Rose Blumkin Jewish Home: Continence Care Failure - NE
The resident required total assistance with basic functions including toileting, bathing and transfers. Federal assessments showed moderate cognitive impairment, with a score indicating the person needed substantial help with upper body dressing and hygiene.
Medical records revealed the resident had an indwelling foley catheter due to obstructive and reflux uropathy, a serious condition where urine flow becomes blocked and backs up into the kidneys. The catheter drains urine directly from the bladder through a tube.
Doctor's orders specifically required staff to change the catheter every 30 days. The protocol included removing the catheter temporarily and monitoring how much urine remained in the bladder after the resident attempted to void naturally. If more than 500 milliliters of urine stayed behind, staff were instructed to replace the catheter immediately.
The catheter change was due September 15, 2025. Treatment records for that month showed no initials in the designated box, indicating staff never performed the procedure.
Federal inspectors reviewed the facility's Treatment Administration Record during their November visit. The document clearly showed the missed catheter change, with an empty space where a staff member's initials should have confirmed completion of the medical order.
The facility's Director of Nursing confirmed the violation during an October interview with inspectors. The nursing supervisor acknowledged that staff failed to change the resident's catheter on the scheduled date and failed to monitor post-void residuals as ordered.
Indwelling catheters require regular replacement to prevent serious complications. Extended use beyond recommended timeframes can lead to urinary tract infections, bladder stones, and kidney damage. For residents with existing urological conditions like obstructive uropathy, delayed catheter changes pose additional risks of urine backing up into the kidneys.
The resident's comprehensive care plan, updated in August, documented the ongoing need for catheter care due to the underlying urological condition. Staff were also ordered to provide catheter care every shift, indicating the medical device required constant attention and monitoring.
Rose Blumkin Jewish Home houses 93 residents in Omaha. The facility received citations for failing to provide appropriate care for residents requiring catheter management and urinary tract infection prevention.
The inspection found the nursing home failed to follow basic protocols for one of the most vulnerable types of medical care. Residents with cognitive impairment and total dependence on staff for personal care rely entirely on nursing personnel to follow doctor's orders for complex medical devices.
Federal investigators classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the failure to change catheters according to medical orders represents a fundamental breakdown in following physician instructions for vulnerable residents.
The resident's condition required careful monitoring of urine output and bladder function. Post-void residual measurements help medical staff determine whether natural urination is possible or if continued catheter use is necessary. Skipping this assessment left the resident without proper evaluation of their urological status.
Treatment records showed the facility had clear, specific orders for catheter management. The 30-day replacement schedule and post-void residual monitoring protocol were documented in the resident's official treatment plan. Staff simply failed to execute the medical orders as written.
The nursing home's violation occurred despite having detailed care plans and treatment schedules designed to ensure residents receive appropriate medical attention. The Director of Nursing's acknowledgment of the failure during the inspection confirmed that supervisory staff were aware of the lapse in care.
For a resident already dealing with serious urological complications and complete dependence on staff for basic needs, the missed catheter change represented a significant failure in medical care coordination.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rose Blumkin Jewish Home from 2025-11-18 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: June 20, 2026 · Our methodology
Rose Blumkin Jewish Home in Omaha, NE was cited for violations during a health inspection on November 18, 2025.
The resident required total assistance with basic functions including toileting, bathing and transfers.
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.