Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Grace Lutheran Communities - River Pines during CMS and state inspections, most recent first.
Failure to communicate reason for ED transfer: A resident with multiple diagnoses, including dementia, CHF, COPD, CKD, and DM2, was sent to the ED after an unresponsive episode. The record documented the resident was unresponsive but breathing, with the POA updated, yet there was no documentation that the facility communicated the reason for transfer to the ED. The DON stated the hospital was notified of another unresponsive episode, but no record of the communication was found.
Failure to Complete Assessments and Coordinate Hospice Care Plans: The facility did not document a full assessment, SBAR, provider notification, or re-admission assessment for a resident after an unresponsive episode and hospital transfer. For two residents on hospice, the care plans and documentation did not align with end-of-life preferences, shower frequency, or transfer equipment needs; staff and hospice relied on verbal communication, and one resident was observed in the wrong Hoyer sling size.
The facility failed to appoint a qualified director for food and nutrition services, affecting all 46 residents. The Dietary Manager has been in the role for over two years without certification, and the facility lacks a full-time RD, relying on contracted services without ensuring 35 hours per week of RD presence.
The facility failed to monitor and ensure proper sanitization of dishware, affecting all 46 residents. Logs showed sanitizer levels were out of range, and staff used incorrect test strips, leading to inaccurate readings. The Dietary Manager was unaware of the issue until the surveyor's inquiry, revealing a failure to report and act on out-of-range results.
A facility failed to implement a restorative care plan for a resident with limited range of motion (ROM). The resident, with conditions including post-polio syndrome and osteoarthritis, had a care plan that was not updated to include a new restorative order. The Treatment Administration Record lacked documentation of exercises, and the Director of Nursing could not find evidence of the program being followed. The resident reported not receiving therapy, and staff indicated that the Kardex did not reflect the updated orders.
A resident with multiple sclerosis and paraplegia was not provided with required lids on cups during meals, leading to spills. Despite a care plan indicating the need for lids to prevent accidents, the resident was observed with uncovered cups during breakfast and lunch. Staff confirmed the oversight, acknowledging the necessity of lids to prevent spills.
A resident with gangliosidosis and quadriplegia received improper pharmaceutical services when an LPN administered an Advair inhaler with only a 10-second interval between puffs, instead of the required 30 seconds. The LPN acknowledged the error but cited the resident's fast breathing as justification. The DON confirmed the correct procedure was not followed.
Failure to Communicate Reason for ED Transfer
Penalty
Summary
The facility did not ensure that appropriate information was communicated to the receiving health care institution or provider for one resident who was transferred to the hospital emergency department. The resident had diagnoses including displaced trimalleolar fracture of the right lower leg, anemia, congestive heart failure, mild cognitive impairment, COPD, chronic kidney disease stage 3B, restless legs, depression, type 2 diabetes mellitus, and dementia. The resident's record documented that on 05/03/2026 at 9:25 PM, the resident was transferred to the ED for evaluation after an unresponsive episode, was noted to be unresponsive with a heartbeat and active respirations at 7:20 PM, had a last known well time of 6:15 PM, and the POA was updated. The note also stated the resident was not tracking with eyes, unable to verbalize responses to questions, or follow commands. The resident's medical record did not document communication with the hospital ED about the reason for the transfer. During interview, the DON stated the hospital was notified of the resident having another unresponsive episode, but the DON did not have access to the agency nurse's documentation. The DON also stated there was a discharge packet and that nurses fax the communication sheet to the ED with resident information and the reason for transfer, but the DON looked in the hospital record system and did not find documentation of the facility's communication to the hospital regarding the resident's reason for transfer.
Failure to Complete Assessments and Coordinate Hospice Care Plans
Penalty
Summary
The facility did not ensure that residents received care and treatment in accordance with assessments, professional standards of practice, and care plans. The report identified failures involving a resident who had diagnoses including displaced trimalleolar fracture of the right lower leg, anemia, CHF, COPD, CKD stage 3B, diabetes, dementia, and mild cognitive impairment; a resident with severe neurologic and respiratory conditions who was dependent on staff for all ADLs; and a resident with dementia, stroke history, HF, and respiratory failure who was receiving hospice services. For the resident who had an unresponsive episode and was transferred to the ED, the record did not document a full assessment with vital signs, SBAR communication, provider notification, or orders at the time of transfer. The record also did not document the resident’s diagnosis and admission to the hospital. When the resident returned from the hospital, the record did not document a full re-admission assessment, discharge diagnoses, or vital signs. The DON stated she could not find a completed assessment with vitals, provider notification, orders, SBAR, or an assessment upon re-admission, and said she would expect an admission assessment to be completed. For the resident on hospice with a terminal prognosis, the care plan did not address the resident’s choices, preferences, and goals near end of life regarding pain management, symptom control, treatment of acute illness, and hospitalization decisions. The hospice communication book documented showers and bedding changes, but it did not include the hospice care plan. The DON stated communication with hospice was verbal and that the facility did not compare care plans to confirm they were the same. For the resident receiving hospice services with facility and hospice care plans, the documentation did not support that the resident received a shower twice weekly as care planned. The facility care plan stated the resident was totally dependent on mechanical transfer and required an extra large sling for showering, while the hospice aide care plan stated bathing every visit with a two-assist hoyer lift transfer. Surveyor observation found the resident in a large sling even though the care plan indicated an extra large sling. Hospice aides and facility CNAs described verbal communication only, and hospice staff were not sure why the hospice care plan indicated showers every visit when they only showered the resident once weekly. The hospice RN stated she did not realize the hospice care plan indicated showers twice weekly. The facility and hospice documentation did not support that the resident was receiving showers twice weekly, and the hospice care plan did not document the sling size.
Deficiency in Food and Nutrition Services Management
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services, which has the potential to affect all 46 residents. The Dietary Manager (DM) has been in the position for over two years but has not completed the necessary steps to become certified. Although the DM enrolled in a course in August 2022, she did not pass the certification exam taken in October 2024 and was planning to retake it after the 90-day waiting period. The facility does not have a full-time Registered Dietician (RD) on-site, and RD services are contracted, with uncertainty about whether the RD is present for at least 35 hours per week. Interviews with the DM and the Nursing Home Administrator (NHA) revealed that the DM lacks the required certification and that the facility does not have a waiver for dietary management. The NHA confirmed that the DM started her role in August 2022 and has been in the position for nearly two and a half years. The NHA also acknowledged that the facility does not have 35 hours per week of RD services, as the RD covers multiple buildings. This lack of qualified personnel and insufficient RD services led to the deficiency identified by the surveyors.
Dishwasher Sanitization Monitoring Failure
Penalty
Summary
The facility failed to properly monitor and ensure the correct sanitization of dishware using their dishwasher, which could potentially affect all 46 residents. The deficiency was identified through interviews, record reviews, and observations. The facility's protocol required staff to report if the wash temperature was less than 110°F, the rinse temperature was less than 120°F, or if the sanitizer test strip did not reach between 50-100 ppm. However, the logs showed that for 7 out of 31 days in January and 9 out of 26 days in February, the sanitizer levels were out of range, testing at 150 ppm, which is above the safe range. During the survey, it was discovered that the staff were using the incorrect test strips to measure the sanitizer levels, which led to inaccurate readings. The Dietary Manager was unaware of the out-of-range results and had not taken any steps to address them until the surveyor's inquiry. The issue was identified when the Dietary Manager demonstrated the use of the test strips and found that the chlorine test strips had been mistakenly switched with iodine test strips, leading to incorrect readings. This oversight in using the correct test strips resulted in the failure to report and act upon the out-of-range sanitizer levels as per the facility's protocol.
Failure to Implement Restorative Care Plan for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the necessary services to maintain or prevent further reduction in ROM. The resident, who was admitted with diagnoses including post-polio syndrome, osteoarthritis, and shoulder pain, had a restorative care plan from therapy that was not implemented. The resident's care plan, last updated in July 2024, did not include the restorative order from January 2025, and the Treatment Administration Record (TAR) for January and February 2025 did not document the completion of the prescribed exercises. Interviews and observations revealed that the resident was not receiving the restorative program as ordered. The Director of Nursing (DON) was unable to find documentation of the exercises being performed and acknowledged that the process was not being followed. The Certified Nursing Assistant (CNA) stated that the Kardex, which guides CNAs on resident care, did not reflect the updated restorative orders, and the exercises were not being conducted due to the resident's sleeping arrangements. The resident also reported not receiving therapy or a restorative program and expressed a belief that they would not benefit from the exercises.
Failure to Provide Assistive Devices During Meals
Penalty
Summary
The facility failed to provide necessary assistive devices during meals for a resident, identified as R2, who was assessed to require lids on cups to prevent spills. R2, who has multiple sclerosis, hypertension, paraplegia, and weakness, was observed during two separate meal times without the required lids on their cups, despite having a care plan and dietary note indicating the need for such assistive devices. During breakfast, R2 was seen with three coffee cups without lids and subsequently spilled coffee on themselves due to shaking movements. Staff responded by cleaning the spill and offering to change R2's pants, which R2 declined. Further observations during lunch revealed that R2 again received cups without lids. Interviews with the Life Enrichment staff and the Director of Nursing confirmed the absence of lids on R2's cups, which contradicted the care plan's requirements. The Director of Nursing acknowledged the oversight and confirmed that R2 needed lids to prevent spills, indicating a failure in adhering to the care plan designed to prevent accidents.
Improper Administration of Advair Inhaler
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident, specifically in the administration of an Advair inhaler. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had diagnoses of gangliosidosis and quadriplegia. During an observation, an LPN administered two puffs of the Advair inhaler to the resident with only a 10-second interval between puffs, contrary to the instructions which required a 30-second wait. When questioned, the LPN acknowledged the need for a longer wait but justified the action by stating the resident breathes fast. The Director of Nursing later confirmed the correct procedure should have included a 30-second wait between puffs.
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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 Altoona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakwood Health Services | 0.1 mi | ★★★★★ | 14 | 0 |
| Dove Healthcare - South Eau Claire | 2 mi | ★★★★★ | 0 | 0 |
| Dove Healthcare - West Eau Claire | 4.1 mi | ★★★★★ | 0 | 0 |
| Chippewa Manor Nursing And Rehabilitation | 8.1 mi | ★★★★★ | 6 | 0 |
| Wi Veterans Home At Chippewa Falls | 9.6 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.