Federal inspectors found the violations at Avon Place Healthcare Center during an October complaint investigation. Both affected residents had intact cognition and were aware of their care.
Resident #44 arrived at the facility in January with multiple sclerosis, muscle weakness, and severe protein calorie malnutrition. His care plan, revised in September, specifically required staff to "secure the catheter tubing to prevent accidental dislodgement." His physician ordered replacement of the catheter securement device every seven days and as needed.
The facility's own treatment records showed a securement device was supposedly in place throughout October, including on October 20. But when inspectors observed the resident that same day at 9:10 a.m., no securement device was attached to his suprapubic catheter.
The Licensed Practical Nurse Manager confirmed what inspectors saw. The resident himself didn't know how long he had been without the safety device.
Resident #15 presented an even starker failure. She had been at the facility since December with paraplegia, diabetes, morbid obesity, and chronic kidney disease. Her care plan explicitly stated she was to have a securement device in place to prevent catheter dislodgement.
Her physician ordered daily monitoring of the catheter stabilization device on October 16. Yet when inspectors examined her on October 22, her suprapubic catheter had no securement device.
Neither the resident nor her husband could recall her ever having a catheter securement device during her stay at Avon Place. The husband was present during the inspection interview.
A certified nursing assistant confirmed both residents lacked the required devices.
The facility's own policy, last revised in September 2024, mandated that catheters "should be secured utilizing a securement device or a leg band." The policy existed. The physician orders were clear. The care plans specified the interventions.
None of it happened.
Suprapubic catheters are surgically placed directly into the bladder through the abdomen. Unlike traditional urinary catheters that enter through the urethra, these devices require careful securing to prevent movement that could cause injury or infection. Accidental dislodgement can result in serious complications requiring emergency medical intervention.
The violations occurred despite multiple layers of supposed oversight. Physician orders required monitoring. Care plans detailed interventions. Treatment records claimed compliance. Yet two residents went without basic safety measures.
Resident #44's case was particularly concerning given his multiple sclerosis and muscle weakness. His condition made him vulnerable to complications from any catheter-related problems. His care plan acknowledged this vulnerability by specifically requiring securement to prevent dislodgement.
The facility maintained 73 residents during the inspection period. The complaint that triggered the investigation focused specifically on catheter care practices.
Staff interviews revealed awareness of the missing devices but no explanation for why they weren't in place. The Licensed Practical Nurse Manager verified the absence of securement devices but provided no documentation of when they were removed or why they weren't replaced according to physician orders.
The treatment administration records for October showed staff were documenting securement devices as present when inspectors found none. This suggested either systematic documentation failures or deliberate falsification of care records.
Federal regulations require nursing homes to provide appropriate catheter care to prevent complications and infections. Securement devices are basic safety equipment, not optional accessories. Their absence exposes residents to preventable risks.
The facility's September 2024 policy update demonstrated awareness of proper catheter securement requirements. The policy specifically mentioned securement devices and leg bands as acceptable methods. Yet implementation failed completely for both residents reviewed.
Resident #15's husband's presence during the inspection interview underscored family awareness of the care failures. His statement that his wife never had a securement device during her facility stay suggested the problem extended beyond the inspection period.
Both residents had intact cognition, meaning they were aware of their care and capable of noticing missing equipment. Their inability to recall having securement devices indicated prolonged noncompliance with medical orders.
The certified nursing assistant's confirmation of missing devices during the inspection showed front-line staff awareness of the violations. Yet no corrective action had been taken despite clear physician orders and facility policies.
The inspection occurred in response to a specific complaint about catheter care practices. The findings validated concerns about basic safety protocols being ignored despite clear medical directives and facility policies requiring compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avon Place Healthcare Center from 2025-10-23 including all violations, facility responses, and corrective action plans.