Vermont Healthcare Center: Catheter Bag Left on Floor - CA
Licensed Vocational Nurse 4 acknowledged the bag was on the floor. She told the inspector she knew it was her responsibility to keep drainage bags covered and secured to the bed frame, and she explained, without prompting, exactly what could go wrong when that doesn't happen: urinary tract infection, contamination, the transfer of pathogens that live and reproduce in the surrounding environment. She knew the standard. The bag was still on the floor.
Resident 44 has a suprapubic catheter, a device inserted directly through the abdomen into the bladder to drain urine. Unlike a standard urinary catheter, a suprapubic catheter bypasses the urethra entirely, which means the entry point is a surgical opening in the skin. Infection risk with any indwelling catheter is serious. A drainage bag resting on the floor, collecting whatever germs live there, connected by tubing to that opening, is not a minor lapse.
A nursing assistant interviewed separately told inspectors that Resident 44 could get an infection and require hospitalization if proper infection control practices weren't followed. That assessment came from a CNA, not a physician or an outside expert. It came from someone who works in the building.
The Director of Nursing, interviewed two days later on April 24, did not soften the finding. The drainage bag should always be kept off the floor and below the level of the bladder, she said, to prevent backflow and reduce the risk of infection. It should be secured to the bed frame. If there is an order for a leg anchor, the catheter tubing should be fastened to the resident's leg to prevent pulling, trauma, and movement of the catheter, which in turn helps keep the bag properly positioned.
None of that had been done.
The Director of Nursing told inspectors that a drainage bag lying directly on the floor, with the catheter unsecured, "was not acceptable and was not consistent with the facility's standard of care." She said it could increase infection risk, including urinary tract infections, and could also lead to catheter dislodgement or trauma from the catheter moving without being anchored.
Catheter dislodgement in a suprapubic catheter is not a minor complication. The tract through the abdominal wall can begin to close within hours if the catheter comes out. Reinsertion can require emergency intervention.
The facility's own written policy on suprapubic catheter management, dated 2024, states that the goal is safe, sterile, and effective management to reduce infection risk, maintain urinary drainage, and promote patient comfort and dignity. The policy existed. The training, presumably, existed. The nurse who found the bag on the floor that morning knew what the standard was well enough to recite it back to an inspector.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting some residents. That classification sits below the most serious tiers on CMS's scale, which reserve higher designations for violations that cause or are likely to cause serious injury. But the facility's own clinical leadership described a scenario, unsolicited, in which a resident ends up hospitalized.
Resident 44 was not described as having developed an infection at the time inspectors documented the finding. Whether that remained true after the inspection closed, the report does not say.
What the report does say is that a nurse walked into a resident's room that morning, saw a catheter bag on the floor, and left it there. When an inspector arrived, she explained the risk in clinical detail. Then she waited to be asked about it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vermont Healthcare Center from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
VERMONT HEALTHCARE CENTER in TORRANCE, CA was cited for violations during a health inspection on April 24, 2026.
Licensed Vocational Nurse 4 acknowledged the bag was on the floor.
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.