Oakwood Village East: Catheter Removed Without Doctor Order - WI
The order was specific: do not manipulate, flush, or exchange the catheter. Do not pull it out. If there are problems, notify urology.
RN D knew all of this. She said so herself during the inspection. She had reviewed the medical record. She knew urology had an afterhours line for exactly these situations. Then she deflated the balloon, decided the catheter wasn't sitting right in the bladder, and removed it anyway. She left a voicemail for the primary provider and tried to reach urology afterward, after the catheter was already out.
She never spoke to a provider before the removal. She never spoke to one after.
When inspectors contacted the urology clinic, a urology clinical nurse was direct: the facility should have left the catheter in place. The nurse at the bedside had no way to confirm placement. A provider should have been consulted. The catheter should not have been removed.
The Director of Nursing, DON B, defended the decision. She told inspectors she did not consider deflating the balloon's 3 milliliters of fluid to be "manipulation" of the catheter. She said RN D removed it because she believed it wasn't positioned correctly, and that the timing, before the clinic opened at 8 a.m., explained why calls went out after the fact rather than before.
The urology clinic had an afterhours number. It was available. Nobody called it.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, and noted it affected only a few residents. The deficiency was cited during a complaint inspection completed October 22, 2025.
The resident whose catheter was removed, identified only as R1 in inspection records, was left without it while the nurse worked backward through a list of calls she should have made first.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakwood Village East Health and Rehab Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
OAKWOOD VILLAGE EAST HEALTH AND REHAB CENTER in MADISON, WI was cited for violations during a health inspection on October 22, 2025.
The order was specific: do not manipulate, flush, or exchange the catheter.
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.