Stellar Care Center: Catheter Care Never Done - OH
A second nurse did the same thing.
The Director of Nursing confirmed it: the catheter exchange was documented as completed in the resident's records but was never physically performed.
Inspectors investigating complaints at the Monroe County facility found the discrepancy during a survey completed September 30, 2025. The inspection was tied to three separate complaint numbers, suggesting someone had already raised concerns about this resident's care before state surveyors arrived.
The resident at the center of the findings, identified only as Resident #05, had a suprapubic catheter, a tube inserted through the abdomen directly into the bladder. Changing that catheter on schedule is not optional maintenance. When it goes unchanged, infection risk climbs. Blockages develop. Tissue breaks down around the insertion site.
LPN #69 told inspectors they had signed the catheter change as completed because they thought it was done. That explanation, offered without apparent awareness of how it sounded, is its own kind of finding. A nurse signed a medical record attesting to a procedure they had not personally performed, based on an assumption that someone else had done it.
Nobody had.
LPN #84 was more direct. In an interview on September 25, 2025, at 7:50 in the morning, she told inspectors she had never switched out Resident #05's suprapubic catheter. Not once. She said she had received no training on how to perform the procedure and, in her own words, wouldn't know how. She also said that to her knowledge, it had never even been an active order.
That last detail is worth sitting with. One nurse believed the procedure had been done by someone else and signed off accordingly. Another believed it was never ordered at all. The record said it was complete. The Director of Nursing confirmed to inspectors that it had never happened.
CMS rated the level of harm as minimal, a designation that applies to the catheter bag specifically rather than the catheter itself. That distinction matters clinically, but it does not change what the records show: a care task was marked done by at least two licensed nurses who either didn't do it, didn't know how to do it, or both.
Stellar Care Center is a nursing facility on Moore Ridge Road in Woodsfield, a small county seat in southeastern Ohio. The inspection was a complaint survey, meaning it was not a routine visit. Someone filed a complaint, and then someone filed another one. Inspectors came to investigate and found a resident whose catheter care existed on paper and nowhere else.
The facility's plan of correction is not included in the inspection documents reviewed for this article. For information on how Stellar Care Center intends to address the deficiency, CMS directs the public to contact the facility or the Ohio state survey agency directly.
What the records do not explain is how long the catheter went unchanged, or whether Resident #05 experienced any symptoms in the interim. The inspection narrative describes the level of harm as minimal, but that assessment reflects what inspectors could document, not necessarily what the resident experienced before anyone came to look.
A nurse who does not know how to change a suprapubic catheter is not automatically at fault for that gap. Training is the facility's responsibility. But signing a record that says a procedure is complete, when you have not done it and do not know how, is a different matter. That is a false entry in a medical record, and it is the kind of entry that allows problems to stay hidden until they become something worse.
Resident #05's name does not appear in the inspection report. Neither does any account of how they are doing now.
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.
A second nurse did the same thing.
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.