Advanced Healthcare Center: Catheter Left on Floor - OH
The resident at Advanced Healthcare Center, identified in inspection records only as Resident #37, was already fighting two infections when inspectors arrived in late January. He had a urinary tract infection serious enough that a physician had prescribed a high-dose antibiotic on January 14. He was also in contact isolation for methicillin-resistant staphylococcus aureus, a drug-resistant bacterial infection, in his urine.
He was admitted to the Toledo facility on September 23, 2025, with a list of diagnoses that left him almost entirely dependent on staff: metabolic encephalopathy, severe protein calorie malnutrition, dementia, a prior heart attack, kidney problems including hydronephrosis and obstructive uropathy, and benign prostatic hyperplasia. His cognition was severely impaired. He needed help with every aspect of daily living, including getting in and out of bed. He could not reposition his own catheter bag.
A urinary catheter drainage bag left on the floor creates a direct path for contamination. Urine drains out of the bladder and into the bag by gravity. When the bag sits at or above bladder level, that flow reverses. Bacteria travel back up the tubing and into the bladder. The facility's own catheter care policy stated exactly this, requiring staff to keep the bag below bladder level at all times to prevent reflux of urine back into the bladder.
His care plan, revised in November, listed the same requirement. Position the bag below the bladder. Secure the tubing to his leg. Keep the drainage bag off the floor.
On January 26, inspectors observed the bag lying on the floor under the bed at 6:42 p.m. A certified nursing aide, identified as CNA #398, was interviewed at 9:16 that night, after the bag had remained on the floor for more than two and a half hours. The aide confirmed the bag was on the floor and said it should be secured to the bed frame. The bag was not moved between those two observations. It was on the floor when inspectors checked at 9:15 p.m.
The following afternoon, January 27 at 3:09 p.m., the bag was on the floor next to the bed again.
On January 29, inspectors returned at 6:05 in the morning and found the bag at the end of the bed, level with the resident's bladder rather than below it. CNA #398 was interviewed three minutes later and confirmed the bag was not positioned correctly and explained why it mattered: the bag had to stay below bladder level to stop urine from flowing backward.
Later that morning, a registered nurse confirmed to inspectors that the facility's catheter policy required the collection bag to stay off the floor, drain properly, and remain secured to the bed below bladder level. The written policy, reviewed by inspectors, said the same.
The inspection was triggered by a complaint, filed under complaint number 2715485. CMS rated the level of harm as minimal harm or potential for actual harm. Three residents with indwelling catheters were reviewed. The problem was found with one.
Advanced Healthcare Center sits at 955 Garden Lake Parkway in Toledo and had 83 residents at the time of the inspection. The facility census was not large. The catheter care failure affected a man who could not advocate for himself, could not reposition his own equipment, and was already battling a drug-resistant infection in the same organ system the catheter was supposed to be helping drain.
The aide who found the bag on the floor at 9:15 p.m. did not move it. The aide who confirmed it should be secured to the bed frame did not secure it. The next day it was on the floor again.
Resident #37 was on Levofloxacin, 750 milligrams each morning, for the urinary tract infection. He was in isolation for MRSA. His kidneys were already compromised. His care plan had been in place for months, spelling out exactly how his catheter was supposed to be managed.
The bag was on the floor anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Healthcare Center from 2026-01-29 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: August 16, 2026 · Our methodology
ADVANCED HEALTHCARE CENTER in TOLEDO, OH was cited for violations during a health inspection on January 29, 2026.
He had a urinary tract infection serious enough that a physician had prescribed a high-dose antibiotic on January 14.
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.