Federal inspectors found the same scene during three separate visits to Avir at Rose Trail between September 28 and October 2. Each time, Resident #4 lay in bed with his Foley catheter completely unsecured to his leg. No securement device was in place.
The catheter hung loose despite facility policy requiring nurses to strap the tubing to residents' inner thighs to prevent painful accidents. The policy, revised in July 2024, specifically states catheters must "remain secured with a leg strap to reduce friction and movement at the insertion site."
RN B told inspectors on October 2 that nurses were responsible for checking catheter security every shift. She admitted she was unaware of the problem with Resident #4's catheter and "probably overlooked it."
The nurse explained why the oversight mattered. Foley catheters must be secured "to prevent the catheter being jerked out, causing trauma or injuries," she said.
ADON K echoed the safety concern during her interview the same day. Catheters need to be secured "so it did not pull out and for good placement for the urine to flow," she told inspectors.
The interim Director of Nursing was even more direct about the consequences during her October 20 interview. If catheters aren't secured properly, "it could pull out and it could hurt the residents," she said.
Administrator acknowledged she relied entirely on clinical staff to prevent such safety failures. During her October 1 interview, she told inspectors she "was not clinical" and expected the Assistant Directors of Nursing and Director of Nursing to oversee nursing staff. Their job was to "ensure the safety and well-being of the resident's health care needs and to ensure the physician orders were followed appropriately."
The facility's own policy outlined the stakes clearly. The catheter care procedure exists "to prevent catheter-associated urinary tract infections" and requires specific securement protocols to protect residents from harm.
Yet for at least four days running, nursing staff on multiple shifts walked past Resident #4's bed without noticing or addressing the obvious safety violation. The unsecured catheter posed risks each time the resident moved, turned, or received care.
Federal inspectors documented the identical scene three times. September 28 at noon: catheter unsecured, no device observed. September 29 at 11:13 AM: catheter unsecured, no device observed. October 2 at 11:13 AM: catheter unsecured, no device observed.
The repetitive nature of the inspectors' findings suggests a systemic breakdown in basic nursing oversight. Multiple nursing shifts had opportunities to identify and correct the safety hazard. None did.
RN B's admission that she "probably overlooked it" points to the kind of routine negligence that can cause serious harm to vulnerable residents. Foley catheters inserted through the urethra can cause excruciating pain and significant injury if accidentally dislodged.
The interim Director of Nursing told inspectors that "everyone needed to ensure the catheters were secured," acknowledging the facility-wide responsibility for resident safety. But the four-day oversight failure suggests that collective responsibility may have meant no one felt individually accountable.
Resident #4's experience illustrates how basic safety protocols can fail when nursing staff don't consistently follow established procedures. The facility had the right policy. Staff knew the risks. Yet a resident remained unnecessarily vulnerable to painful injury for days.
The violation occurred despite clear facility guidelines requiring catheter securement to prevent both infection and physical trauma. The policy specifically mandated leg strap placement to minimize movement at the insertion site, exactly the kind of movement that could have caused serious harm to Resident #4.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But for Resident #4, lying in bed with an unsecured catheter for multiple days, the potential for painful trauma was immediate and ongoing.
The case demonstrates how seemingly minor oversights in nursing care can expose residents to serious injury. A simple leg strap, checked during routine rounds, stands between proper care and potential emergency room visits for catheter-related trauma.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Rose Trail from 2025-10-02 including all violations, facility responses, and corrective action plans.