Westport Rehab: Catheter Care Skipped for Paralyzed Resident - VA
The resident, identified in inspection records only as Resident 104, was admitted to Westport with quadriplegia, spinal stenosis, and a history of transient ischemic attacks. Because of an obstructive neurogenic bladder, the resident depended on a urinary catheter around the clock. Cognitive function was not a factor: a mental status assessment conducted in October 2025 showed the resident scored a perfect 15 out of 15, fully alert and aware.
The care plan, in place since August 2024, was specific. Catheter care every shift. Watch for dark or cloudy urine, signs of blockage, signs of infection. Notify the doctor if something looked wrong.
The physician orders were equally specific. Measure catheter output every day shift and every night shift. Flush the catheter daily with 60 milliliters of normal saline. If urine flow turned sluggish, flush again with 10 milliliters as needed, also every shift.
None of that appeared in the records for multiple shifts across three months.
The medication and treatment administration records, the logs where nurses document completed care, showed gaps on October 21, October 24, and October 25. More gaps in November: the 9th, the 11th, the 19th, the 24th. The records covered both day and night shifts. Catheter output monitoring, the daily saline flush, the shift-by-shift catheter care — entries were missing across all of it.
On December 16, an inspector asked a licensed practical nurse at the facility a direct question: if catheter care isn't documented, does that mean it wasn't done?
"If it is not documented it was not done," the nurse said.
That answer, offered plainly and without qualification, became the clearest statement in the inspection record. The nurse confirmed what the missing entries already suggested: the resident, paralyzed and entirely dependent on staff for every aspect of physical care, went without catheter maintenance on shifts where no one signed off that it had been completed.
The following day, December 17, inspectors sat down with the facility's top leadership. The administrator, the director of nursing, and two assistant directors of nursing were all present when inspectors described what the records showed. The inspection report notes they were made aware of the concerns. It records nothing further that the facility offered in response before inspectors left.
Westport's own catheter care policy said licensed nurses would perform catheter care every shift and document it in the medical record. The policy and the physician orders pointed the same direction. The treatment records pointed somewhere else.
Urinary catheters carry infection risk under ordinary circumstances. For a resident who is quadriplegic, dependent on staff for bathing, dressing, transfers, and eating, and who cannot independently manage any aspect of catheter care, the consequences of neglected maintenance are not abstract. Catheter-associated urinary tract infections can escalate quickly in residents with complex medical histories. The inspection cited the violation at the level of minimal harm or potential for actual harm, meaning inspectors found no documented injury to the resident during the period in question.
What the records could not show was what happened on the shifts where nothing was written down at all.
Resident 104 was still living at the facility at the time of the inspection. Fully alert, entirely dependent, and relying on the same staff whose documentation gaps had just been laid out in a federal deficiency report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westport Rehabilitation and Nursing Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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: September 23, 2026 · Our methodology
WESTPORT REHABILITATION AND NURSING CENTER in RICHMOND, VA was cited for violations during a health inspection on October 22, 2025.
Because of an obstructive neurogenic bladder, the resident depended on a urinary catheter around the clock.
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.