The Crescent: Foley Catheter Safety Failure - Sugar Land, TX
The catheter belonged to Resident 1. The nursing assistant involved, identified in inspection records as CNA B, told inspectors she was not assigned to the resident and had stepped in to help with care. At some point during that assistance, the catheter was dislodged.
A Foley catheter is a flexible tube inserted into the bladder to drain urine. It sits in place with a small inflated balloon inside the bladder. Dislodging one is not a minor inconvenience. It can cause pain, bleeding, urinary tract infection, and trauma to the urethra, particularly in elderly residents whose tissues are more fragile.
The fix is straightforward. A leg strap secures the catheter tubing to the resident's inner thigh, reducing tension and movement at the insertion site. The Crescent's own catheter care policy, last revised in September 2014, stated exactly that: the catheter should remain secure with a leg strap to reduce friction and movement, with tubing strapped to the inner thigh.
The Director of Nursing confirmed it to inspectors during an interview on November 13. All residents with Foley catheters, she said, should have a leg strap to prevent dislodging.
CNA B did not say whether a leg strap was in place when she assisted with Resident 1's care, or whether one was missing. The inspection record does not resolve that question. What it documents is that the catheter came out.
Inspectors cited the deficiency under F0690, which covers the treatment and care of urinary incontinence and catheters. They rated the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected, meaning the problem was not isolated to a single case.
The Crescent is located at 11353 Sugar Park Lane in Sugar Land, a suburban city southwest of Houston. The inspection was completed November 18, 2025. It was a complaint survey, meaning someone reported a concern that prompted the visit.
The facility's catheter care policy has not been updated since George W. Bush's second term. That policy was clear enough. The question inspectors left open is why, eleven years after it was written, a resident's catheter still came loose in a staff member's hands.
Resident 1's name does not appear in the inspection report. What happened to her after the catheter was dislodged, whether she required reinsertion, whether she developed an infection, whether she experienced pain, is not recorded in the pages inspectors made public. The report moves on. Her chart does not follow.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Crescent from 2025-11-18 including all violations, facility responses, and corrective action plans.
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 1, 2026 · Our methodology
The Crescent in Sugar Land, TX was cited for violations during a health inspection on November 18, 2025.
The catheter belonged to Resident 1.
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.