The 83-year-old man with Alzheimer's disease and severe cognitive impairment had the surgically-inserted catheter tube draining urine through his abdominal wall. His urologist had ordered staff never to remove the device.
On April 14, Licensed Nurse H cleaned the catheter site on the resident's abdomen, then attached the stabilization device to his left upper thigh. The next morning, Licensed Nurse I repeated the same incorrect procedure, securing the tubing from the abdomen to the thigh rather than keeping it anchored to the abdominal area.
Both nurses violated basic catheter care standards. Suprapubic catheters must be secured to the abdomen to prevent pulling that could dislodge the tube or cause internal injury.
When questioned, Licensed Nurse H admitted ignorance about proper placement. "They were unaware of a Stat-lock being adhered to the abdomen and would ask the Administrative Nurse D for directions," according to the inspection report.
Administrative Nurse D initially defended the leg placement, telling inspectors she "would expect the Stat-lock to be anchored to the leg." But when confronted with the facility's own training materials, she backtracked completely.
The facility's suprapubic catheter competency checklist clearly states that tubing "should be secured to the abdomen." Administrative Nurse D admitted she had reviewed this checklist multiple times but somehow missed the requirement.
"Administrative Nurse D stated they were unaware the competency checklist required the tubing to be anchored to the abdomen the previous times they reviewed the checklist," inspectors wrote.
The resident's complex medical history made proper catheter care critical. His electronic medical record documented chronic kidney disease, benign prostatic hyperplasia, obstructive uropathy, and urinary retention. These conditions had already compromised his urinary system's function.
His cognitive assessment scored just four out of 15 points, indicating severely impaired mental status that left him unable to communicate discomfort or problems with his catheter.
The facility's own care plan, dating to August 2023, included specific instructions for catheter maintenance. Staff were directed to apply liquid skin barrier before attaching the stabilization device. Yet this detailed care planning apparently never addressed the fundamental question of where to secure the tubing.
The nursing staff's confusion extended beyond individual mistakes. Administrative Nurse D acknowledged that the facility's catheter policy contained no guidance about Stat-lock placement for suprapubic catheters, creating a dangerous gap between written procedures and actual practice.
This policy gap persisted even as the facility maintained a competency checklist that did specify abdominal anchoring. The disconnect between training materials and daily practice protocols left nurses guessing about critical safety procedures.
Federal inspectors found the improper anchoring created risk of catheter dislodgement, which could cause serious complications including internal bleeding, infection, or the need for emergency surgical replacement.
The resident had lived with his suprapubic catheter since at least December 2025, when care assessments documented his indwelling device. For months, staff may have been securing his catheter incorrectly, creating ongoing risk each time they performed routine maintenance.
The inspection revealed a facility where supervisory nurses either didn't know their own training requirements or failed to ensure frontline staff followed them. Administrative Nurse D's admission that she had repeatedly reviewed the competency checklist without noticing the abdominal anchoring requirement suggests systemic oversight failures.
The resident's family had trusted the facility to provide specialized care for his complex medical needs. Instead, staff repeatedly performed a basic procedure incorrectly, potentially endangering a vulnerable man who couldn't advocate for himself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Halstead Health and Rehabilitation Center from 2026-04-15 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Halstead Health and Rehabilitation Center
- Browse all KS nursing home inspections
