September 2, 2025, requiring his catheter to be changed "every month at the facility using an 18-French catheter, every night shift starting on the second and ending on the second of every month." The order was revised on October 2.
Staff last changed the catheter on September 2. By the time inspectors arrived on October 15, the device had been in place for 43 days.
The resident suffers from bladder neck distention, a condition where the bladder enlarges because the opening connecting it to the urethra becomes blocked. He depends entirely on staff for dressing, showering, toileting and mobility, though cognitive testing showed he remained mentally intact with a score of 12 out of 15.
A nursing note from October 3 revealed staff knew about the problem. "The resident's catheter did not get changed during shift," the note stated. Staff contacted an on-call provider and received authorization for a one-time order to change the catheter during the overnight shift between October 3 and 4.
That change never happened either.
Licensed practical nurse #1, interviewed on October 13, acknowledged that indwelling catheters should be changed every 30 days. She knew the resident's suprapubic catheter had been placed by urology in August 2025 but spent several minutes searching the electronic medical record trying to find when it was last changed.
"She said she did not know when the urinary catheter was last changed," inspectors noted.
The director of nursing, interviewed on October 15, confirmed awareness of the physician's orders for monthly catheter changes. She acknowledged seeing the October 3 note about the missed change and the one-time order for day shift to handle it.
"Based on what she saw documented on the task administration record, she did not think the catheter change had been completed yet," the inspection report stated.
The nursing director understood the medical risks. If a urinary catheter remains in place too long, "there could be a chance of infection or the catheter might not work properly," she told inspectors. "The urinary catheter should not be placed and then never replaced or removed."
South Platte's own catheter care policy, dated April 11, 2025, requires the facility to "ensure that residents with indwelling catheters receive appropriate catheter care." The resident's care plan, initiated in May 2024 and revised in September 2025, specifically called for monitoring and reporting any signs of urinary tract infection to physicians and ensuring the catheter tubing was "securely anchored to prevent accidental removal."
The care plan also required "providing dressing changes to the suprapubic catheter site per the physician's orders."
Suprapubic catheters are surgically inserted directly through the abdominal wall into the bladder, typically used when standard urethral catheters are not appropriate or have failed. They require careful maintenance to prevent complications including infection, blockage, and tissue damage around the insertion site.
The facility's failure occurred despite having clear documentation systems in place. The resident's electronic medical record contained his care plan, physician orders, and task administration records that should have tracked when the catheter change was due.
The October 3 nursing note showed staff recognized the oversight and took steps to get authorization for the change. But even with a specific one-time order and nearly two weeks of additional time, the catheter remained unchanged when inspectors arrived.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. The finding was part of a complaint investigation completed on October 15, 2025.
The resident's case illustrates how documentation gaps and communication failures can leave vulnerable patients at risk for preventable complications, even when staff understand proper procedures and facility policies exist on paper.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Platte Rehabilitation and Nursing LLC from 2025-10-15 including all violations, facility responses, and corrective action plans.
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