Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Specialty Care during CMS and state inspections, most recent first.
A resident who was dependent for toileting hygiene and always incontinent of urine and bowel was observed receiving incontinence care from two CNAs who washed hands and donned PPE at the start, but did not change gloves or wash hands between dirty and clean tasks. Staff handled soiled clothing, an incontinent brief, and a urine-soiled wheelchair cushion, then continued cleansing and dressing the resident and later handled soiled equipment and room items. The DON stated the wheelchair should have been cleaned and staff should change gloves and wash hands between dirty and clean tasks.
The facility failed to maintain adequate staffing levels, particularly on weekends, as indicated by a one-star staffing rating and excessively low weekend staffing. Interviews with staff, including CNAs and the DON, confirmed that the number of residents and their needs were overwhelming, leading to delays in care. The facility assessment was outdated and did not reflect current staffing needs, with high staff turnover and increased resident acuity exacerbating the issue.
The facility failed to maintain sanitary conditions in the kitchen and residents' refrigerator, with issues such as unlabeled and undated food, improper hand hygiene, and lack of cleaning schedules. The dietary manager's recent departure left other departments to manage the kitchen, leading to deficiencies in food handling and storage practices.
The facility failed to serve correct portions for residents on pureed and mechanical soft diets, affecting 14 residents. During a lunch meal service, incorrect scoop sizes were used, resulting in residents receiving less than the required portions. The Activities Director, responsible for plating, was unaware of the need for different scoops and continued using incorrect sizes even after some scoops fell on the floor. Interviews revealed a lack of sufficient serving utensils and a misunderstanding of serving requirements.
The facility failed to maintain safe food temperatures during meal service, with salads and cottage cheese left without cooling, and entrees served below recommended temperatures. The AD and DON recorded temperatures that did not meet the facility's food safety guidelines, leading to a deficiency.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairment. The MDS Assessment did not document schizophrenia, although the EHR later indicated it as an active diagnosis. Changes in the resident's Olanzapine prescription were linked to schizophrenia without proper documentation or a physician's diagnosis. The DON confirmed the LPN responsible for the entry was no longer employed, and the facility's policy did not ensure accurate records, leading to the deficiency.
A resident with a urinary catheter was observed receiving care without proper infection control practices. The CNA failed to wear the required PPE gown and did not perform hand hygiene between steps, contrary to the facility's policies on Enhanced Barrier Precautions and Hand Hygiene. The resident had a neurogenic bladder and required assistance with all ADLs.
The facility failed to serve room trays at regular times comparable to normal mealtimes, delaying lunch tray delivery past 1:00 p.m. Observations showed that room trays were prepared and delivered late, causing dissatisfaction among residents.
Hand Hygiene Not Performed During Incontinence Care
Penalty
Summary
The facility failed to perform appropriate hand hygiene during personal care for a resident who was dependent for toileting hygiene and was always incontinent of urine and bowel. The resident’s MDS dated 8/20/25 documented diagnoses including non-Alzheimer’s dementia and Parkinson’s Disease, and the care plan dated 5/5/25 identified urinary incontinence and frequent bowel incontinence. On 9/3/25, the resident was observed in the dining room with a puddle of urine under his wheelchair, and staff then assisted him to his room for incontinence care. During the observed care, two CNAs washed their hands and donned gowns and gloves before transferring the resident to bed, but then continued care without changing gloves or washing hands between dirty and clean tasks. Staff lowered and removed soiled clothing and the incontinent brief, handled the soiled brief and clothing, and cleansed the resident’s abdomen, groin, and buttocks with disposable wipes. The wheelchair cushion was soiled with urine, and later staff handled the soiled clothing, moved the soiled wheelchair to the bathroom, and managed room items while wearing clean gloves. The facility policy on handwashing/hand hygiene required hand hygiene before and after direct resident contact, before moving from a contaminated body site to a clean body site, after handling contaminated equipment, and after removing gloves.
Inadequate Staffing Levels on Weekends
Penalty
Summary
The facility failed to maintain adequate staffing levels to meet the needs of its residents, as evidenced by the Payroll Based Journal (PBJ) Staffing Data Report for the fiscal year's Quarter 2, which indicated excessively low weekend staffing and a one-star staffing rating. The facility's assessment for 2024, provided by the Administrator, outlined a daily staffing pattern that was not met, particularly on weekends. The facility had an average daily census of 50.6 residents, but the staffing schedules from January to March 2024 showed insufficient staffing on 26 out of 26 weekend day nursing shifts and 23 out of 26 evening nursing shifts. Certified Nursing Assistants (CNAs) were also inadequately staffed, with 24 out of 26 day shifts, 16 out of 26 evening shifts, and 24 out of 26 night shifts being insufficiently staffed. Interviews with staff members, including CNAs and the Director of Nursing (DON), confirmed the staffing shortages. Staff reported that the number of residents and their needs were overwhelming, leading to delays in resident care. The DON acknowledged the staffing issues and noted that agency staff, the DON, Assistant DON, and the MDS nurse sometimes covered shifts when short-staffed. The facility assessment was not updated to reflect the current staffing needs, and there was confusion regarding the availability of previous assessments. The DON reported that the facility had experienced high staff turnover and that the resident acuity had increased, further complicating staffing adequacy.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the kitchen, as observed during a survey. The kitchen had multiple issues, including a microwave with dried food debris, a frying pan with a damaged Teflon coating, and refrigerators with food particles and spillage. Additionally, several food items were found unlabeled and undated, such as prune juice, half & half, milk, applesauce, blueberries, and various meats. The Victory Freezer also contained unlabeled and undated food items. The facility lacked a policy on maintaining kitchen equipment, and the dietary manager had recently quit, leaving other departments to manage the kitchen. Staff interviews revealed a lack of proper hand hygiene and food handling practices. Staff C was observed placing utensils on the steam table after handling trash without washing hands. The garbage can was overflowing, and the ceiling above the steam table had gray, fuzzy debris. During a follow-up visit, many of the initial issues remained unresolved, including unlabeled food items and a scratched frying pan. The facility had no cleaning schedules for 2024, and the dietician was uncertain about the contents of some food containers. The residents' refrigerator also had issues, with expired and unlabeled food items, such as honey ham, yogurt, pizza slices, and mighty shakes. Staff interviews indicated confusion about who was responsible for cleaning the refrigerator. The Director of Nursing was unaware of the cleaning schedule, and the Regional Dietary Manager confirmed that mighty shakes should be discarded after seven days if thawed. The facility's policies on food handling and storage were not being followed, contributing to the deficiencies observed during the survey.
Improper Portioning of Meals for Residents on Special Diets
Penalty
Summary
The facility failed to serve the appropriate portions for residents on pureed and mechanical soft diets, affecting a total of 14 residents. The deficiency was identified during a lunch meal service where the dietary manager, Staff C, prepared the meals. Observations revealed that Staff C used incorrect scoop sizes for serving the chicken, resulting in residents receiving less than the required portions. Specifically, residents on a mechanical soft diet were supposed to receive 4 7/8 oz. of ground chicken but were served only 4 oz., while residents on a pureed diet were supposed to receive 5 5/8 oz. of pureed chicken but were served only 2 oz. The Activities Director (AD), responsible for plating the food, was unaware of the need to use two different scoops for the different diet textures and continued to use incorrect scoop sizes even after some scoops fell on the floor during the meal service. Interviews with the consulting dietician and Staff C revealed that there was an expectation for staff to follow the menu and serve the proper serving sizes. However, Staff C reported a lack of sufficient serving utensils in the kitchen and had informed the Administrator about the need to order more. The AD confirmed that she referred to the menu book and a colored chart for serving sizes but did not realize the need for different scoops for the pureed and ground chicken. This oversight, combined with the inadequate number of serving utensils, led to the improper portioning of meals for residents on special diets.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe and palatable food temperatures during meal preparation and service, as observed during a survey. On the specified date, plates of lettuce salad with ham, turkey, and boiled eggs, along with bowls of cottage cheese, were left on the counter without any cooling mechanism. The Activities Director (AD) and Director of Nursing (DON) checked the temperatures of various food items, revealing that the lettuce salad and cottage cheese were at 54.1°F and 49.6°F, respectively, which are above the recommended cold food storage temperature of 41°F. Additionally, the ground chicken and pureed rice/broccoli casserole were served at temperatures below the expected minimums, with the ground chicken dropping to 134°F and the casserole to 136.8°F by the end of the meal service. The surveyor observed that cheese slices, which were not kept on ice, were placed on hamburger patties for several residents, and salads and cottage cheese were served to others. The dietician consultant confirmed that the expected serving temperatures for the rice casserole and chicken were at least 145°F and 165°F, respectively. The facility's policy on preventing foodborne illness emphasized the importance of maintaining proper food temperatures, yet the observed practices did not align with these guidelines, leading to the deficiency.
Inaccurate Medical Records for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with severe cognitive impairment, as evidenced by discrepancies in the documentation of the resident's medical diagnoses and medication orders. The Minimum Data Set (MDS) Assessment did not include a diagnosis of schizophrenia, despite the Electronic Health Record (EHR) indicating it became an active diagnosis. The Medication Administration Record (MAR) showed changes in the resident's Olanzapine prescription, initially linked to unspecified dementia and bipolar disorder, and later to schizophrenia, without proper documentation or a physician's diagnosis. The Director of Nursing (DON) confirmed that the Licensed Practical Nurse (LPN) who entered the schizophrenia diagnosis into the EHR was no longer employed at the facility, and the facility could not determine the reason for this entry. The facility's policy on Electronic Medical Records did not ensure that medical records were accurate and complete, contributing to the deficiency. The pharmacy sought clarification from the Mental Health Nurse Practitioner (NP), who later confirmed the diagnosis, but the initial lack of documentation and linkage to an active diagnosis in the resident's record highlighted the facility's failure to maintain accurate medical records.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices for a resident with a urinary catheter, leading to a deficiency in preventing cross-contamination of invasive medical equipment. The resident, who was unable to complete a mental status interview, had a neurogenic bladder, cerebral palsy, bipolar disorder, and required assistance with all activities of daily living. The resident's care plan included Enhanced Barrier Precautions (EBP) due to the presence of a colostomy and suprapubic catheter, and staff were directed to perform catheter care according to facility protocol. During an observation, a Certified Nurse Aide (CNA) was seen emptying the resident's urinary catheter collection bag without wearing the required Personal Protective Equipment (PPE) gown for EBP. The CNA also failed to perform hand hygiene between emptying the urine into a container and cleaning the catheter bag drain. The Director of Nursing confirmed that staff should have been appropriately gowned and should have performed hand hygiene between the steps. The facility's policies on Enhanced Barrier Precautions and Handwashing/Hand Hygiene were not followed, contributing to the deficiency.
Delayed Room Tray Delivery for Lunch Meal
Penalty
Summary
The facility failed to serve room trays at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care, by delaying room tray delivery for the lunch meal past 1:00 p.m. The Director of Nursing stated that meal times are scheduled at 8:00 a.m., 12:00 p.m., and 5:45 p.m. Observations on 5/23/24 showed that staff began serving individual meal plates to residents in the dining room at 12:15 p.m. and completed serving by 12:37 p.m. Room trays were prepared at 12:40 p.m., with deliveries to hall 1 occurring between 12:50 p.m. and 12:52 p.m., and deliveries to hall 2 starting at 1:00 p.m. and ending at 1:11 p.m. On 5/28/24, similar delays were observed, with room trays for hall 1 leaving the kitchen at 1:00 p.m. and for hall 2 at 1:10 p.m., with the last tray served at 1:18 p.m. Interviews with residents receiving food trays revealed dissatisfaction with the late serving time.
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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 Albia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Ottumwa | 18.1 mi | ★★★★★ | 13 | 0 |
| Ridgewood Specialty Care | 18.1 mi | ★★★★★ | 5 | 0 |
| Centerville Specialty Care | 19.1 mi | ★★★★★ | 6 | 0 |
| Mercyone Centerville Medical Center | 20 mi | ★★★★★ | 15 | 0 |
| Accura Healthcare Of Ottumwa | 20.2 mi | ★★★★★ | 2 | 0 |
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