Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Dove Healthcare - Regional Vent Center during CMS and state inspections, most recent first.
The facility failed to notify the Ombudsman of resident transfers and discharges for 5 residents, and it could not locate a related policy. Records for residents with serious conditions such as respiratory failure, ventilator dependence, and Guillain-Barre Syndrome did not show Ombudsman notification when they were transferred to the hospital or discharged home, and the NHA stated documentation could not be found.
Unsafe food handling and storage practices were observed in the dietary department. A cook served fried eggs to 3 residents without checking the temperature, a staff member's lunch was stored in a resident refrigerator, cottage cheese was left in bowls without a label or date, cereal was served uncovered to a resident in their room, baking pans were stored uncovered or not inverted, and an open bag of macaroni lacked an open or use-by date.
The facility failed to promptly notify the provider when two residents had significant respiratory changes. One ventilator-dependent resident developed dyspnea and SOB during nebulizer treatments, and staff held ordered nebs for two days without timely MD notification. Another resident with COPD, chronic respiratory failure, and a trach had an acute episode with O2 sat of 40%, required bagging and suctioning, and was transferred to the ED the next day with pneumonia, with no documentation that the provider had been notified of the change in condition.
A resident receiving Medicare A benefits was not given an accurate SNFABN when coverage ended, and surveyors could not find documentation that the notice was provided. The NHA acknowledged the omission and stated the staff member responsible for completing beneficiary notices had not worked since September 2025, so the form was missed.
Missing Care Plans for Fluid Overload and Anticoagulation: A resident with complex respiratory, nutritional, and metabolic conditions returned from the hospital after fluid overload and was started on apixaban via G-tube BID for DVT. The care plan did not include problems or interventions for fluid overload, edema monitoring, or the new anticoagulation therapy, despite the order to monitor for anticoagulant side effects every shift.
Failure to revise a resident’s care plan after repeated refusals of nighttime ventilator use, trach suctioning, nebulizer treatments, and ordered fluid restrictions. The resident had chronic respiratory failure, COPD, a trach, and CHF, was cognitively intact, and was documented as noncompliant with fluids with associated weight gain and respiratory-related hospitalization/ED evaluation. The care plan was not updated to reflect the refusals, education, risk/benefit discussion, or alternative interventions.
A resident dependent on a ventilator was not connected to the stationary liquid oxygen tank as required, leading to their death. The facility failed to perform scheduled ventilator spot checks and did not document oxygen levels, resulting in a deficiency. Similar failures were noted for two other residents, indicating a systemic issue with adherence to respiratory care policies.
The facility failed to maintain proper sanitation and food handling practices by not having a separate handwashing sink, affecting 11 residents. Staff used a single sink for handwashing, food preparation, and dishwashing, contrary to FDA guidelines. Interviews revealed a lack of education on the need for separate handwashing facilities, and key personnel were unaware of this requirement.
The facility failed to maintain proper infection control practices, as CNAs did not perform appropriate hand hygiene and glove changes during resident care, leading to potential contamination. Additionally, two residents were observed with Foley catheter drainage bags resting on the floor, contrary to facility policy, increasing the risk of infection.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility did not notify the Ombudsman of resident transfers or discharges for 5 of 5 residents reviewed, including residents who were sent to the hospital or discharged from the facility. The facility was also unable to locate a policy related to Ombudsman notification for transfers. During interview, the Nursing Home Administrator stated he could not find documentation showing that the Ombudsman was notified of resident transfers and/or discharges and said the staff member responsible for Ombudsman notification had left in September 2025. Resident R7 had a change in condition and was transferred to the hospital. Resident R31, who was admitted with diagnoses including respiratory failure, ventilator dependence, and renal insufficiency/failure, was transferred to the hospital multiple times, and the medical record did not show Ombudsman notification for any of those discharges. Resident R20, admitted with diagnoses including acute respiratory failure, neuromuscular dysfunction, cranial injury, and ventilator dependence, was also transferred to the hospital multiple times without documentation of Ombudsman notification. Resident R33, admitted with Guillain-Barre Syndrome requiring ventilator assist via tracheostomy, was discharged home after successful weaning, and the record did not indicate Ombudsman notification. Resident R4, admitted with diagnoses including acute and chronic respiratory failure, malnutrition, diabetes with nephropathy, tracheostomy, and dependence on ventilator support, was hospitalized and the surveyor did not find documentation that the Ombudsman was contacted regarding the transfer.
Unsafe Food Handling and Storage Practices
Penalty
Summary
Food handling safety was not maintained in accordance with professional standards in the dietary department. During a kitchen tour, a cook fried eggs over easy for 3 residents' breakfast and did not check the temperature before serving them. The facility's policy stated that food temperatures would be checked on all items prepared in the dietary department, and the dietary director later agreed that all prepared cooked food should have a temperature taken to ensure it was cooked to a safe temperature before serving to residents. Additional observations showed multiple food storage and labeling issues. A brown neoprene lunch bag containing a staff member's personal lunch was stored in a resident refrigerator, cottage cheese was dished into bowls on a tray in the refrigerator without a label or date, cereal was served to a resident in their room without a cover, rectangular baking pans were stored on a bottom shelf not enclosed, covered, or inverted, and an open bag of macaroni was on a kitchen shelf without an open or use-by date. The dietary director stated staff were not to place personal lunch bags in the resident refrigerator and agreed that prepared food should be covered or dated and opened packaged foods should be dated with open or use-by dates.
Failure to Notify Provider of Respiratory Changes and Held Nebulizer Treatments
Penalty
Summary
The facility failed to immediately notify the resident’s physician when there was a need to alter treatment for two residents with respiratory conditions. The deficiency involved failure to report changes in condition and failure to notify the provider when nebulizer treatments were held or when respiratory status worsened. Facility policy and AMDA guidance reviewed by the surveyor stated that changes in condition warrant assessment and notification of the medical provider, and that acute or sudden symptoms or symptoms unrelieved by prescribed measures require immediate notification. For one resident, who was ventilator dependent and had diagnoses including chronic respiratory failure with hypoxia and hypercapnia, the record showed difficulty tolerating nebulizer treatments with increased dyspnea and shortness of breath. Nursing staff held ordered nebulizer treatments for two days, and the provider was not notified promptly of the resident’s condition change or the held treatments. Documentation showed episodes of shortness of breath during nebulizer administration, increased oxygen needs, and repeated holding of nebulizer treatments because the resident was not tolerating them. Interviews with nursing leadership and the medical director confirmed that provider notification was expected when medications were held or when respiratory changes could not be corrected in a timely manner. For the second resident, who was night ventilator dependent, had COPD, chronic respiratory failure, and a tracheostomy, the record showed an episode of gasping with oxygen saturation at 40%, resistance during bagging, and need for lavage and suctioning before oxygenation improved. There was no documentation that the provider was notified of this respiratory event. The next day the resident was transferred to the emergency room and diagnosed with pneumonia. Interviews with staff and leadership confirmed that no documentation could be provided showing provider notification for the respiratory change, and the DON acknowledged that the event would have required physician notification.
Failure to Provide SNFABN When Medicare Coverage Ended
Penalty
Summary
The facility did not provide an accurate Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to inform a resident of potential financial liability when Medicare Part A coverage ended. Record review showed that R7 was receiving Medicare A benefits and that coverage ended on 12/12/25, but surveyors could not find documentation that a SNFABN form was given to R7. During an interview on 04/14/26 at 1:13 pm, the Nursing Home Administrator acknowledged that R7 was not given a SNFABN form when benefits were about to end and stated that the person responsible for ensuring beneficiary notices were completed had not worked since September 2025, resulting in the form being missed for R7.
Missing Care Plans for Fluid Overload and Anticoagulation
Penalty
Summary
A comprehensive person-centered care plan was not developed for a resident with fluid overload and new anticoagulation medication administration after hospitalization. The resident was admitted with multiple diagnoses including acute and chronic respiratory failure with hypercapnia and hypoxia, malnutrition, diabetes with nephropathy, anxiety, gastrostomy status, tracheostomy, and dependence on a ventilator. The resident also had a history of restrictive lung disease secondary to post-polio syndrome, chronic hypoxic and hypercapnic respiratory failure, ventilator dependence via tracheostomy, malnutrition with PEG, and recurrent ventilator-associated pneumonia. The resident had fluid overload concerns with pitting edema when transferred to the hospital and was later re-admitted after being diuresed and placed on anticoagulation medication twice daily. The physician orders included apixaban 2.5 mg via G-tube two times a day for DVT, with monitoring for anticoagulant side effects every shift and documentation in a progress note if side effects were noted. Review of the care plan showed no problems or interventions related to the recent hospitalization for fluid overload or assessing for edema, and no problems or interventions related to the new anticoagulation therapy. The DON stated that both comprehensive care plans should have been in place.
Failure to Revise Care Plan for Refusals of Ventilator Use and Fluid Restriction
Penalty
Summary
The facility did not review and revise the person-centered comprehensive care plan for one resident, R13, after quarterly or comprehensive assessment reviews to reflect repeated refusals of nighttime ventilator use and noncompliance with fluid restrictions. R13 was admitted with diagnoses including dependence on a ventilator due to chronic respiratory failure with hypoxia and hypercapnia, COPD, tracheostomy, and chronic heart failure, and had a BIMS score of 15/15, indicating cognitive intactness and ability to make own health care decisions. The resident’s care plan, last revised on 02/19/2026, included goals and interventions related to nighttime ventilator dependence, weight maintenance, infection prevention, fluid restriction, tracheostomy suctioning, and tracheostomy care. Observation and record review showed R13 was not using the ventilator at night and was using portable oxygen during the day, and the resident stated, “I want to get out of here. I don't know why I have to have this trach in place. I don't need it.” Nursing documentation showed repeated refusals of tracheostomy suctioning, nebulizer treatments, and nighttime ventilator use since 01/26/2026, along with ongoing intake above the ordered fluid restriction and a 7.61% weight gain over 90 days. The resident had been hospitalized for respiratory complications from 01/30/2026 to 02/12/2026 and evaluated in the emergency department on 03/25/2026 for respiratory complications. The care plan did not include revised risk/benefit discussion, education related to the resident’s refusal of fluid restriction, or alternative interventions for refusal of suctioning, nebulizer treatments, or nighttime ventilator use.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen with ventilator support. Resident 1, who was ventilator-dependent, was not connected to the stationary liquid oxygen tank when put to bed, but instead remained on a portable oxygen tank that depleted overnight. The respiratory therapist did not perform the scheduled ventilator spot checks at 2:00 AM, and Resident 1 was found with low oxygen saturation and no pulse at 6:00 AM, leading to their death. Interviews with staff revealed that the portable oxygen tank was not checked for its oxygen level, and the stationary liquid oxygen tank was not brought into the resident's room as required by facility policy. The staff, including the respiratory therapist and certified nursing assistants, failed to follow the established procedures for ensuring the resident's oxygen supply was maintained. Additionally, there was a lack of documentation for the required spot checks, which were not completed as per the facility's policy. The deficiency was further evidenced by similar failures in the care of two other residents, who also did not have documented respiratory spot checks on multiple occasions. The facility's policies on oxygen administration and ventilator checks were not adhered to, resulting in a reasonable likelihood of serious harm and death for Resident 1. The facility's investigation into the incident was inadequate, with no proper documentation or staff education following the event.
Removal Plan
- RTs educated on expectation of completing oxygen checks and documentation/refusals of the 2am spot checks.
- CNAs educated on expectation of putting residents on stationary liquid tank when transferring to bed.
- Clinical staff educated on ensuring proper oxygen source prior to start of their next shift.
- Clinical staff educated on facility policy on oxygen administration prior to start of their next shift.
- Clinical staff educated on facility procedure for oxygen source switching prior to start of their next shift.
- Clinical staff educated on completing oxygen checks and completion of documentation/refusals as designated in the TAR.
- Clinical staff educated on oxygen safety check signs placed in resident rooms prior to start of next shift.
- Facility reviewed policy and procedure of oxygen administration and updated to include the use of stationary liquid tanks when oxygen dependent residents are in bed.
- Facility created a procedure for Oxygen Source Switching.
- Facility updated Liquid Oxygen Portable Fill policy to reference source switching procedure.
- Clinical Managers will conduct audits on oxygen checks.
- Clinical Managers will conduct audits on appropriate oxygen source connection.
- Results of the audits will be reviewed at QAPI meetings for further recommendations.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices, which could prevent the outbreak of foodborne illness. Specifically, the facility did not have a separate handwashing sink apart from those used for food preparation. This deficiency affected 11 residents. Observations revealed that staff members were washing their hands in a single sink used for multiple purposes, including food preparation and dishwashing. This practice was contrary to the FDA Code, which mandates that food employees clean their hands in a designated handwashing sink or approved automatic handwashing facility, not in a sink used for food preparation or warewashing. During interviews, staff members admitted to using the same sink for handwashing, food rinsing, and dishwashing, and they had not received education on the importance of separate handwashing facilities. The surveyor noted that water from handwashing could splash onto the countertop, and staff had to walk a short distance to obtain paper towels, potentially dripping water along the way. Additionally, the Robot Coup used for pureeing food was located close to the sink, further complicating the situation. The Dietary Manager, Nursing Home Administrator, and Director of Nursing were unaware of the requirement for separate handwashing sinks.
Infection Control Deficiencies in Hand Hygiene and Catheter Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use by Certified Nursing Assistants (CNAs) during personal care for a resident. CNA D was observed touching various surfaces and objects, such as a light switch, sink faucet, and dirty laundry bin, with gloved hands before proceeding to wash the resident's face and underarms without changing gloves or performing hand hygiene. Similarly, CNA C did not change gloves or sanitize hands after gloves were contaminated with bowel movement during peri care, and continued to provide care with the same contaminated gloves. Additionally, the facility did not adhere to its policy on urinary catheter management, as observed with two residents who had Foley catheter drainage bags resting on the floor. This practice contradicts the facility's policy, which states that catheter bags should not touch the floor to prevent catheter-associated urinary tract infections. The Director of Nursing acknowledged that the staff are expected to ensure the drainage bags are hung below the bladder but not touching the floor.
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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 Chippewa Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wi Veterans Home At Chippewa Falls | 1.5 mi | ★★★★★ | 0 | 0 |
| Chippewa Manor Nursing And Rehabilitation | 2.9 mi | ★★★★★ | 6 | 0 |
| Oakwood Health Services | 10.9 mi | ★★★★★ | 14 | 0 |
| Grace Lutheran Communities - River Pines | 10.9 mi | ★★★★★ | 3 | 0 |
| Dove Healthcare - West Eau Claire | 11.6 mi | ★★★★★ | 0 | 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.