The resident, identified as Resident 4 in inspection records, required an indwelling catheter for obstructive uropathy, a condition where blocked urine flow can damage kidneys. The catheter had been ordered on August 27 following the resident's readmission to the facility.
When inspectors observed the resident's room at 10:00 a.m., they found both the drainage bag and connecting tubing resting on the floor. The bag was also not enclosed in a dignity bag, as required by facility policy.
Licensed Vocational Nurse 6 was present during the inspection. The nurse verified that the drainage bag and tubing were indeed touching the floor and acknowledged this violated proper catheter care protocols.
"It should not be touching the floor and should be inside a dignity bag," LVN 6 told inspectors. The nurse promised to place the drainage bag inside a dignity bag and put something underneath to prevent floor contact.
The facility's own catheter care policy, revised December 19, 2022, explicitly requires that residents with indwelling catheters receive appropriate care with dignity bags available and drainage bags covered at all times. The policy mandates catheter care every shift and as needed by nursing personnel.
Federal guidelines from the Centers for Disease Control and Prevention are equally clear. The CDC's 2009 Guideline for Prevention of Catheter-Associated Urinary Tract Infections specifically states facilities must "keep the urine collection bag below the level of the bladder at all times" and "do not rest the bag on the floor."
The Director of Nursing confirmed the violation during an interview at 10:35 a.m. The DON acknowledged that while Resident 4 was on a low bed, something should have been placed under the drainage bag to prevent floor contact.
"Resident 4's drainage bag will be changed and placed inside the dignity bag," the DON told inspectors.
Catheter-associated urinary tract infections represent one of the most common healthcare-acquired infections in nursing homes. When drainage bags touch the floor, bacteria can travel up the tubing and into the bladder, causing painful infections that can spread to the kidneys or bloodstream.
The violation occurred despite the facility having clear written protocols. The catheter care policy emphasizes maintaining resident dignity and privacy while ensuring proper infection control measures. Staff are specifically trained that drainage bags must remain elevated and covered.
Resident 4's medical condition made proper catheter care particularly crucial. Obstructive uropathy already compromises kidney function by preventing normal urine drainage. Adding a preventable infection could cause serious complications for someone with this underlying condition.
The inspection was conducted in response to a complaint, suggesting someone reported concerns about care quality at the facility. Federal inspectors classified the harm level as minimal, but noted the potential for actual harm from bacterial growth and urinary tract infections.
The facility's failure extended beyond just positioning the drainage bag incorrectly. Staff also failed to use the dignity bag, which serves both infection control and privacy purposes. These bags prevent exposure of medical equipment while providing an additional barrier against contamination.
LVN 6's immediate recognition that the setup was wrong suggests staff knew the proper procedures but weren't following them consistently. The nurse's quick promise to correct the situation indicated awareness of both facility policy and infection control principles.
The violation highlights broader challenges in nursing home infection control. Even basic protocols like keeping drainage bags off the floor require constant vigilance from staff who may be managing multiple residents with complex medical needs.
For Resident 4, the immediate risk was bacterial contamination that could lead to a painful urinary tract infection. Left untreated, such infections can cause confusion, falls, and hospitalization in elderly residents. The combination of an indwelling catheter and compromised kidney function made infection prevention especially critical.
The DON's acknowledgment that the drainage bag would be changed suggests the facility recognized potential contamination had already occurred. Simply repositioning a bag that had been touching the floor might not eliminate bacteria that had already entered the drainage system.
Federal inspectors documented the violation as part of broader infection prevention and control requirements. The finding demonstrates how seemingly minor oversights in basic care can create significant health risks for vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Anaheim Healthcare Center, LLC from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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