Regency at Jackson: Catheter Care Failures Ignored - MI
The resident, identified in inspection records only as Resident 10, has lived at the facility since February 2019 and has chronic kidney disease. He has a suprapubic catheter, a tube surgically placed directly into the bladder through the abdomen. He is cognitively sharp. When tested during the inspection period, he scored 14 out of 15 on a standard mental status exam.
By April 2026, his catheter had started failing. Urine was leaking into his brief from his urethra rather than draining into the bag. The bag itself held very little, and what was there was heavily concentrated. He made an appointment at a urology clinic.
The urology notes from that April 21 visit are detailed. The urologist wrote that the resident "thinks it is longer between exchanges than" the monthly schedule that had been ordered. The resident and the aide with him "confirm he is NOT getting any catheter flushes." The urologist's assessment identified sediment buildup as the likely cause of the leaking, a direct consequence of the missed irrigations. The clinic exchanged the catheter that day and placed an order for nursing staff to irrigate it daily with 50 milliliters of normal saline, and additionally as needed if it clogged.
Then inspectors pulled the medication administration records for April and May.
Staff had been documenting completion of a twice-daily flush using 60 milliliters. Not once a day. Twice. Sixty milliliters each time. Documented as done.
The resident said it wasn't happening. His urologist's notes said it wasn't happening. The physical state of his catheter when he arrived at the urology clinic, leaking, clogged, barely draining, said it wasn't happening. The paperwork said otherwise.
When a state inspector sat down with the director of nursing on May 28, she was 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 did not match the orders in the resident's chart, which specified a scheduled flush. It also did not match basic clinical guidance. The Cleveland Clinic's published instructions on suprapubic catheters state that flushing at least once a day is necessary to prevent blood clots from blocking the device and to keep it clean and working properly.
The resident had flagged the problem himself. On May 21, when an inspector observed him sitting in his wheelchair, he brought it up without being asked. He said the catheter had recently gotten clogged, that there were orders to keep it open by flushing it regularly, and that it had not been done.
He was right. The records confirmed he was right. His urologist had confirmed he was right a month earlier.
Inspectors cited the facility for failing to provide catheter care consistent with professional standards. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting few residents. Three residents with catheters were reviewed; the violation applied to one.
What the inspection did not resolve is how long the documentation had been wrong. The medication administration records showed the flushes logged as completed throughout April and into May. The resident told his urologist in April that he wasn't sure when the catheter had last been exchanged, that he thought it had been longer than a month. The urologist noted the same uncertainty, writing that the monthly exchange schedule had been ordered but that it was "unsure if this is happening every month."
A man who knew exactly what was supposed to be done for his own body, who was alert enough to track it, who raised it with his doctor and then raised it again with an inspector, spent weeks with a catheter that wasn't being maintained while the records showed it was.
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 resident, identified in inspection records only as Resident 10, has lived at the facility since February 2019 and has 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.