SAINT JOSEPH, MO — Federal health inspectors identified a pattern of deficient bowel and bladder care at Carriage Square Rehab and Healthcare Center following a complaint investigation completed on December 23, 2025, finding the facility failed to properly manage catheter care and prevent urinary tract infections across multiple residents.
Inspectors Find Pattern of Inadequate Continence and Catheter Care
The complaint investigation at Carriage Square Rehab and Healthcare Center resulted in a citation under federal regulatory tag F0690, which requires nursing facilities to provide appropriate care for residents who are continent or incontinent of bowel and bladder, deliver proper catheter care, and take appropriate steps to prevent urinary tract infections.
Inspectors determined the deficiency represented a Level E severity — indicating a pattern of non-compliance rather than an isolated incident, with potential for more than minimal harm to residents. While no actual harm was documented at the time of the investigation, the widespread nature of the failures raised concerns about systemic care gaps.
The catheter care citation was one of two deficiencies identified during the inspection, suggesting broader quality-of-care issues at the Saint Joseph facility.
Why Proper Catheter Care Is a Critical Safety Issue
Urinary catheter management is one of the most consequential areas of nursing home care. Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections in long-term care settings, and they are largely preventable with proper protocols.
When catheter care is not performed correctly, bacteria can enter the urinary tract through the catheter insertion site or drainage system. For elderly nursing home residents — many of whom have weakened immune systems and multiple chronic conditions — a urinary tract infection can escalate rapidly. UTIs in older adults can lead to sepsis, kidney infections, hospitalization, and in severe cases, death. UTIs are also a leading cause of delirium and cognitive decline in elderly patients, sometimes being mistaken for worsening dementia.
Proper catheter care protocols include regular hygiene around the insertion site, maintaining a closed drainage system, ensuring the collection bag remains below bladder level, and routinely assessing whether the catheter is still medically necessary. The standard of care calls for removing catheters as soon as clinically possible to reduce infection risk.
For residents managing incontinence without catheters, appropriate care includes timely toileting assistance, proper skin care to prevent breakdown, and individualized continence programs. When these protocols are not followed consistently, residents face increased risk of skin infections, pressure injuries, and diminished dignity.
A Pattern, Not an Isolated Lapse
The Level E designation is significant. Federal inspection protocols classify deficiencies on a grid based on scope and severity. A Level E finding means inspectors observed the problem affecting multiple residents or occurring across multiple staff interactions — not a one-time oversight by a single caregiver.
This pattern-level finding suggests that the facility's systems for monitoring continence care, training staff on catheter protocols, or ensuring timely toileting assistance were inadequate at a programmatic level. It points to potential gaps in staff training, supervisory oversight, or care plan implementation.
Facility Response and Correction Timeline
Carriage Square Rehab and Healthcare Center submitted a plan of correction and reported the deficiency as corrected by December 24, 2025 — just one day after the inspection. While a rapid correction timeline can indicate responsiveness, a single-day turnaround for a pattern-level deficiency raises questions about the depth and sustainability of the corrective measures implemented.
Meaningful correction of systemic catheter care and continence management failures typically requires staff retraining, updated care plans for affected residents, revised monitoring procedures, and ongoing auditing to verify sustained compliance.
Industry Context
Catheter care deficiencies remain one of the more frequently cited issues in federal nursing home inspections nationwide. The Centers for Medicare and Medicaid Services has emphasized reducing unnecessary catheter use and improving infection prevention as key quality priorities for long-term care facilities.
Families of residents at Carriage Square Rehab and Healthcare Center can review the complete inspection findings through the [CMS Care Compare](https://www.medicare.gov/care-compare/) database or request records directly from the facility.
The full inspection report, including all deficiencies cited during this investigation, is available on the facility's federal inspection profile.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carriage Square Rehab and Healthcare Center from 2025-12-23 including all violations, facility responses, and corrective action plans.