Regency at Jackson: Catheter Care Failures Ignored - MI
The man, identified in inspection records only as Resident 10, has lived at the facility since February 2019 and carries a diagnosis of chronic kidney disease. He is cognitively sharp, scoring 14 out of 15 on a standardized mental status exam. He uses a suprapubic catheter, a tube surgically placed directly into the bladder, and he had a standing order for it to be flushed regularly to prevent sediment from building up and blocking flow.
By April, the catheter wasn't working. He was leaking urine into his briefs. Less urine was reaching the bag. He went to a urology clinic on April 21.
The urologist's note from that visit is specific. The resident reported the catheter "seems to not work as well lately." He was "noticing more leaking in his brief from the urethra and less urine in the bag." The aide who accompanied him to the appointment confirmed it: he was not getting catheter flushes. The urologist examined him, found the catheter bag leaking and "very minimal concentrated urine" in the bag, and replaced the catheter in the clinic that day. The assessment attributed the leaking to sediment buildup, the direct result of the missed flushes. A new order was written: irrigate the catheter daily with 50 milliliters of normal saline, and additionally as needed if clogging occurred.
Back at Regency at Jackson, the medication administration records for April and May told a different story. Staff had been documenting that they completed a twice-daily 60-milliliter flush. The entries were there, signed off, logged. The flushes, according to the resident and his urologist, were not.
When a state inspector spoke with the resident on May 21, he said it again: the catheter had recently gotten clogged, there were orders to keep it open by flushing it, and it had not been done.
The director of nursing was interviewed on May 28, the last day of the inspection. Asked what the expectation was for flushing a suprapubic catheter, she said the most recent guidance was that it should be done "as needed." That answer contradicted the standing order in the resident's own chart, which called for daily flushing, and it contradicted the urologist's explicit instruction written after the April visit. It also contradicted basic clinical guidance, which holds that suprapubic catheters should be flushed at least once a day to prevent clots and sediment from blocking the device.
The director of nursing's answer also raised a harder question: if the facility's leadership believed flushing was only necessary as needed, why were staff signing off on twice-daily flushes in the medication administration record? Either the flushes were being documented without being performed, or staff were performing them without anyone in a supervisory role understanding why.
The inspection cited the facility for failing to provide catheter care consistent with professional standards. The level of harm was classified as minimal harm or potential for actual harm, one of the lower tiers in the federal deficiency system. Inspectors reviewed three residents with catheters and found the problem in one.
What that classification doesn't capture is the timeline. This wasn't a single missed treatment. The resident's catheter clogged. He went to a specialist. The specialist replaced the catheter, wrote a new order, and documented in plain language what had gone wrong and why. Weeks passed. An inspector arrived. The resident said, again, that the flushes still weren't happening.
He had been telling people since at least April. The records, throughout, showed the opposite.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency At Jackson from 2026-05-28 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 21, 2026 · Our methodology
Regency at Jackson in Jackson, MI was cited for violations during a health inspection on May 28, 2026.
The man, identified in inspection records only as Resident 10, has lived at the facility since February 2019 and carries a diagnosis of chronic kidney disease.
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.