Careview Health and Rehab: Catheter Failures Cause Harm - WI
Nobody called the doctor any of those nights either.
When federal inspectors reviewed the medical records of two catheterized residents this September, they found two months of documentation so incomplete it was sometimes indistinguishable from noise. Output amounts were logged as "xx," "cna," "yello," "N," "A," and "CLR" — none of which constitutes a measured amount. On at least a dozen individual shifts across July and August, nothing was written at all. The inspection, completed September 3, cited the facility for causing actual harm to residents.
The first resident, identified in inspection records as R2, had a Foley catheter. His care plan directed staff to document output every shift and to notify a provider if there were signs of urinary tract infection, including no output. His physician had ordered the same thing in writing. Over the course of July and August, inspectors counted more than 20 shifts where the output column was either blank, zero with no follow-up, or filled with a word or letter that recorded nothing meaningful. On July 20, the nightshift entry read "cna." On August 7, it read "yello." On August 13, it read "A." On August 27, it read "N."
What any of those entries were meant to convey is not explained in the inspection report. What is clear is that none of them told anyone how much urine the resident produced.
When output is recorded as zero for a catheterized patient and no one investigates, the consequences can be severe. A blocked or kinked catheter can cause urine to back up into the kidneys. Infection can develop and spread. The care plan for R2 specifically listed the warning signs staff were supposed to watch for: pain, burning, blood-tinged urine, cloudiness, no output. The record shows that on multiple nights when output was zero, the response was silence.
The second resident, R5, had a suprapubic catheter — a tube inserted directly through the abdomen into the bladder — placed there because of a neuromuscular dysfunction that prevented normal urination. He also had osteomyelitis of the vertebra. His physician order, written in December 2024, was identical in intent: document suprapubic catheter output every shift. His care plan carried the same instructions about monitoring for UTI signs and reporting them to the doctor.
Inspectors found the same pattern. On July 2, no output was documented. On July 4, no output for dayshift. On July 8, dayshift recorded zero with no provider notification. On July 14, both dayshift and nightshift were zero, and again no one called. In August, there were five consecutive days, August 16 through 19, where output documentation was either missing entirely or absent for the day shift. On August 27, the entry was zero. No provider notification noted.
The facility provided no additional documentation to explain the gaps.
What makes the record striking is its duration. This was not a bad week or a single nurse's oversight. Across both residents, the failures stretched across the full months of July and August, spanning multiple shifts, multiple staff members, and multiple occasions when a catheterized patient's output hit zero and the response was to write nothing, or to write something that meant nothing, and move on.
On July 25, R2's catheter was changed because it had become displaced. The facility didn't have the right size on hand — a 16 French catheter — so staff got a verbal order to use an 18 French instead. The note from that day is detailed: catheter secured to right leg, patient tolerated well, wife updated. It is the kind of entry that shows staff knew how to document when they chose to. The same record that contains that careful note also contains, just days earlier and days later, entries that read "cna" and "xx" where a urine measurement should be.
Careview Health and Rehab of Minocqua sits on Old Highway 70 on the edge of a lakeside tourist town in northern Wisconsin. The residents inside it, some with catheters threaded into their bladders or through their abdominal walls, depended on nightshift nurses to write down a number. For two months, that did not reliably happen.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careview Health and Rehab of Minocqua from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
CAREVIEW HEALTH AND REHAB OF MINOCQUA in MINOCQUA, WI was cited for violations during a health inspection on September 3, 2025.
Nobody called the doctor any of those nights either.
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.