Groves Center: Catheter Wound Care Failures - FL
The catheter had been rubbing against the resident's skin long enough to cause gangrene. When inspectors interviewed the facility's director of nursing that afternoon, she did not dispute the severity of what had happened. "If a resident had wounds from their catheter rubbing and gangrene," she told inspectors, "then it did not happen overnight."
Then she said she would have expected it to appear on skin assessments.
It hadn't.
The violation involves a basic principle of catheter care. An indwelling catheter in a male resident must be taped to the thigh to straighten the angle where the catheter meets the body, reducing pressure on the urethra. Without that securement, the catheter moves. Movement causes friction. Friction, over days and weeks, causes wounds. In this case, it caused gangrene.
The director of nursing's own words describe the timeline that makes the failure significant. Gangrene does not develop in a day. It develops when a wound is missed, or documented and not acted on, or never documented at all. The DON acknowledged skin assessments should have caught this. The inspection record does not indicate they did.
Industry guidance on exactly this kind of injury has existed for years. The Association for Professionals in Infection Control and Epidemiology published updated best practices for preventing catheter-associated complications as recently as March 2025, specifically addressing securement devices and how they must be applied. The Joint Commission has addressed medical device-related pressure injuries since at least 2018, noting that devices must be the proper size, properly secured to limit movement, and that skin must be padded to reduce friction. Neither standard is obscure. Both are aimed at preventing precisely what happened to this resident.
The inspection was triggered by a complaint, not a routine survey. That distinction matters. It means the injury had already come to someone's attention outside the facility before inspectors arrived. It means the harm was visible enough that someone made a call.
Groves Center, located at 512 South 11th Street in Lake Wales, received a deficiency citation under F0690, which covers the treatment and care of residents with catheters. The level of harm was cited as minimal harm or potential for actual harm, a designation that reflects regulatory classification rather than the condition of the resident, who had developed gangrene.
The director of nursing's interview was conducted at 5:25 in the evening on the day of the inspection. She spoke about what she would have expected. She spoke about what should have been on the skin assessments. She did not, according to the inspection record, explain why it wasn't.
The resident with wounds and gangrene is not named in the report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Groves Center from 2025-10-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
GROVES CENTER in LAKE WALES, FL was cited for violations during a health inspection on October 29, 2025.
The catheter had been rubbing against the resident's skin long enough to cause gangrene.
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.