That is what a federal inspector found at Castleton Health Care Center on November 6, 2025.
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The deficiency, tagged at the actual harm level, affected a small number of residents.
Four residents, identified in the report as Residents 4, 5, 6, and 7, had described to staff how CNA G made them feel.
The incident happened on October 27, 2025.
The catheter had been rubbing against the resident's skin long enough to cause gangrene.
Resident C had dementia, heart failure, and a prosthetic heart valve.
The resident at the center of the allegation is identified in inspection records only as Resident B.
That was the morning of September 30, 2025, at Metropolis Rehab & Health Care Center.
The inspection, completed November 11, 2025, focused on one resident identified in the report as R5.
Inspectors watched it happen both times.
As of September 24, 2025, at 5:30 in the afternoon, no interdisciplinary team notes had been produced.
That's what federal inspectors found when they visited the facility on November 4, 2025, responding to a complaint.