Resident #5 received no documented catheter flushes from late January through mid-April 2025, even though urologists recommended the procedures. The facility also failed to document any catheter changes for the resident from December 28, 2024 through May 26, 2025, when hospital records finally showed a replacement.
The Director of Nursing confirmed during an October inspection that no flushes were documented as administered for February, March and half of April. She told inspectors that "different urology consult providers were coming into the building and that they all had different ways of communicating with the facility."
She said catheter changes happened only when urologists visited for consultations, but couldn't provide documentation to prove it. When pressed, she admitted she would need to contact the providers for records that the catheters were actually changed.
A second resident faced similar neglect.
Resident #11 had orders dating to December 2022 requiring catheter changes every four weeks. The resident suffered from obstructive and reflux uropathy along with an overactive bladder. November 2024 records showed proper changes on November 1 and November 29.
Then the care stopped.
The facility discontinued the four-week change order on December 9, 2024, switching to "change as needed" two days later. No documented catheter changes appeared in treatment records from January through July 2025.
Multiple urology consultation notes from November 2024 through March 2025 consistently stated the same instruction: "Please perform routine exchange the SPC routinely every 4-6 weeks." None of the notes indicated the specialists had actually changed the catheter themselves.
The contradiction became clear in a December progress note. A registered nurse wrote that staff had told the resident's representative "that the SPC was changed monthly by the urology staff."
But urology staff hadn't seen Resident #11 monthly in 2025.
When inspectors asked the urology provider about facility expectations, the specialist explained that outside providers only change catheters in specific circumstances. Staff #6 said providers might handle "an initial change after placement or a complicated catheter," but otherwise "it is the expectation that the facility would change the catheters per the Resident's individual plan of care."
The provider confirmed that any catheter changes by specialists would be documented in progress notes from those visits. No such documentation existed.
Suprapubic catheters drain urine directly from the bladder through the abdominal wall, bypassing the urethra. Regular changes prevent bacterial buildup and blockages that can cause dangerous infections or kidney damage. The devices require sterile technique and careful monitoring.
Federal nursing home regulations require facilities to provide necessary care and services to maintain each resident's highest possible physical and mental well-being. The missed catheter care violated these standards.
The facility's explanation shifted blame to outside providers while internal records showed staff had stopped following their own treatment orders. The December order change from scheduled replacements to "as needed" came without medical justification in the resident's file.
Both residents' cases revealed the same pattern: clear medical orders, documented early compliance, then months of undocumented care with staff claiming specialists handled the procedures.
At the inspection's conclusion, facility administrators provided no documentation proving either resident received required catheter changes during the identified periods. The Director of Nursing's promise to contact providers for missing records suggested the facility lacked basic documentation of critical medical procedures.
The inspection occurred following a complaint about the facility's care practices. Federal investigators classified the violations as causing minimal harm or potential for actual harm to few residents, but the months-long gaps in required care created serious infection risks for vulnerable patients dependent on properly maintained medical devices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Overlea from 2025-10-22 including all violations, facility responses, and corrective action plans.
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