Average — CMS composite of the measures below.
A standard survey is most likely before around March 2027
Estimate from public CMS data, current as of October 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.
Failure to Treat Residents with Dignity and Respect: Two residents were not treated with dignity and respect. One resident with dementia, depression, HF, and renal failure reported being told to wet the brief or pants while staff were busy with another resident, and staff were overheard making a similar statement. Another resident with intact cognition, CP, depression, and chronic pain stated a CNA was not nice and did not treat the resident with dignity and respect. Care plans for both residents directed staff to communicate calmly, validate concerns, and respect resident rights.
A resident with memory impairment, moderately impaired decision-making, and dependence for multiple ADLs fell after staff heard a loud crash and found the resident on the floor with the walker nearby. Staff assisted the resident to a wheelchair and recliner, but family notification was delayed until the next morning, despite the resident representative expecting prompt notice after the fall.
Failure to Timely Report Abuse and Theft Allegations Staff did not report two residents’ allegations of mistreatment and misappropriation to DIAL within the required 2 hours. One resident with severe cognitive impairment and incontinence was overheard being told to urinate in her brief while staff were busy with another transfer, and another resident with intact cognition alleged a CNA stole coins from her drawer and retaliated against her with wheelchair contact. Staff interviews showed the allegations were discussed internally, but the required external reporting timeframe was not met.
Failure to document and investigate abuse and theft allegations: A CNA told a cognitively impaired resident to urinate in her pants, and the resident later said she felt embarrassed because staff repeatedly made similar comments. In a separate incident, a resident alleged a CNA stole coins from her room, but staff did not promptly report or investigate the allegation and instead only kept the CNA away from the resident. The clinical records lacked documentation of both allegations.
Failure to use two staff for EZ-stand transfers: A resident with intact cognition, dementia, depression, muscle weakness, and a hx of stroke required total assist for transfers and had a care plan directing EZ-stand use with two staff. Although two CNAs were observed completing one transfer, the resident and multiple staff members reported that EZ-stand transfers were sometimes done with only one staff member, despite facility expectations for two staff at all times.
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.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of quality of life for 2 of 7 residents reviewed. One resident had diagnoses including anemia, heart failure, renal failure, non-Alzheimer's dementia, and depression, with a BIMS score of 5 indicating severely impaired cognition and dependence on staff for toileting hygiene, dressing, and personal hygiene. The care plan directed staff to approach and speak in a calm manner, validate concerns, and communicate clearly. Staff reported overhearing a CNA tell the resident to just wet her pants while standing outside the resident's closed bedroom door, and the resident later stated that staff told her to urinate in her brief while they were assisting the roommate and that this left her feeling embarrassed. Another resident had diagnoses including anemia, cerebral palsy, depression, and chronic pain, with a BIMS score of 15 indicating intact cognition and dependence on staff for toileting, bathing, dressing, and personal hygiene. The care plan directed staff to validate concerns and maintain respect for the resident's rights to make lifestyle choices. The resident stated that a CNA was not nice and did not treat the resident with dignity and respect. Facility documentation also noted the resident disliked new staff and preferred familiar staff, and the Administrator and an RN acknowledged that staff must treat all residents with dignity and respect at all times as a facility expectation.
Failure to Notify Family After Resident Fall
Penalty
Summary
The facility failed to notify a resident representative/family after a resident fall for 1 of 6 residents reviewed, Resident #4. Resident #4 had documented short- and long-term memory problems, moderately impaired decision-making, dependence for toileting hygiene, dressing, personal hygiene, transfers, and ambulation, and diagnoses including cancer, diabetes mellitus, and hypertension. The care plan identified Resident #4 as at risk for falls because the resident did not remember to use a walker for long-distance ambulation and needed reminders. Interventions included keeping the bed low, placing the call light within reach, providing non-skid shoes, and placing a sign reminding the resident to take the walker when ambulating. An incident report documented staff hearing a loud crash and finding Resident #4 lying on the floor on the resident's back with the head near the bathroom door, feet toward the middle of the room, and the walker beside the end of the bed. Two staff assisted the resident to standing, placed the resident in a wheelchair, transported the resident to the north lounge, and transferred the resident to a recliner. Staff observed the resident 10 minutes before the fall and documented plans to notify the resident's family member in the morning. Progress notes later documented a call to the resident's wife to provide an update regarding the fall, and the resident's family member stated they expected notification following the fall. The Administrator and an RN stated nursing staff must notify family members regarding a resident's change of condition, including falls and new or discontinued medications.
Failure to timely report allegations of abuse and theft
Penalty
Summary
The facility failed to report all alleged violations involving mistreatment and misappropriation of resident property to DIAL within 2 hours for two residents. The report states the facility had a census of 60 residents and that staff and resident interviews, clinical record review, facility investigation, and facility policy were used to identify the deficiency. The facility policy required allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property to be reported immediately and no later than 2 hours. For one resident, the record documented severe cognitive impairment, urinary incontinence, dependence for toileting hygiene and dressing, and diagnoses including anemia, heart failure, renal failure, non-Alzheimer's dementia, and depression. Staff B reported overhearing Staff C tell the resident to just wet her pants or go to the bathroom in her pants while the resident was behind a closed bedroom door. Staff B later told the DON about the statement and described the resident as upset and embarrassed by comments telling her to urinate in her brief. Staff C acknowledged telling the resident it was okay to urinate in her brief and that staff would clean her up after finishing another transfer. The DON interviewed staff and reviewed statements, but the allegation was not reported to DIAL within the required 2-hour timeframe. For the second resident, the record documented intact cognition, urinary incontinence, dependence for toileting hygiene, partial to maximal assistance with dressing and personal hygiene, and diagnoses including anemia, heart failure, renal failure, non-Alzheimer's dementia, and depression. The resident alleged that Staff F stole collector coins from her drawer and retaliated by bumping her wheelchair and kicking her chair. Staff E, the Administrator, submitted a self-report to the state agency regarding potential theft and abuse, but staff later stated they did not report the resident's allegation immediately because the resident frequently accused staff of stealing. Staff G acknowledged hearing the allegation and not escalating it to the DON or Administrator. The investigation summary documented conflicting dates and a lack of evidence identifying Staff F as the source of the missing coins, but the allegation itself was not reported to DIAL within 2 hours as required.
Failure to document and investigate abuse and theft allegations
Penalty
Summary
The facility failed to ensure staff treated residents with dignity and respect when a CNA told a cognitively impaired resident to just wet her pants or go to the bathroom in her pants while the resident was behind a closed bedroom door. Resident #10 had a BIMS score of 5, was severely cognitively impaired, and required staff assistance with toileting hygiene, dressing, and personal hygiene. Staff B reported overhearing the statement during a medication pass, and later stated the DON was informed about the incident, but the resident’s clinical record lacked documentation of the allegation of personal degradation. The investigation records showed conflicting accounts of what was reported and when. Staff B stated the DON was told that the CNA told Resident #10 to urinate in her pants, while the DON documented that Staff B spoke vaguely and that the resident said she made it to the bathroom that morning. Staff C acknowledged telling Resident #10 that it felt okay to urinate in her brief and that staff would clean her up after a transfer. Resident #10 later stated she felt upset and embarrassed because staff repeatedly told her to urinate in her brief for later cleanup. The facility also failed to document and investigate an allegation of misappropriation of property involving another resident. Resident #11 had a BIMS score of 13 and required assistance with toileting hygiene, dressing, and personal hygiene. Resident #11 alleged that a CNA stole collector coins from her drawer or coin purse, and staff overheard her making the accusation, but the clinical record lacked documentation of the allegation. Staff G stated the allegation was not reported because Resident #11 frequently accused staff of stealing, and staff were told only to keep the CNA away from the resident rather than initiate an investigation. The Administrator later confirmed that staff were expected to separate the parties and begin an investigation immediately.
Failure to Use Two Staff for EZ-Stand Transfers
Penalty
Summary
The facility failed to ensure staff members used two staff during EZ-stand mechanical lift transfers for Resident #2. Resident #2 had a BIMS score of 13, indicating intact cognition, and was documented as having adequate vision, the ability to understand others, and the ability to make self understood. The resident required staff dependence for toileting hygiene, dressing, and transfers, with setup help for oral and personal hygiene, and had diagnoses including hypertension, non-Alzheimer's dementia, depression, and muscle weakness. Resident #2's care plan identified a need for assistance with ADLs related to a history of stroke affecting the left dominant side and directed staff to transfer the resident with an EZ-stand using two staff members. During observation, two CNAs used the EZ-stand to transfer Resident #2 from a recliner to a wheelchair. However, Resident #2 stated staff sometimes used the EZ-stand with only one staff member present. An LPN, an RN, and a CNA each confirmed that staff sometimes performed EZ-stand transfers with only one staff member, despite facility expectations requiring two staff members at all times for mechanical lift and EZ-stand transfers. The DON and the Administrator also confirmed that the facility expectation was to always use two staff members for these transfers.
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 | ★★★★★ | 0 | 0 |
| Concord Care Center | 11.5 mi | ★★★★★ | 3 | 0 |
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