Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dove Healthcare - West Eau Claire during CMS and state inspections, most recent first.
Failure to notify the Ombudsman of resident hospital transfers. The facility did not include several residents on monthly transfer notices, and records showed multiple hospital transfers with no documentation that the Ombudsman was informed. An SW stated the submitted lists were accurate but could not locate the residents on the documentation.
Failure to honor a resident's refusal of a Scopolamine patch. An MA attempted to apply the patch without first explaining the procedure, and the resident showed non-verbal signs of refusal by pulling away, shaking the head, and grimacing. Even after the resident indicated no, the MA held the resident's face and placed the patch anyway. RN stated these were signs of refusal, and the DON acknowledged the MA did not follow standards of care.
A resident’s comprehensive care plan was not updated after major changes in condition and treatment. The resident no longer had a trach and was eating orally on a fork-mashable texture with thin liquids, but the care plan still listed trach care interventions and tube feeding with a full liquid diet. Observation, interview with the family member, and record review confirmed the outdated plan, and the DON acknowledged the missed updates.
Improper Wound Care and Hand Hygiene During Sacral Pressure Injury Treatment: A resident with dementia, chronic respiratory failure, diabetes, sepsis history, and an existing stage 3 sacral pressure injury did not receive wound care consistent with professional standards. During dressing change, an RN entered without hand hygiene, placed supplies on an unsanitized end table among personal items, handled scissors with contaminated hands, and continued using contaminated gloves while cleansing, prepping, and dressing the open sacral wound.
The facility did not provide appropriate catheter care for two residents with indwelling catheters. One resident’s Foley tubing was observed unsecured and clipped to the bed sheet instead of being secured with a strap or stat lock, despite care plan and order requirements. Another resident with a suprapubic catheter had a leaking bag, urine on the floor mat and floor, and staff placed the bag in a pink basin on the floor or under the wheelchair; staff also reported the catheter bag and tubing had been changed for a leak, but this was not documented in the medical record.
A resident with dysphagia and a PEG tube was observed receiving medications through the tube before a documented RN assessment of tube placement was completed. The MA said a nurse had checked placement earlier, but the record had no assessment documentation, and the RN later stated they had not yet assessed the tube. The DON confirmed that only the RN is expected to complete the placement assessment before PEG medication administration.
Failure to Complete Required Pre- and Post-Nebulizer Assessments: An RN administered a nebulizer treatment to a resident with asthma and chronic respiratory failure but did not complete the required post-treatment respiratory assessment, and the surveyor did not observe the pre-treatment assessment being performed. The resident’s order required complete pre and post assessments, including lung sounds, RR, pulse, and O2 sat, and the DON stated RNs were expected to complete lung assessments within 15 minutes before and after nebulizer treatment.
Medication administration errors were observed for two residents. An MA administered Voltaren gel without measuring the ordered 4 grams and applied it to areas other than the ordered site. For another resident receiving meds via PEG tube, the MA crushed and mixed multiple medications with unmeasured water, caused medications to spill during preparation and administration, used inconsistent flush amounts between meds, and administered a sublingual medication through the tube. The DON acknowledged the practice was not professional standard of practice.
A CNA provided restorative care to a resident on EBP for an indwelling Foley catheter without wearing PPE. In a separate event, an MA administered meds via a G-tube to another resident while wearing the same gloves throughout multiple tasks and without hand hygiene, including after handling linens, touching surfaces, and before giving meds, removing a Scopolamine patch, and administering insulin.
The facility did not appoint a director of food and nutrition services who met the required qualifications. The Nutritional Services Director's only credential was a food safety manager certificate, which does not fulfill the certified dietary manager requirement. A Registered Dietician visits the facility periodically, but the director's qualifications were found lacking, potentially impacting all residents.
Staff failed to follow proper infection control and food safety procedures, including not allowing thermometer probes to air dry between food temperature checks, not performing hand hygiene between delivering water pitchers to residents, and not sanitizing hands or changing gloves appropriately when preparing and serving food. These actions resulted in unsanitary food handling and service for multiple residents.
A resident at moderate risk for pressure injuries did not receive consistent repositioning or heel off-loading as required by their care plan. Despite being non-ambulatory and dependent on staff for mobility, the resident was repeatedly observed with heels directly on the bed and without prescribed protective devices in place. Staff interviews revealed confusion about the use of heel protectors and repositioning schedules, and observations confirmed that interventions to prevent skin breakdown were not reliably implemented.
A CNA failed to provide required supervision and did not maintain care-planned fall prevention interventions for a resident with severe cognitive impairment and a history of multiple falls. The CNA removed the floor mat and body pillow and left the resident unattended several times while preparing for a shower, despite knowing the resident's high fall risk. Facility leadership confirmed that staff are expected to keep interventions in place and supervise such residents.
Surveyors found that medications, including prescription drugs, were left unsecured and unattended in several instances. An LPN left a medication cart unlocked and out of view with medications on top, while prescribed Nystatin powder was left in an unlocked drawer in a resident's room by a CNA. Staff confirmed that prescription medications should be kept locked unless in use by licensed personnel.
Staff failed to follow infection control protocols during wound care and personal care for several residents, including not performing hand hygiene before donning PPE, not disinfecting surfaces or equipment, and not changing gloves or sanitizing hands between tasks. These lapses were observed among an LPN and multiple CNAs, with staff acknowledging the failures when interviewed.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers to the hospital for 4 of 5 residents reviewed, including R76, R51, R30, and R1. Facility policy titled Transfer and Discharge, revised 11/2025, states that transfer notices will be provided to the Ombudsman and may be sent when practicable on a monthly basis if the notice meets content requirements. However, the surveyor found that the Ombudsman notification fax for March 2026 did not include R76 or R51, and the facility had no documentation showing that either resident was reported after their hospital transfers. For R30, the record showed multiple hospital transfers on 04/03/26, 04/11/26, 04/17/26, 05/15/26, 05/22/26, and 05/29/26, and the surveyor found no documentation that the Ombudsman was notified of any of these transfers. For R1, the record showed hospital transfers on 02/10/26 and 05/30/26, but the February and May 2026 Ombudsman notification faxes did not include this resident. During interview, the Social Worker stated the lists provided were accurate and included all residents transferred and discharged, but was unable to locate R76 or R1 on the submitted documentation and later stated that R76, R51, R30, and R1 were somehow not on the list and the Ombudsman was not notified of their transfers.
Failure to Honor a Resident's Refusal of a Scopolamine Patch
Penalty
Summary
The facility did not ensure a resident had the right to refuse a medication when Medication Aide H continued to place a Scopolamine patch on R76 despite non-verbal signs of refusal. During observation, MA H attempted to apply the patch behind R76's left ear without first explaining the procedure. R76 grimaced, pulled the head away, and jerked the head from side to side while MA H tried to place the patch. When MA H asked if it was okay to try again, R76 shook the head to indicate no. MA H then gently held R76's face with one hand and placed the patch behind the left ear with the other hand while R76 continued to pull away. During interview, MA H stated R76 does not usually refuse the patch and acknowledged the patch should have been explained before attempting placement or reapproaching. RN L stated that shaking the head, shutting the mouth, swatting away, and similar actions are non-verbal indicators of refusal, and that staff should educate the resident, reapproach if needed, and document any refusal. DON B was informed of the observation and acknowledged MA H did not follow standards of care and should have approached the situation differently.
Outdated Care Plan for Tracheostomy and Nutrition
Penalty
Summary
The facility did not ensure timely revisions to R66’s person-centered, comprehensive care plan after changes in condition and treatment. R66 had a tracheostomy removed and no longer had a trach, yet the care plan still included tracheostomy-related interventions such as securing trach ties. R66 also changed from receiving nutrition via gastrostomy tube and a full liquid diet to taking food orally on a fork-mashable texture with thin liquids, but the care plan continued to state that all nutrition was administered via tube feeding and that the resident was on a full liquid diet. During observation and interview, R66 was seen without a tracheostomy, and the family member stated the trach had been removed months earlier and that the resident now ate by mouth and required very soft food. Record review confirmed the outdated care plan entries for both tracheostomy care and nutrition. The facility’s policy required the comprehensive care plan to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and the DON acknowledged that the care plan updates had not been made despite multiple quarterly MDS assessments after the trach removal and diet change.
Improper Wound Care and Hand Hygiene During Sacral Pressure Injury Treatment
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. The facility did not ensure that one resident with a history of pressure injuries and current diagnoses including unspecified dementia, asthma, chronic respiratory failure, severe sepsis with septic shock, infection reaction due to an indwelling urethral catheter, type 2 diabetes mellitus, pressure ulcer of the sacral region stage 3, and benign prostatic hyperplasia received wound care consistent with professional standards of practice to prevent further deterioration and promote healing of an existing pressure injury on the coccyx/sacrum. The resident had a suprapubic Foley catheter in place prior to admission, was identified by MDS as at risk for pressure injuries with one stage 3 pressure injury, and had a care plan addressing a history of pressure injuries to the coccyx and heels and MASD to the buttocks, gluteal cleft, and upper thigh area. During observed wound care, the RN entered the resident’s room without hand hygiene, placed wound care supplies on the resident’s counter and then on the end table among personal belongings without sanitizing the surface or creating a barrier, and handled scissors with contaminated bare hands. The RN and CNA removed the sacral dressing, cleansed the wound, and then the RN continued with contaminated gloves while prepping the skin, cutting dressing material, and placing contaminated foam border material into the open sacral pressure injury before covering it with a Mepilex dressing. The RN later acknowledged missed opportunities to change contaminated gloves and sanitize hands, and the DON stated the RN should have sanitized hands before entering, sanitized or created a clean barrier on the end table, and doffed contaminated gloves before prepping the skin.
Catheter Securement and Leak Management Not Followed
Penalty
Summary
The facility did not ensure appropriate care for residents with indwelling urinary catheters to prevent complications or urinary tract infections. Two residents were identified with catheter care concerns: one resident with an indwelling Foley catheter and another resident with a suprapubic catheter. Facility policy stated that catheter tubing should be secured with a stat lock or leg secure device and that abnormal findings should be reported to the nurse and documented in the resident record. One resident was admitted with acute pyelonephritis and urinary retention and had an indwelling Foley catheter already in place. The resident’s care plan and orders called for a catheter securement device, including checking placement every shift and using a Foley strap instead of adhesive. During observation, the resident was found lying in bed with the Foley tubing not secured to the resident and clipped to the bed sheet instead. Staff told the surveyor different explanations, including that no securement device was used in bed because of adhesive irritation, while other staff stated a Velcro strap should have been in place. The DON also stated that a securement device should be in place. A second resident with diagnoses including dementia, chronic respiratory failure, severe sepsis with septic shock, infection reaction due to an indwelling urethral catheter, diabetes, and a stage 3 sacral pressure ulcer had a suprapubic catheter. The resident’s care plan required a stat lock or catheter securement device and checking proper placement every shift. Surveyors observed the catheter bag sitting in a pink basin under the wheelchair, later lying on the floor without a privacy bag, and urine odor in the room. Staff observed liquid dripping from the floor mat and described the mat as saturated with urine. Nursing staff reported that a pink basin had been used under the catheter bag as a barrier between the bag and the floor, and one RN stated staff sometimes used pink basins to keep catheter bags from touching the floor. The RN also reported that the catheter bag and tubing had been changed due to a leak, but this was not documented in the resident’s medical record.
PEG Tube Placement Not Verified Before Medication Administration
Penalty
Summary
The facility did not ensure that a resident with a PEG tube received the required assessment of tube placement before medications were administered through the tube. R76 was admitted with dysphagia following a cerebral infarction and had a PEG tube in place on admission for enteral feeding and medication administration. Facility policy stated that licensed nurses must verify tube placement before beginning a feeding and before administering medications, but on 06/09/26 a Medication Aide disconnected the tube feeding, attached a syringe to the PEG tube, and pulled back on the plunger to administer medications. During the observation, the Medication Aide stated that a nurse had assessed the PEG tube placement sometime before 7:00 AM, but the medical record did not contain PEG tube assessment documentation for that date. When interviewed later that morning, the RN stated they had not yet assessed the PEG tube placement and said a Medication Aide cannot administer medications via PEG tube without a nurse first completing the assessment. The DON also stated that only the RN can complete the assessment and that the expectation is for the nurse to do so before medications are administered via PEG tube.
Failure to Complete Required Pre- and Post-Nebulizer Assessments
Penalty
Summary
The facility did not ensure appropriate respiratory care was provided for one resident during nebulizer administration. The resident was re-admitted with diagnoses including unspecified dementia, asthma, chronic respiratory failure, severe sepsis with septic shock, infection related to an indwelling urethral catheter, type 2 diabetes mellitus, a stage 3 sacral pressure ulcer, and benign prostatic hyperplasia. The resident had orders for budesonide inhalation suspension via nebulizer twice daily for asthma, with instructions to ensure complete pre and post assessments, document lung sounds, respiratory rate, pulse, and oxygen saturation, and perform post-treatment evaluation. On observation, an RN entered the resident’s room with the nebulizer treatment, placed the mask on the resident, turned the machine on, and then exited the room, telling the resident the nurse would be back soon. The surveyor did not observe a pre-nebulizer assessment being performed. Later, a nursing support staff member entered the room, removed the nebulizer mask, and exited; the surveyor did not observe a post-nebulizer assessment. When interviewed, the RN stated a pre-treatment assessment had been completed but acknowledged that a post-treatment assessment was not performed. The RN also stated they usually return within 30 minutes after starting the nebulizer but did not do so. The DON stated the expectation was that RNs perform lung assessments within 15 minutes before and after nebulizer treatment.
Medication Administration Errors Involving Incorrect Dose, Route, and Tube-Feeding Technique
Penalty
Summary
Medication administration errors were observed for 2 of 4 residents, including incorrect dose, incorrect route, and inaccurate administration technique. For one resident, the medication aide administered Voltaren gel 1% without measuring the ordered 4 grams, instead placing two dime-size amounts on the aide’s gloved hand and rubbing the gel on the resident’s left hip, back of the neck, and bilateral shoulders rather than the ordered right shoulder. When questioned, the aide stated there was not a set amount and then acknowledged the dose should have been measured. For another resident receiving medications via gastrostomy tube, the medication aide crushed multiple medications and placed them in separate cups, including Hyoscyamine Sulfate oral tablet ordered sublingually. The aide added unmeasured water to dissolve the medications, used a syringe to flush and mix the medications in a way that caused splashing and spilling onto the table, the resident’s sheet, and a washcloth, and administered varying amounts of water between medications rather than the ordered flush amount. The aide stated the flush amount was about 10 mL, while the facility policy required at least 15 mL between medications and stated sublingual medication would not be administered through an enteral tube. The DON acknowledged the observed practice was not professional standard of practice and that, because of the spilling, there was no way to know exactly how much of each medication was administered.
Infection Prevention and Control Lapses During Resident Care and Medication Administration
Penalty
Summary
The facility did not provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents reviewed. One resident was on Enhanced Barrier Precautions related to an indwelling Foley catheter, and a CNA entered the resident’s room to perform restorative care without donning any PPE. When interviewed, the CNA stated they did not wear PPE for restorative care and thought PPE was only required for personal area care, although they also stated education for EBP had been provided. A second resident received medications via a G-tube while a medication aide wore gloves but did not change gloves or perform hand hygiene throughout the medication pass. The medication aide removed soiled linens from a bedside table, cleared items from the table, touched the bathroom handle to retrieve water, and unhooked the tube supplying nutrition to the G-tube before administering medications, removing an old Scopolamine patch, placing a new patch, and giving insulin. The medication aide stated they should have changed gloves and performed hand hygiene prior to medication administration and between each type of task. The DON acknowledged these events were not standards of practice and stated precaution education is provided upon hire, annually, and more often when needed.
Unqualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to designate a director of food and nutrition services who met the minimum qualification requirements for the position. During an interview, the Nutritional Services Director (NSD) stated that her only relevant training was an all-day certification course, and she provided a certificate from the National Registry Of Food Safety Professionals for International Food Safety Manager. The certificate did not meet the requirements for a certified dietary manager. The NSD confirmed she had no other schooling or training beyond this certificate. Although a Registered Dietician visits the facility a few times a week and is available daily, the NSD's qualifications were found insufficient according to regulatory standards. This deficiency potentially affected all 63 residents in the facility.
Failure to Maintain Sanitary Food Preparation and Service Practices
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner, as evidenced by multiple observations of staff not following established infection control and food safety procedures. One Nutritional Service Aide (NSA) was observed checking the temperature of multiple food items by wiping the thermometer probe with an alcohol prep pad and immediately inserting it into each food item without allowing the probe to air dry, contrary to facility policy which requires a 10-15 second drying period. The Nutritional Service Director confirmed that this practice could potentially contaminate the food being served to all residents. Additionally, another NSA was observed delivering water pitchers to residents without performing hand hygiene between rooms. The aide handled both clean and used water jugs, placing used jugs on the clean water cart, and did not sanitize hands between resident rooms as required by facility policy. The aide admitted to not being trained to sanitize hands between passes, but acknowledged the importance of the practice when questioned. Further observations revealed that an NSA preparing and serving food did not perform proper hand hygiene between glove changes and frequently touched contaminated surfaces, such as their face, glasses, and mask, with gloved hands before handling ready-to-eat foods. The aide also failed to use tongs as required and did not sanitize hands between removing and donning new gloves. The Nutritional Service Director confirmed that staff are expected to sanitize hands between glove changes and after contact with contaminated surfaces.
Failure to Consistently Reposition and Off-Load Heels for At-Risk Resident
Penalty
Summary
A deficiency was identified when a resident at moderate risk for pressure injury development did not receive care consistent with professional standards to prevent skin breakdown. The resident, who was non-ambulatory and required total assistance for bed mobility and repositioning, was observed multiple times over two days lying supine in bed with heels directly on the mattress. Despite care plan interventions that included the use of an air mattress, heel off-loading with Podus boots, and scheduled repositioning, the resident's heels were not elevated, and the Podus boots were consistently found in the wheelchair rather than on the resident. Staff interviews revealed uncertainty and inconsistency regarding the use of Podus boots and the frequency and adequacy of repositioning. Certified Nurse Assistants and Registered Nurses were unsure about the specific requirements for heel off-loading and did not consistently implement the care plan interventions. Observations confirmed that the resident was not repositioned as scheduled, and when repositioning was attempted, it was insufficient to fully off-load pressure from the sacrum and heels. The facility's policy required regular repositioning and heel off-loading for residents at risk of pressure injuries, but these interventions were not reliably provided. Staff acknowledged gaps in their knowledge and practice, and documentation did not reflect consistent adherence to the care plan. The resident remained at risk for pressure injury development due to these lapses in care.
Failure to Maintain Fall Prevention Interventions and Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to provide adequate supervision and did not follow care-planned fall prevention interventions for a resident with a high risk of falls. The resident had a history of multiple falls, severe cognitive impairment, dependence on staff for bed mobility and transfers, and diagnoses including encephalopathy and psychological disorders. The resident's care plan and CNA safety precautions required the bed to be kept low, a floor mat to be in place on the exit side, and pillows for positioning to minimize fall risk. During the observed incident, the CNA removed the floor mat and body pillow from the resident's bedside and left the resident unattended multiple times while preparing for a shower, despite knowing the resident's fall history and risk factors. The CNA was observed leaving the resident's bedside to gather supplies, empty a urinal, and obtain clothing, leaving the resident without the prescribed fall prevention interventions in place. The resident was seen moving and rolling in bed toward the side where the mat had been removed, increasing the risk of a fall. The CNA acknowledged awareness of the resident's fall risk and the importance of the interventions but did not maintain supervision or ensure the interventions were in place when away from the bedside. Facility leadership confirmed that staff are expected to keep fall interventions in place and remain at the bedside for residents at high risk of falling.
Failure to Secure and Properly Store Medications
Penalty
Summary
Surveyors observed multiple instances where drugs and biologicals were not stored or labeled according to accepted professional principles. In one instance, an unlocked and unattended medication cart was found in a hallway with resident-specific medications, including Famotidine, left on top of the cart. The responsible LPN was not in the vicinity and could not see the cart from their location, leaving the medications unsupervised and accessible to unauthorized individuals. Additionally, staff walked by the unattended cart without addressing the unsecured medications. Further observations revealed that prescribed Nystatin powder was left unattended in a resident's room on two separate occasions. A CNA was seen returning Eucerin cream and prescribed Nystatin powder from a bath house and placing them in an unlocked drawer in the resident's room, despite a lockable drawer being available. The CNA explained that only nurses had access to the locked drawer. Upon review, a nurse tech confirmed that the prescribed medication should have been secured in the locked drawer and subsequently moved it there. The nurse manager stated that prescription medications in resident rooms are expected to be kept locked at all times unless being used by licensed staff.
Failure to Maintain Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff caring for residents with wounds and those on Enhanced Barrier Precautions. In one instance, an LPN did not sanitize hands before entering a resident's room, failed to disinfect the bedside table before placing wound care supplies, and used contaminated scissors from a scrub pocket to cut wound dressing material, which was then applied directly to the resident's wound. The LPN acknowledged not following proper procedures, including not sanitizing equipment or surfaces as required. Further observations revealed improper hand hygiene during wound and personal care. A CNA, after assisting a resident with incontinence and wound care, did not change gloves or perform hand hygiene before continuing with other tasks such as dressing the resident and using a Hoyer lift. The CNA also failed to use hand sanitizer or wash hands after removing gloves and before donning new gloves, contrary to facility policy. The CNA later acknowledged the lapse when questioned by the surveyor. Another CNA was observed providing care to a resident on Enhanced Barrier Precautions due to a feeding tube, but did not perform hand hygiene before donning PPE or between glove changes while handling soiled linens and preparing the resident for a shower. The CNA admitted to the oversight when interviewed. The facility's Infection Control Preventionist confirmed that the expectation is for staff to perform hand hygiene prior to donning PPE and between glove changes to minimize the spread of organisms.
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Illustrative
What surveyors actually found near you
We read the 77 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eau Claire
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grace Lutheran Communities - River Pines | 4.1 mi | ★★★★★ | 3 | 0 |
| Oakwood Health Services | 4.2 mi | ★★★★★ | 14 | 0 |
| Dove Healthcare - South Eau Claire | 5.1 mi | ★★★★★ | 0 | 0 |
| Chippewa Manor Nursing And Rehabilitation | 8.9 mi | ★★★★★ | 6 | 0 |
| Wi Veterans Home At Chippewa Falls | 10.6 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 August 2026) and official state health department websites.