The violations affected residents who depended on catheters due to obstructive and reflux uropathy, a condition that blocks normal urine flow and can lead to dangerous complications without proper care.
Resident 79 arrived at the facility on September 30 with urinary retention and required a foley catheter. Her physician ordered catheter care every shift, and her care plan specified staff would provide this care as ordered.
But treatment records showed staff skipped her catheter care repeatedly in October. They missed night shift care on October 3, 9, and 10, plus day shift care on October 10 and 17. The Director of Nursing confirmed these lapses during an October 21 interview with inspectors.
The second case proved far more extensive. Resident 120, a dementia patient admitted in December 2022, required a suprapubic catheter inserted directly into his bladder. His care plan called for catheter care and output monitoring as ordered.
Staff missed his suprapubic catheter care 15 times between May and July. The gaps included day shift on May 1 and June 9, plus night shift failures on May 2, 8, 9, 14, 22, 27, and 28. Additional misses occurred on June 2, 11, 24, 27, 30, and July 2.
When his catheter type changed in July, the problems continued. His physician ordered foley output monitoring every shift starting July 22, but staff failed to track his urine output 32 more times through September.
The monitoring lapses clustered heavily on night shifts. Staff missed checking his output on July 22, 23, and 31, then again on August 3, 6, 7, 19, 20, 26, 28, and 29. September brought additional failures on the 5th, 8th, 16th, 17th, 19th, 22nd, 25th, and 26th.
Day shift staff also missed monitoring on July 25 and August 16.
In total, Resident 120 went without proper catheter care or output monitoring 47 times over four months.
The facility's own policy, dated April 2013, required catheter care every shift and as needed. The policy applied to both residents but staff consistently failed to follow it.
For patients with urinary blockages, catheter care prevents infections and ensures proper drainage. Without regular monitoring, urine output problems can signal dangerous complications like blocked catheters or kidney issues.
Resident 79's urinary retention meant her body couldn't empty its bladder naturally. Resident 120's obstructive uropathy created similar drainage problems. Both conditions make consistent catheter maintenance critical for preventing serious medical complications.
The Director of Nursing acknowledged all the documented care failures when questioned by inspectors. The admission came during a complaint investigation numbered 2601761, suggesting someone had reported concerns about catheter care at the 120-bed facility.
Neither resident's medical records indicated whether the missed care caused immediate health problems. But the pattern of skipped treatments stretched across multiple shifts and different staff members, suggesting systemic problems with following physician orders.
The violations occurred despite clear documentation requirements. Treatment administration records tracked when care should happen, making the gaps obvious to anyone reviewing the charts.
For Resident 79, the missed care began just days after her admission when she was adjusting to a new facility while managing a serious urinary condition.
For Resident 120, the problems persisted across a catheter change, indicating staff failed to adapt their care routine when his medical needs evolved.
The facility policy emphasized catheter care should happen not just on schedule but "as needed," giving staff discretion to provide additional care when residents showed signs of problems.
Yet the documented failures showed staff weren't meeting even the basic scheduled requirements, let alone providing the enhanced monitoring that vulnerable residents might need.
The inspection found these catheter care violations among just three residents reviewed for urinary catheter issues, suggesting the problems might extend to other residents not included in this particular investigation.
Both affected residents required catheters due to serious underlying conditions that made proper urinary drainage essential for their health and comfort.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altenheim from 2025-10-21 including all violations, facility responses, and corrective action plans.