Altenheim

In the surveyor’s words

From the most serious findings on record at Altenheim, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 21, 2025

  Based on observation, medical record review, witness statement review, policy review and interview, the facility failed to ensure Resident #120's right great toe ulcer/abrasion was timely identified, assessed, monitored and treated and failed to complete wound treatments as ordered for Resident #90. Actual harm occurred when Resident #120, who was assessed as severely cognitively impaired, totally dependent on staff for most activities of daily living (ADL's) and had a history of infection to the right great toe, was found to have a right great toe skin impairment beginning in 05/05/25, however there was no nurse assessment or monitoring or physician-ordered treatment of the right great toe skin impairment from 05/05/25 to 07/05/25. […]

• No harm, potential for more than minimal, widespreadF880Oct 21, 2025

  Based on record review, observation and interview, the facility failed to implement proper infection control policies and procedures including surveillance of facility infections and contact isolation precautions (wearing gown and gloves) when in Resident #60's room. This affected one (Resident #60) of three residents reviewed for isolation precautions but had the potential to affect all residents related to not performing proper infection control surveillance. The facility census was 120.Findings include:1. Review of the monthly infection control surveillance logs from September 2024 through October 2025 revealed the facility did not have surveillance for the months of August 2025, September 2025 and October 2025. Interview on 10/21/25 at 12:00 P.M. […]

• No harm, potential for more than minimal, widespreadF812Jul 25, 2024

  Based on observation, interview, and facility policy review, the facility failed to ensure appropriate food storage in the kitchen's main freezer and the memory care unit refrigerators. The kitchen area had the potential to affect all residents receiving meals from the kitchen. The facility identified three residents (#36, #78, and #96) who had nothing by mouth (NPO) diet orders. The facility identified 24 residents (#16, #18, #19, #21, #24, #31, #37, #39, #50, #52, #55, #56, #59, #60, #66, #67, #69, #71, #72, #80, #83, #87, #90, and #95) on the memory care unit. The facility census was 115. Findings include: Observation on 07/22/24 from 8:15 A.M. to 8:30 A.M. […]

• No harm, potential for more than minimal, isolatedF690Oct 21, 2025

  Based on record review and interview, the facility failed to ensure staff performed urinary catheter care and monitored urine output as ordered by the physician. This affected two (Residents #79 and #120) of three residents reviewed for urinary catheters. The facility census was 120.Findings include:1. Review of the medical record for Resident #79 revealed an admission date of 09/30/25 with diagnoses including urinary retention, obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing normally). Review of the physician's orders for Resident #79 revealed an order for foley catheter care each shift dated 09/30/25. […]

• No harm, potential for more than minimal, isolatedF881Oct 21, 2025

  Based on record review and interview, the facility failed to implement their antibiotic stewardship program to ensure appropriate use of antibiotics. This affected one (Resident #120) of three residents reviewed for antibiotic usage. The facility census was 120.Findings include:Review of the medical record for Resident #120 revealed an admission date of 12/17/22 with diagnoses including dementia, pressure ulcers, history of urinary tract infections and cellulitis of the right great toe, Review of the facility infection control surveillance for September 2024 through July 2025 revealed Resident #120 had been on antibiotics on 10/15/24 (for urinary tract infection), 11/01/25 (for urinary tract infection), 11/20/25 (for clostridium difficile, or infection of the colon that causes diarrhea),… […]