The 77-year-old woman, identified in inspection records as Resident #90, was admitted in July 2024 with dementia, chronic kidney disease and pressure ulcers on both heels. Her left heel wound was classified as "unstageable" — meaning inspectors couldn't determine how deep the injury went because dead tissue obscured the wound's base.
Her doctor ordered daily treatment: cleanse the left heel wound with saline, pat dry, swab with Betadine antiseptic, cover with an abdominal pad and wrap with gauze. The order was dated July 17, 2025, nearly a year after her admission.
Staff documented the missed treatments themselves. Treatment administration records showed nursing staff failed to perform the wound care on September 6, 10, 12, 15, 26 and 29. They missed it again on October 4, 5, 10, 13, 18 and 19.
That's 12 missed treatments in 44 days.
The facility's Director of Nursing confirmed the lapses during an October 21 interview with state inspectors. No explanation was provided for why the treatments were skipped or what happened to the resident's wound during those gaps in care.
Altenheim's own policy required staff to follow current standards of practice for wound care. The policy stated that dressings should only be removed when ordered changes were due, unless there were signs of contamination or clinical problems that demanded immediate attention.
The resident's care plan, dated July 19, 2025, acknowledged she was "at risk for impaired skin integrity" and required treatments "as ordered by the physician." Yet those physician-ordered treatments were routinely ignored.
Pressure ulcers develop when sustained pressure cuts off blood flow to skin and underlying tissue. They're particularly dangerous for elderly residents with conditions like dementia, who may not be able to communicate pain or reposition themselves. Untreated pressure ulcers can become infected, expand deeper into tissue, and in severe cases prove fatal.
The wound's "unstageable" classification meant it was already serious enough that dead tissue prevented medical staff from assessing its true depth. Such wounds require consistent, careful treatment to remove dead tissue and promote healing.
Federal regulations require nursing homes to provide necessary care and services to help residents achieve their highest level of well-being. They must also ensure residents receive proper treatment and care for wounds, consistent with professional standards of practice.
The inspection was triggered by a complaint filed against the facility. State investigators classified the violation as causing "actual harm" to residents — meaning the deficient care had already damaged someone's health or safety, not just created a risk.
This wasn't a case of inadequate supplies or unclear orders. The facility had a specific treatment protocol. Staff had documented physician orders. The Director of Nursing understood what should have been done.
They simply didn't do it.
The resident arrived at Altenheim already bearing pressure ulcers on both heels. Nearly 14 months later, staff were still failing to provide the basic wound care her doctor had ordered. In the critical window between September and October 2025, when consistent treatment might have helped her heal, she received gaps in care instead.
Resident #90's unstageable pressure ulcer represents more than a documentation problem or staffing oversight. It's a wound that couldn't heal because the people responsible for her care repeatedly chose not to provide it.
The inspection report doesn't say whether her condition worsened during those 12 missed treatments. It doesn't describe whether she experienced pain, infection, or further tissue damage while waiting for care that never came.
But it documents something simpler and more damning: a nursing home that couldn't manage to treat a vulnerable resident's wound on 12 separate days, despite having clear orders, adequate policies, and a Director of Nursing who knew exactly what wasn't being done.
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.