Stellar Care Center: Catheter Left on Floor - OH
The resident, identified in inspection records only as Resident #9, lives with quadriplegia, neuromuscular dysfunction of the bladder, and severely impaired cognition. He has had an indwelling urinary catheter in place since at least February 2025, with orders to change it every 30 days. The catheter drains into a collection bag. Where that bag sits matters.
When urine drains into a bag resting on the floor, the pathway reverses. Bacteria from the floor can travel back up the tubing toward the body. For a man who cannot move his limbs and cannot advocate for his own care, that risk doesn't announce itself.
Inspectors arrived at his room on the morning of September 16, 2025, at 9:38. He was resting. The catheter bag was on the floor. They came back 37 minutes later, at 10:15. He was still resting. The bag was still on the floor.
They returned two days later, on September 18, at 1:09 in the afternoon. Same room. Same resident. Same bag on the floor.
At 1:10 p.m., one minute after that third observation, inspectors spoke with Licensed Practical Nurse #8. The nurse confirmed what inspectors had already seen: the catheter bag was on the floor.
That confirmation closed the loop on what the inspection report describes as a failure to ensure infection control practices were in place. The facility census at the time of the inspection was 35 residents. Inspectors reviewed catheter care for two of them. One had a bag on the ground.
The violation was rated at the level of minimal harm or potential for actual harm. That classification reflects where the harm stood at the moment inspectors documented it, not where it was headed if nothing changed. Urinary tract infections are among the most common and serious infections in nursing home residents, particularly those with indwelling catheters. A catheter bag on the floor is not a theoretical problem.
Stellar Care Center is a small facility. Thirty-five residents is not a large population, and the staff-to-resident ratio that comes with a census that size is one of the few structural advantages a small nursing home can offer. A catheter bag that stays on the floor through a morning, then through another afternoon two days later, suggests the problem wasn't a momentary lapse that corrected itself. It persisted long enough for two separate inspection visits to find it unchanged.
Resident #9's care plan, last updated in August 2025, noted that he was frequently incontinent of bladder, which is precisely why the catheter was ordered in the first place. His cognition was documented as severely impaired. He could not reposition the bag himself. He could not call out to a passing aide to fix it. He could not tell a family member during a visit that something was wrong with his equipment.
What he had was the catheter, the bag, and whatever attention the staff chose to give them.
The inspection was conducted as a complaint visit, meaning someone outside the facility, likely a resident, family member, or staff person, contacted authorities with a concern before inspectors arrived. The report does not identify what the original complaint covered or whether the catheter finding was what triggered the visit. Complaint inspections tend to be narrower in scope than standard annual surveys, focused on the specific allegation rather than a facility-wide review.
That narrowness cuts both ways. It means inspectors were not conducting a comprehensive look at every resident and every practice in the building. It also means that what they found, they found while looking at only two residents receiving catheter care.
One of the two had a bag on the floor.
The LPN who confirmed the finding is identified in the report only by number. There is no record in the inspection document of what explanation, if any, was offered. No supervisor was quoted. No administrator was interviewed about the finding. The record shows the observation, the return observation, the third observation, and the one-sentence confirmation from the nurse.
Resident #9 was admitted to the facility on a date the report does not disclose. His diagnoses, his catheter order, his care plan, his room, his bed at a low position while he rested, the bag beside it on the floor — these are the details the inspection captured. The report does not say whether the bag was moved after the nurse confirmed it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stellar Care Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
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 12, 2026 · Our methodology
STELLAR CARE CENTER in WOODSFIELD, OH was cited for violations during a health inspection on September 30, 2025.
He has had an indwelling urinary catheter in place since at least February 2025, with orders to change it every 30 days.
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.