Life Care Center South Las Vegas: Catheter Care Failures - NV
The resident, identified in inspection records only as Resident 2, was admitted with paraplegia, obstructive uropathy, and urine retention. A physician had ordered a size 18 French Foley catheter, to be maintained on straight drainage and cleaned every shift. Those orders were not followed.
When a unit manager entered the resident's room on May 21 to check the catheter, she found a 16 French catheter with an orange port, a smaller size than what the doctor had ordered. The resident told her the catheter had been swapped out the week before at the resident's own request, and that the resident had specifically asked staff to use the 16 French size.
There was no physician order authorizing the switch. There was no documentation the old catheter had been removed. There was no documentation the new one had been inserted. The medical record was silent on all of it.
The unit manager acknowledged that afternoon that physician orders had not been followed. She could not explain why the order for catheter care every shift had never been entered into the medication administration record. Because it wasn't in that record, there was no way to confirm the care was being done at all.
The Director of Nursing confirmed the same findings at 10:31 that morning. She told inspectors the documentation gap on catheter care happened because of a data entry error when the batch order was entered, one that flagged no documentation requirements. The catheter care task, in other words, fell out of the system entirely. Nobody caught it.
The Director of Nursing said directly that the resident had been placed at risk for a urinary tract infection and other catheter-related complications.
The inspection found no documentation the catheter had ever been changed since the resident's admission, a gap the unit manager identified herself when she reviewed the medical record before entering the room. A physician order from April 7 had specified the catheter should be changed for infection, obstruction, or when the closed system was compromised. Whether any of those conditions applied when staff swapped the catheter at the resident's request, nobody documented.
The resident also had a stage four sacral wound, the most severe category of pressure injury, reaching through skin and tissue to muscle or bone. The catheter order existed in part because of that wound. During an earlier observation on May 18, a wound care nurse was treating the sacral wound while the resident was rolled to one side, a covered urinary bag hanging from the right side of the bed.
The inspection was triggered by a complaint. Inspectors rated the violation as causing minimal harm or potential for actual harm, and found it affected few residents. The deficiency covered catheter care and appropriate measures to prevent urinary tract infections.
What the record showed, in the end, was a resident managing a serious and permanent disability, with an open wound and a catheter that had been changed at their own request, using a size they preferred, with no physician consulted and no nurse documenting that any of it had happened. The routine cleaning that was supposed to happen every single shift, morning, afternoon, and night, had no paper trail at all.
The Director of Nursing said a data entry error caused the documentation to drop out. That may be true. It does not explain why no one noticed, across however many shifts passed between the April 7 order and the May 21 inspection, that the catheter care task had disappeared from the record entirely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of South Las Vegas from 2026-05-27 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: August 12, 2026 · Our methodology
LIFE CARE CENTER OF SOUTH LAS VEGAS in LAS VEGAS, NV was cited for violations during a health inspection on May 27, 2026.
The resident, identified in inspection records only as Resident 2, was admitted with paraplegia, obstructive uropathy, and urine retention.
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.