The incident at Regency Village unfolded when the resident's catheter stopped working properly, soaking him in his own waste. Despite having direct medical orders to change the catheter and the resident's repeated requests for help, Licensed Vocational Nurse S refused to act.
The resident described the encounter to federal inspectors during their December 1 visit. He said he told LVN S his catheter was leaking and asked her to change it. She responded that the catheter was fine. When he persisted, explaining he was sitting in his urine and needed help, LVN S told him "That's fine, do whatever you want."
So he did. The resident called 911 himself.
Emergency Medical Services worker B arrived to find the resident exactly as described — covered in urine from his mid-chest down to his lower body. The EMS worker said the resident explained that his catheter had stopped working, he had told LVN S about the problem, and she had told him not to worry about it.
When the resident threatened to call emergency services if she wouldn't help him, EMS B said, LVN S told him to "do whatever he wanted" and walked out of the room.
The facility had clear medical orders for catheter care. The Director of Nursing told inspectors that when a resident has a leaking foley catheter and orders to flush or change it, she expected nurses to flush the catheter first to see if that resolved the leaking. If not, she expected them to change the catheter entirely.
LVN S admitted to inspectors she saw the resident's catheter leaking and observed that he was covered in urine. She said he asked her to change his catheter, but she wanted to call the medical doctor first to see what he wanted to do — even though orders already existed to change it.
She said she did not clean up the resident or change his catheter because he didn't want to wait for her to call the doctor. She also admitted she never attempted to irrigate the catheter that day, despite that being the first step the facility expected.
The medical consequences of ignoring a leaking catheter are serious. Licensed Vocational Nurse R, who spoke with the resident after he returned from the hospital, told inspectors that failing to change a malfunctioning catheter could cause a urinary tract infection, obstruction, or a full bladder.
The Director of Nursing echoed those concerns, telling inspectors that leaving a catheter unchanged could cause a urinary tract infection or even a burst bladder.
Despite witnessing what happened to the resident, LVN R never reported the incident to facility management.
The facility's own policies, revised as recently as February 2021, require employees to "treat all residents with kindness, respect, and dignity." The policy specifically guarantees residents "the right to a dignified existence" and to "be treated with respect, kindness, and dignity."
Federal and state laws guarantee residents the right to be free from abuse and neglect, and to be supported by the facility in exercising their rights.
The Director of Nursing told inspectors she first learned about the incident on November 30, when the resident filed a formal grievance about LVN S refusing to change his catheter. That was one day before federal inspectors arrived at the facility.
The timeline reveals a troubling gap in communication and oversight. The incident occurred, the resident was transported to the hospital by emergency services, he returned to the facility, and he spoke with other nursing staff about what happened. Yet facility leadership remained unaware until the resident filed a formal complaint.
The resident's experience illustrates the vulnerability of nursing home patients who depend entirely on staff for basic medical care and human dignity. Unable to change his own catheter or clean himself, he was forced to choose between sitting in his own waste or calling emergency services for help that should have been provided by facility staff.
The inspection found the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The violation affected few residents but created minimal harm or potential for actual harm, according to federal regulators.
LVN S's decision to prioritize calling a doctor over following existing orders and addressing the resident's immediate distress left him in an undignified and medically dangerous situation. Her response when confronted with his desperation — telling him to "do whatever you want" — violated both professional nursing standards and basic human decency.
The incident raises questions about nursing supervision and training at Regency Village. Multiple staff members knew about the resident's treatment, yet none reported it to management until the resident himself filed a grievance.
For the resident, the consequences extended far beyond the physical discomfort of sitting in urine. He was forced to call emergency services to receive basic nursing care, transported to a hospital, and left to advocate for himself when the very staff paid to care for him refused to act.
The facility's policy promises residents will be "supported in exercising their rights." In this case, the resident had to exercise those rights by calling 911 from his bed while covered in his own waste, abandoned by a nurse who walked away rather than provide the care he desperately needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency Village from 2025-12-01 including all violations, facility responses, and corrective action plans.