Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakwood Care Center during CMS and state inspections, most recent first.
Uncovered kitchen garbage containers were observed near food prep and clean dish areas, including a can beside the meal prep table with its lid off and other cans left open by the drink cart. The DM acknowledged Dietary staff were not keeping lids on the garbage cans, and the ADM stated staff were expected to keep the cans covered and stored away from food prep areas when not in use. The facility’s Food Handling policy did not address covering garbage cans when not in use.
A resident’s code status was not congruent across the IPOST, EMR, and care plan. The care plan and EMR documented full code, while the signed IPOST listed DNR. Staff reported checking code status in different parts of the EMR, and the facility policy stated the clinical record would maintain each resident’s resuscitation status.
EBP was not implemented for a resident with wounds and a urinary catheter. An LPN provided wound care while wearing gloves but not the required gown, despite an EBP sign and supplies being posted outside the room and the care plan directing EBP use. The LPN said she forgot the gown, and the DON acknowledged the lapse. The facility policy did not include direction for EBP, although CDC and CMS guidance addressed EBP for residents with wounds or indwelling medical devices.
A resident with dysphagia, cognitive impairment, and dependence for feeding had an emesis episode while lying down, followed by coughing and continued vomiting. The next morning, the resident was nonresponsive to voice, refused meds and supplement, and had crackles, tachypnea, cyanosis, and labored respirations before transfer to the hospital for possible aspiration pneumonia. Hospital records later showed septic shock and sepsis secondary to pneumonia, and staff confirmed the chart lacked the expected change in condition documentation and lung sound assessment.
The facility failed to maintain adequate chlorine levels in their dishwasher, with readings consistently below the required 50 ppm, affecting the sanitization of dishes for 60 residents. Despite the installation of a new dishwasher, the kitchen staff used incorrect test strips, and the Sales Technician suggested that high water temperatures might be burning off the sanitizer. The issue persisted despite the dishwasher operating within the acceptable temperature range.
A facility failed to ensure consistent documentation of a resident's code status, resulting in discrepancies between the IPOST, EHR, and Care Plan. The Care Plan and EHR indicated Full Code, while the IPOST, signed by the resident and physician, indicated DNR. Staff interviews revealed reliance on the EHR for code status, and the facility policy requiring consistency was not followed.
A facility failed to notify the state ombudsman of a resident's transfer to the hospital, as required. The resident was taken to the ED by ambulance and admitted to the hospital. The facility's Ombudsman report lacked documentation of this transfer, and the administrator confirmed the omission.
The facility inaccurately documented MDS assessments for two residents. One resident's MDS noted significant weight loss, but weights were found to be incorrect due to issues with the weight stand. Another resident's MDS incorrectly recorded a discharge to a hospital instead of home. Staff interviews confirmed these errors.
A resident with severe cognitive impairment and multiple health conditions experienced a significant weight loss, which the facility failed to assess and follow up on. Despite the facility's policy, the weight loss was not communicated to the physician or family, and staff were unaware of the issue. Observations showed the resident had a poor appetite, and there was inconsistency in meal consumption and weight documentation.
An LPN in a facility failed to follow proper infection control protocols during blood sugar checks and insulin administration for two residents with diabetes. The LPN did not clean the blood sugar meter between uses, neglected to use a barrier under supplies, and did not perform hand hygiene between residents. Additionally, gloves were not worn during insulin administration, and hand hygiene was compromised by using a washcloth to dry hands. These actions violated the manufacturer's guidelines and CDC infection control requirements.
Uncovered kitchen garbage containers near food prep areas
Penalty
Summary
The facility failed to cover 3 garbage containers with lids in the kitchen area. On 12/29/25, a kitchen garbage can that was not actively in use was observed next to the meal preparation table, touching the table surface, with its lid off and resting next to the garbage on the floor. On 12/31/25, the lid to the kitchen garbage was observed on the floor propped against the prep table near disposable foam dish storage, and garbage was seen by clean dishes and snack carts with 2 other garbage cans also left uncovered by the drink cart. The Dietary Manager acknowledged the facility had an issue with Dietary staff not keeping lids on garbage cans in the kitchen and stated the Corporate Dietary Consultant had recommended keeping garbage cans covered and away from food prep areas. The Administrator stated she expected staff to cover the garbage cans with lids in the kitchen and to store the garbage cans and lids away from food preparation areas when not in use. The facility's Food Handling policy, revised October 2023, lacked direction related to covering garbage cans when not in use.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure Resident #10’s code status was consistent across the Iowa Physician Orders for Scope of Treatment (IPOST), the EMR, and the care plan. The care plan identified the resident’s advanced directive status as full code and directed staff to check the EMR for code status. The EMR Profile tab, Orders tab, and MAR also documented the resident as full code. However, the resident’s IPOST, dated and signed by the resident and physician, listed the resident as DNR in the event her heart stopped beating. Staff interviews showed that an LPN and an RN both reported checking code status in different parts of the EMR, and the MDS Coordinator stated care plans were updated within a week of changes and that any nurse could change the care plan. The Administrator stated the Social Worker addressed code status at care conferences and that staff were to update code status timely in the chart, while also confirming staff were to look for code status in the EMR Profile tab. The facility policy stated the clinical record would maintain each resident’s resuscitation status.
EBP Not Followed During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was not followed when Enhanced Barrier Precautions (EBP) were not used for a resident with wounds and a urinary catheter. Resident #5 had a BIMS score of 15, indicating intact cognition, and the MDS listed pressure ulcers to the left heel and sacral region, osteomyelitis, and diabetes. The EHR also listed an unspecified open wound to the left lower leg. The care plan directed staff to use EBP, including wearing a gown and gloves during wound care. During observation, an LPN gathered supplies and entered the resident’s room to provide wound care to the left lower leg, and an EBP sign and EBP supplies were posted outside the doorway. The LPN wore gloves but did not wear the required gown while performing the wound care. In interview, the LPN stated the resident was on EBP and she forgot to wear a gown. The DON acknowledged the LPN did not follow EBP during the wound care. The facility’s Infection Control Manual Surveillance policy dated September 2023 did not include direction for EBP, while CDC guidance and CMS QSO-22-08-NH identified EBP for residents with wounds or indwelling medical devices.
Failure to Assess Lung Sounds After Emesis
Penalty
Summary
The facility failed to assess lung sounds after a resident had an episode of emesis, despite the resident later developing respiratory changes and being transferred to the hospital with septic shock related to aspiration pneumonia. Resident #4 had diagnoses including hypertension, seizure disorder, anxiety, depression, and dysphagia, and the MDS documented memory impairment, impaired decision-making, rare understanding, rare ability to make self-understood, and dependence for ADLs including eating assistance. The care plan identified the resident as needing 1:1 feeding assistance and staff assistance with oral care and personal hygiene. On the evening of the emesis event, the resident was found with vomit on her gown, hair, face, and mouth, continued to cough and have emesis for several minutes, and was then cleaned up and resting in a recliner. The next morning, the resident did not swallow medications, refused her supplement, was not making eye contact, did not react to voice, and had no coughing noted after being placed in a wheelchair. At that time, lung sounds were documented as crackles in the bases bilaterally, respirations were 46 breaths per minute and somewhat labored, nail beds were cyanotic, and fingers were cool to touch. The resident was transferred to the hospital for tachypnea not responding and vomiting while lying down, with the transfer form listing possible aspiration pneumonia. Hospital documentation later showed the resident was admitted to the CCU for septic shock, was hypotensive, and was transitioned to comfort care with sepsis secondary to pneumonia. Staff interviews verified that nurses were expected to complete a change in condition form for abnormal symptoms, and staff confirmed the record lacked documentation of that form and lacked documentation of lung sounds after the emesis.
Inadequate Chlorine Levels in Dishwasher
Penalty
Summary
The facility failed to ensure that the chlorine levels in their dishwasher were adequate for sanitizing dishes, affecting the safety and hygiene of food service for 60 residents. On multiple occasions, the dishwasher's chlorine levels were tested and found to be below the required 50 parts per million (ppm), with readings between 25 ppm and 50 ppm. The kitchen staff and the Housekeeping/Laundry Supervisor acknowledged the low chlorine levels, and the facility's Dietitian noted that a new dishwasher had been installed recently, which might have contributed to the issue. The Sales Technician for the dishwasher confirmed that the chlorine levels should be at least 50 ppm and suggested that the water temperature might be too high, potentially burning off the sanitizer. The facility's corporate dietitian later confirmed that the kitchen staff had been using the wrong test strips, although the Sales Technician indicated that the type of strip used should not affect the readings. The dishwasher's temperature was observed to be 134 degrees Fahrenheit, within the acceptable range for a low-temperature dish machine, but the chlorine levels remained insufficient. The Service Manual for the dishwasher specified that the sanitizer should be a 6% solution of sodium hypochlorite, with free chlorine in the final rinse at 50 ppm or more, highlighting the facility's failure to meet these standards.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure consistency in the code status documentation for a resident, leading to a discrepancy between the Iowa Physician Orders for Scope of Treatment (IPOST), the electronic health record (EHR), and the Care Plan. The Care Plan indicated the resident's code status as Full Code, while the IPOST, signed by both the resident and physician, indicated a Do Not Resuscitate (DNR) status. However, the EHR documented the resident's code status as Full Code. Interviews with staff revealed that they relied on the EHR for code status information, and there was a lack of awareness that the EHR should have been updated to reflect the IPOST. The facility's policy required that the code status in the IPOST should match the designation in the EHR, which was not adhered to in this case.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the state ombudsman regarding the transfer of a resident to the hospital, which constitutes a deficiency in the required notification process. Specifically, the clinical record review and staff interview revealed that the facility did not document the transfer of a resident to the hospital in their Ombudsman report for April 2024. The resident was taken to the emergency department by ambulance and admitted to the hospital, as noted in the emergency care physician notes. The resident was readmitted to the facility from the hospital a few days later. The facility's administrator confirmed that the resident should have been included in the Ombudsman report, indicating a lapse in the notification process.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document and submit Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the assessment process. For one resident, the MDS recorded a Brief Interview for Mental State (BIMS) score indicating moderate cognitive impairment and noted significant weight loss. However, a review of the resident's weights showed discrepancies, with an incorrect weight being struck out and no documentation supporting the reported weight loss. The dietician admitted to recording the weight loss on the MDS based on available weights but later acknowledged the weights were inaccurate and should have been modified. The facility administrator confirmed issues with the weight stand during that period, which contributed to the inaccurate weights. For another resident, the MDS inaccurately documented the resident's discharge to a short-term general hospital, while progress notes indicated the resident was discharged home with family. The MDS coordinator acknowledged the coding error, stating the MDS should have reflected the resident's discharge to home. These inaccuracies in the MDS assessments were identified through clinical record reviews and staff interviews, highlighting a failure to ensure the assessments accurately reflected the residents' statuses as instructed by the Resident Assessment Instrument (RAI) manual.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately assess and follow up on a significant weight loss for a resident with severe cognitive impairment and multiple health conditions, including diabetes mellitus and heart disease. The resident experienced a 6.03% weight loss over a 30-day period, which was not addressed by the facility staff. Despite the facility's policy requiring immediate notification of significant weight changes to the physician and family, this did not occur for the resident in question. Observations and interviews revealed that the resident was able to feed himself but had a poor appetite, consuming only small portions of meals. Staff interviews indicated a lack of awareness regarding the resident's significant weight loss, and there was inconsistency in the documentation of meal consumption and weight records. The facility's weight monitoring policy was not followed, as the resident's weight loss was not communicated to the necessary parties, and there was no documentation of any assessment or intervention in the medical records. The facility's failure to adhere to its weight monitoring policy and lack of communication with the physician and family about the resident's weight loss contributed to the deficiency. The resident's spouse was also not informed of the weight fluctuation, and the care plan nurse and other staff members were unaware of the significant weight change, indicating a breakdown in communication and monitoring processes within the facility.
Inadequate Infection Control During Blood Sugar Checks and Insulin Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during blood sugar checks and insulin administration for two residents. Staff B, an LPN, was observed performing blood sugar checks on Resident #21 without cleaning the blood sugar meter between uses, failing to use a barrier under supplies, and not wearing gloves during insulin administration. Additionally, Staff B did not perform hand hygiene after completing care for Resident #21 and before proceeding to the next resident. Resident #53, who also has diabetes and severe cognitive impairment, was similarly affected by the lack of proper infection control practices. Staff B was observed using the same blood sugar meter without cleaning it between residents and failed to use a barrier under the supplies. After administering medications, Staff B washed his hands but used a washcloth to dry them due to the absence of paper towels, which compromised hand hygiene. The LPN continued to handle medical equipment and administer insulin without proper sanitation or hand hygiene. The facility's failure to follow the manufacturer's guidelines for cleaning and disinfecting the blood sugar meter and the CDC's infection control requirements contributed to the deficiency. The Assure Prism Manual and interviews with staff confirmed that the blood sugar meter should be cleaned and disinfected between each resident, and gloves should be worn during insulin administration. However, these protocols were not followed, leading to potential risks of cross-contamination and infection transmission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clear Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercyone North Iowa Medical Services | 6.7 mi | — | 0 | 0 |
| I O O F Home And Community Therapy Center | 8.9 mi | ★★★★★ | 3 | 0 |
| Good Shepherd Health Center | 10 mi | ★★★★★ | 7 | 0 |
| Heritage Care And Rehabilitation Center | 10.6 mi | ★★★★★ | 7 | 0 |
| Concord Care Center | 11.5 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.