Federal inspectors responding to a complaint found the facility failed to follow its own policy requiring catheter bags to be secured below bladder level and kept off the ground. The violation affected at least one resident and represented what inspectors classified as minimal harm with potential for worse.
The facility's Director of Clinical Operations admitted during an October 22 interview that the drainage bag should never have been on the floor. He told inspectors that everyone was responsible for monitoring catheter placement but acknowledged he was new to his position.
"It was important to keep Foley catheter drainage bags off the floor to prevent urinary tract infections, maintain infection control practices, and prevent injuries," the DCO explained to inspectors. He said he would have provided staff training if he had known about the problem.
The Administrator echoed these concerns during the same day's interviews. Catheter bags should have been secured to the bed and kept off the ground, she told inspectors. All staff carried responsibility for monitoring proper catheter positioning.
She emphasized that nursing staff should routinely check catheters. "It was important to ensure the Foley catheter drainage bag was kept off the ground to prevent the spread of infection to others or prevent Resident #1 from obtaining a urinary tract infection," she said.
The facility's own policy, dated April 2021, explicitly addressed catheter care. The document stated that residents with urinary catheters "will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complication." The policy specifically required staff to "secure urinary drainage bag below the level of the bladder and keep off the floor."
Despite having clear written protocols, staff failed to implement basic catheter safety measures. The inspection found that multiple levels of the facility's hierarchy - from direct care staff to administrators - understood the infection risks but failed to prevent the violation.
Urinary catheters require careful positioning to function properly and safely. When drainage bags touch the floor, they can collect bacteria and other contaminants that can travel back through the catheter system into the resident's bladder and urinary tract.
The facility's response revealed systemic gaps in oversight. While both the DCO and Administrator stated that "everyone was responsible" for monitoring catheter placement, the violation suggested that diffused responsibility led to no one taking ownership of proper care.
The DCO's admission that he was new to his position raised questions about training and supervision protocols during leadership transitions. His statement that he would have provided staff education "if he had known" indicated a reactive rather than proactive approach to quality assurance.
The Administrator's emphasis on routine monitoring by nursing staff highlighted the disconnect between policy and practice. Despite clear expectations for regular catheter checks, staff failed to notice or correct the improper bag placement.
Federal inspectors classified the violation as having caused minimal harm with potential for actual harm. This designation suggests that while no immediate injury occurred to the resident, the improper catheter care created conditions that could have led to serious complications.
The inspection occurred on November 26, 2025, in response to a complaint. The complaint-driven nature of the investigation indicates that problems may have persisted for some time before coming to regulatory attention.
Focused Care at Mount Pleasant operates at 1606 Memorial Avenue in Mount Pleasant, Texas. The facility's catheter care policy had been in place for over four years at the time of the violation, suggesting that the problem stemmed from implementation rather than policy gaps.
The case illustrates how fundamental infection control failures can occur even when facilities have appropriate written protocols and leadership understands the risks. The resident whose catheter bag was found on the floor faced unnecessary exposure to potential urinary tract infections due to staff oversight failures that multiple administrators acknowledged should never have happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Mount Pleasant from 2025-11-26 including all violations, facility responses, and corrective action plans.
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