Resident #11 required the specialized catheter due to obstructive and reflux uropathy and an overactive bladder. The catheter, which drains urine directly from the bladder through the abdominal wall, needs regular replacement to prevent infection and other complications.
Medical records showed the facility initially followed proper protocols. In November 2024, staff documented changing the catheter on November 1st and November 29th, adhering to the original order from December 30, 2022, which specified replacement every four weeks on the Friday night shift.
Then the documentation stopped.
On December 9, 2024, the facility discontinued the regular replacement order. Two days later, they changed it to "as needed" replacement. From January through July 2025, treatment records contained no documentation that staff changed the catheter at all.
Meanwhile, the resident's medical team continued issuing clear instructions. Urology consultation notes from visits on November 15, 2024, December 13, 2024, December 27, 2024, January 24, 2025, and March 26, 2025, all contained identical language: "Please perform routine exchange the SPC routinely every 4-6 weeks."
None of the consultation notes indicated the catheter had actually been exchanged.
When inspectors arrived on October 22, 2025, they immediately identified the gap. At 9:49 AM, a surveyor reviewed Resident #11's medical record and discovered the missing documentation. By 10:05 AM, the surveyor requested proof from the Director of Nursing that staff had changed the catheter according to medical recommendations.
The Director of Nursing couldn't provide it.
During an interview at 11:47 AM, she told inspectors she had reached out to consulting providers to request documentation of catheter changes for Resident #11. But when inspectors completed their exit interview, no records had materialized to show the catheter was changed during the seven-month period from January through July 2025.
The violation represents a failure to follow physician orders and provide necessary medical care. Suprapubic catheters require regular replacement because they can become blocked, infected, or develop other complications that put residents at risk. The four-to-six-week replacement schedule ordered by the resident's medical team reflects standard medical practice for preventing these problems.
The facility's shift from scheduled replacement to "as needed" replacement appears to have resulted in no replacement at all. While the original December 2022 order specified changes every four weeks, the consulting physicians' repeated instructions allowed for replacement every four to six weeks, giving staff flexibility while maintaining safety.
Instead, Resident #11 went at least seven months with the same catheter in place.
The inspection occurred in response to a complaint, suggesting someone outside the facility noticed problems with care quality. Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents, but the finding demonstrates a breakdown in basic medical care protocols.
The facility's inability to produce documentation raises questions about whether other medical orders are being followed. When nursing staff change a catheter, they typically document the procedure in treatment records, noting the date, time, and any observations about the resident's condition. The complete absence of such documentation for seven months suggests either the procedures weren't performed or record-keeping systems failed entirely.
For Resident #11, the consequences of delayed catheter replacement could include urinary tract infections, bladder stones, catheter blockages, or more serious complications requiring hospitalization. The resident's underlying conditions of obstructive and reflux uropathy already put them at increased risk for urinary problems, making regular catheter maintenance even more critical.
The Director of Nursing's response during the inspection indicates she was unaware of the documentation gap until inspectors pointed it out. Her immediate attempt to contact consulting providers suggests the facility may not have adequate systems for tracking and ensuring completion of routine medical procedures.
Federal regulations require nursing homes to follow physician orders and provide necessary care to maintain each resident's highest possible level of functioning. The seven-month gap in catheter replacement documentation at Autumn Lake Healthcare at Overlea represents a clear failure to meet these basic requirements, leaving a vulnerable resident without essential medical care.
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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