Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Oakwood Health Services during CMS and state inspections, most recent first.
Failure to Document and Provide Non-Pharmacological Pain Interventions: A review of 7 residents found no documentation that ordered non-drug pain interventions were attempted, despite pain care plans and physician orders calling for measures such as heat, cold, positioning, massage, and distraction. Several residents reported ongoing pain, one resident said pain meds were delayed, another said the facility ran out of oxycodone, and staff interviews confirmed the interventions were not consistently offered or documented.
Failure to assess and supervise medication self-administration: A cognitively intact resident with sacral fracture, osteoporosis, and unsteadiness had medications left at the bedside without a self-administration assessment or provider order. Surveyors observed the resident asleep with a med cup on the table, and the resident later said she wanted to know what she was taking because some meds were making her dizzy. An LPN admitted she did not verify the resident swallowed the pills, and the DON confirmed an assessment and provider order were required.
A resident was not fully informed of medication names and related information before an RN administered meds. During a med pass, the resident said the meds had been changed so much that the resident did not know what was being taken, reported dizziness, and asked what a pill was. The RN could not accurately identify the medication, gave conflicting information about losartan vs torsemide, and continued the med pass while the resident also had a nosebleed.
Missing Background Screening for Newly Hired LPN: Record review and interview showed the facility did not complete required background screening for an LPN before the employee began working. The BID showed prior residence in Minnesota, but no Minnesota background check or updated BID was found, and the NHA stated the background had been missed because of role changes in the facility.
Improper Suprapubic Catheter Positioning and Drainage: A resident with MS, neurogenic bladder, and a suprapubic catheter had catheter tubing observed above bladder level in a Broda chair, looped off the side of the bed, and attached to a Hoyer lift hook above bladder level during transfer. Two CNAs provided catheter care, and urine poured into the drainage bag when the tubing was moved onto the bed. The DON stated the tubing should allow urine to flow freely into the bag, and the resident had recently been treated for a UTI.
Dialysis Residents Not Weighed Before Treatments: The facility did not ensure ongoing pre-dialysis assessment and weight monitoring for two residents receiving HD. Both residents had ESRD and related chronic conditions, with orders for pre- and post-dialysis assessments and weights before and after treatments, but staff used the previous dialysis day's weight instead of obtaining a current pre-dialysis weight. Interviews showed CNA and RN uncertainty about the timing of weights, and the DON acknowledged the expectation for full vitals, including weights, before and after dialysis.
A surveyor found a resident’s opened Roxanol bottle in the narcotic box with no open date label on the medication cart. The MA confirmed opened liquid controlled substances should be labeled, and the DON stated that all opened liquid bottles are expected to have an open date so staff can track expiration and reconcile controlled substances.
Failure to provide ordered adaptive eating equipment was identified for a resident with dementia, stroke, dysphagia, diabetes, and severe cognitive impairment. During lunch, the resident was observed using a divided plate with regular cup and utensils while being fed by a CNA, despite the care plan and dietary card indicating the need for a nosey cup and built-up utensils. The CNA later confirmed the resident was supposed to have the adaptive items, and the Dietary Manager stated staff should follow the residents' tickets.
An infection prevention and control deficiency occurred during a resident's wound vac dressing change when an LPN wiped stool from the resident's uncovered colostomy stoma and then continued care without changing gloves or performing hand hygiene. The open end of the suction tubing had been lying on the floor, but it was reconnected to the wound vac without being cleaned or disinfected first; the DON stated the tubing should have been cleaned before reconnection.
A resident with cognitive impairment and right-sided paralysis was transferred using a large Hoyer lift sling instead of the care planned medium size, despite clear documentation and recent staff education. The error was discovered during a surveyor observation, and the CNA confirmed the care plan requirements had not been followed.
A resident with Parkinson's disease was subjected to a straight catheterization against her will, resulting in immediate jeopardy. Despite her objections, an RN and two CNAs proceeded with the procedure, holding her down while she cried and resisted. The resident did not meet the facility's criteria for a urine culture, as she did not have a fever. The incident was reported to law enforcement and APS, and the resident was transferred to a hospital after expressing feelings of unsafety.
The facility failed to establish an effective Infection Control Program, leading to deficiencies in infection prevention and control practices. Incomplete infection control logs, improper use of PPE, and inadequate hand hygiene were observed. A resident was placed on prolonged contact precautions without justification, and Enhanced Barrier Precautions were not implemented for a resident with an indwelling catheter. These actions indicate a lack of adherence to infection control protocols, potentially affecting all residents and staff.
A resident with intact cognition and a desire to smoke was not provided a person-centered care plan addressing his smoking preferences. Despite the facility's policy allowing smoking in designated areas, the resident's care plan lacked specific interventions, leading to frustration and negative behaviors. Staff were unable to consistently accommodate the resident's smoking requests due to time constraints, impacting the resident's quality of life.
A resident with limited ROM did not receive documented ROM exercises as per their care plan. Despite staff claims of performing exercises, no documentation was found. The DON acknowledged the lack of documentation, and the NHA noted gaps in the restorative program.
A resident with mobility issues and a risk for falls was transferred without the use of a gait belt, contrary to facility policy. The CNA assisting the resident did not use a gait belt, instead holding the resident's pant waist band and underarms. Interviews with staff revealed that the use of a gait belt is expected during transfers, but the CNA was not instructed to do so, highlighting a communication gap in policy adherence.
The facility failed to provide appropriate pressure ulcer care for two residents, leading to the development of severe pressure injuries. One resident developed an unstageable pressure injury and sepsis due to lack of notification and intervention, while another resident's care plan was not followed, resulting in unaddressed pressure injury risks. The deficiency was marked by inadequate communication, documentation, and implementation of care plans.
A resident with multiple health issues developed a deep tissue injury and experienced changes in vital signs, including tachycardia and low blood pressure, without the facility notifying the physician. The resident's condition, which included a pressure injury and potential signs of sepsis, was not communicated to the physician until the resident was sent to the emergency room.
The facility failed to implement an effective Infection Control Program, resulting in a scabies outbreak affecting staff and residents. Infected staff continued working across multiple units, spreading the infection. The facility lacked timely documentation and contact precautions, and did not conduct comprehensive skin assessments. Leadership was unaware of the outbreak's extent, delaying surveillance and treatment efforts.
A resident with a history of constipation was admitted to a facility and did not receive appropriate bowel management care. Despite having orders for medications like MiraLAX and Senna Plus, and standing orders for Milk of Magnesia, Bisacodyl suppository, and Fleets enema, there was no documentation of these being administered. The facility lacked a bowel management policy and did not conduct a formal bowel assessment. The resident expressed feeling constipated and refused a bedpan, preferring other options that were not documented as given. The resident was transferred to the hospital after not having a bowel movement for four days.
A resident at high risk for dehydration did not have their fluid intake properly calculated or monitored by the facility. Despite being on a diuretic and having a history of conditions that increase dehydration risk, the resident's fluid intake was significantly below the recommended levels. Interviews with staff confirmed the lack of assessments to ensure adequate hydration.
Failure to Document and Provide Non-Pharmacological Pain Interventions
Penalty
Summary
Safe, appropriate pain management was not provided for 7 of 7 residents reviewed (R7, R11, R39, R41, R44, R70, and R74). The facility’s pain management policy required pain management to be consistent with professional standards, the comprehensive person-centered care plan, and residents’ goals and preferences, and it listed non-pharmacological interventions such as heat, cold, positioning, massage, music, relaxation, and distraction. For each of the seven residents, survey review found no documentation that non-pharmacological pain interventions were attempted, despite physician orders directing staff to document those interventions. R74, who was cognitively intact and had diagnoses including chronic kidney disease with heart failure, congestive heart failure, lymphedema, and peripheral venous insufficiency, reported chronic pain in both knees and legs and stated no non-pharmacological interventions had been offered since admission. R44, also cognitively intact and diagnosed with peripheral vascular angioplasty with implants and grafts, polyneuropathy, and stroke history, reported the facility ran out of oxycodone and that he was not aware diclofenac gel was available because it had never been offered. The record showed the TAR was blank for non-pharmacological interventions and the diclofenac gel was never administered. A progress note documented that R44 was out of oxycodone and awaiting a new script. R11, R39, R70, and R7 also had pain-related assessments, care plans, and physician orders that included non-drug interventions, but the records contained no documentation that those interventions were carried out. R11 reported neck and back pain after a fall, with pain ranging from 3 to 9 on a 0 to 10 scale, and the March records showed blank areas for non-pharmacological interventions. R39 reported daily sacral pain after a fracture, with pain ranging from 4 to 7, and the record showed no documentation of non-drug therapies despite care plan directions to implement them. R70 had a fractured right wrist in a hard cast and reported pain up to 10 out of 10, yet no non-pharmacological interventions were documented. R7, who was cognitively intact and had chronic leg pain, stated pain medication had changed from scheduled to PRN and that if he did not watch the clock his pain became intolerable; the TAR and other records contained no documentation of non-pharmacological pain interventions. R41’s care plan included hot or cold therapy and repositioning for generalized pain and restless legs, but staff stated those interventions were not being offered and the MAR/TAR did not contain the order. Staff interviews reflected that nurses and aides expected pain assessments and non-pharmacological interventions to be documented, but the records reviewed did not show that this occurred.
Failure to Assess and Supervise Medication Self-Administration
Penalty
Summary
The facility failed to determine safe self-administration of medications for one resident who was cognitively intact but had diagnoses including sacral fracture, age-related osteoporosis, and unsteadiness on her feet. The resident did not have an assessment for self-administration and did not have a physician's order permitting self-administration, even though facility policy required both a prescriber’s order and appropriateness for safe self-administration. Surveyors observed a cup of medications on the resident’s bedside table while she was asleep in her chair, and the resident did not wake when the surveyor knocked on the open door. During the observation, the resident had three pills in the medication cup and later stated she was concerned and wanted to know what the medications were because some were making her dizzy. The LPN identified the medications as vitamin D, Senna plus, and torsemide, and the resident then took them one at a time. The LPN stated she had not gone through the resident’s medications when giving them that morning and admitted she did not know whether the resident had spit them out, saying she probably should have stayed and watched to make sure the resident swallowed them. The resident also stated she had told several nurses she wanted to know what she was taking and preferred to take medications with applesauce, one pill at a time. The DON stated residents who request to self-administer medications require a provider order and an assessment, and agreed nursing staff should explain medications when asked and ensure residents take their oral medications.
Failure to Inform Resident of Medications Before Administration
Penalty
Summary
The facility did not ensure that one resident was fully informed of resident rights, medication information, and options before medications were administered. During a medication administration observation, RN N entered the resident’s room and placed medications on the table. The resident asked for applesauce, stated that chocolate pudding was not wanted, and said the resident did not want to take medications because the resident did not know what medications were being taken. The resident reported that medications had been changed so much that the resident no longer knew what was being taken and stated that something was causing dizziness, which had already been reported to staff. RN N told the resident that a list of medications could be made but that the nurse could not leave until the medications were taken. The resident then took medications one at a time, dropped two pills on the floor, and asked what one of the pills was. RN N said the medication was not entirely known but thought it was losartan, even though the surveyor later clarified that losartan was not the medication being administered and that the order for losartan was at bedtime, not in the morning. RN N then stated the pill must have been torsemide. The resident also began having a nosebleed during the medication pass. RN N later acknowledged that the resident should have been educated before taking the medications, and the DON stated that RN N should have printed the MAR and educated the resident before administering medications.
Missing Background Screening for Newly Hired LPN
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after record review and interview showed the facility did not ensure employees were screened for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility policy stated that before new employees are permitted to work with residents, prospective employees' backgrounds will be checked and a criminal background check will be conducted. Surveyors reviewed 8 random staff Background Information Disclosures and found that LPN M, hired on 01/29/26, had a BID dated 09/13/24 showing a prior residence in Minnesota from 2001 to 2021, but no Minnesota background check was found before LPN M began working at the facility. Surveyors also did not find an updated BID form for the facility to run an updated background check upon hire. During interview, the NHA stated that the Minnesota background was missing because of role changes in the facility and said the background would be completed that day because it had not been performed on the hire date.
Improper Suprapubic Catheter Positioning and Drainage
Penalty
Summary
Appropriate care was not provided to prevent UTIs for a resident with a suprapubic catheter. The resident had diagnoses including multiple sclerosis, urinary retention, bladder dysfunction, cystostomy, and a history of MRSA, and was dependent on staff for toileting and catheter management. The resident’s MDS showed moderately impaired cognition with a BIMS score of 6 out of 15, and the care plan identified the need for an indwelling suprapubic catheter due to neurogenic bladder secondary to MS. The facility policy stated drainage bags were to be located below bladder level to discourage backflow of urine. During observations, the resident’s catheter tubing was seen above bladder level while the resident was in a Broda chair and hanging in a coil that would not allow proper drainage. Later, the tubing was observed below bladder level but looped off the side of the bed and not looped on top of the bed to allow adequate drainage, with the clip not secured. During morning care, two CNAs provided suprapubic catheter care, and when the tubing was moved onto the bed, a significant amount of urine poured into the drainage bag. After the resident was transferred with a Hoyer lift, the drainage bag was attached to the top hook on the lift approximately 1 1/2 feet above the resident’s bladder, then clipped by the foot of the Broda chair with the tubing coiled in a downward loop. The CNA stated it probably would not drain well, then repositioned the bag under the seat of the chair so urine could flow freely. The record also showed the resident had been treated for a UTI with Cipro from 1/9/26 to 1/19/26.
Dialysis Residents Not Weighed Before Treatments
Penalty
Summary
Provide safe, appropriate dialysis care/services for residents who require such services was not met when the facility did not ensure ongoing assessment of residents' conditions and monitoring for complications before dialysis treatments for 2 of 2 residents reviewed. The facility policy for hemodialysis stated that care would include ongoing assessment before and after dialysis treatments and nutritional/fluid management including documentation of weights. For one resident, admitted with hypertensive heart and chronic kidney disease with heart failure, stage 5 chronic kidney disease/end stage renal disease, and dependence on renal dialysis, orders required pre-dialysis assessment and weights before and after dialysis on Mondays and Fridays. Survey review showed weights were not obtained before dialysis appointments and the previous dialysis day's weight was used instead, although weights were obtained after return from dialysis. A second resident, admitted with hypertensive heart and chronic kidney disease with heart failure, stage 5 chronic kidney disease/end stage renal disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and dependence on renal dialysis, had orders for pre-dialysis assessment and weights before and after dialysis on Mondays, Wednesdays, and Fridays. Survey review showed the same pattern: no pre-dialysis weights were obtained and the previous dialysis day's weight was used in place of a new one, while post-dialysis weights were obtained after return. During interviews, a CNA stated she was not sure when dialysis residents were weighed, an RN stated pre- and post-dialysis assessments were to be completed but was unsure whether one or both residents required a weight before dialysis, and the DON acknowledged that the expectation was for full vital signs including weights before and after dialysis appointments.
Unlabeled Open Roxanol Bottle
Penalty
Summary
The facility did not ensure drugs and biologicals were labeled with an open date and expiration date in accordance with accepted professional principles for one resident, R11. During observation of the Aspen unit medication cart, the surveyor found R11’s Roxanol 20 mg/ml liquid bottle in the narcotic box opened with no open date label. The Medication Aide confirmed that liquid controlled substances should be labeled with an open date and reviewed R11’s MAR, noting that R11 had received a second dose of Roxanol at 3:00 AM that day. The DON later stated that all opened liquid bottles are expected to be labeled with the open date so staff know when they expire and can reconcile controlled substances, and acknowledged that the bottle should have been labeled when opened.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
Provide special eating equipment and utensils for residents who need them and appropriate assistance was not done for 1 of 17 residents reviewed, R14. R14 required a divided plate, built-up utensils, and a nosey cup, but during lunch R14 was observed using a divided plate, regular cup, and regular utensils while being fed by CNA K. R14 was admitted with diagnoses including dementia, stroke, abnormal posture, dysphagia, and diabetes, and had a most recent BIMS score of 0 of 15, indicating severe cognitive impairment. R14's care plan, revised 01/27/26, identified risk for nutritional status due to diabetes and dementia and included interventions for set up assistance and use of a divided plate, nosey cup, built-up utensils, and clothing protector. The dietary card also noted adaptive equipment of a divided plate, nosey cup, and built-up utensils. When asked, CNA K confirmed R14 was supposed to have the nosey cup and built-up utensils and then retrieved them. The Dietary Manager stated that staff should follow what is on the residents' tickets.
Infection Control Lapse During Wound Vac Care
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident observed during wound care. During observation of the resident's surgical wound change, the LPN wiped stool from the resident's uncovered colostomy stoma and then continued the procedure without changing gloves or performing hand hygiene before handling the resident's suction tubing. The resident was admitted with a diagnosis including encounter for surgical after care following surgery on the digestive system and had orders for a wound vac to the abdomen at 125 mmHG with green foam and a transparent semipermeable cover dressing on scheduled days and as needed. The resident's suction tubing remained attached to the suction machine on one end, while the open end had been lying on the floor under the bed; the LPN then plugged that end into the newly applied wound vacuum tubing without cleaning or disinfecting it first. The LPN stated she did not realize the open tubing had touched the floor, and the DON stated the expectation was that the tubing end would have been cleaned with an alcohol prep pad before reconnecting and that gloves should have been changed with hand hygiene performed after cleaning stool from the colostomy stoma.
Incorrect Hoyer Sling Size Used for Dependent Resident
Penalty
Summary
Staff failed to ensure the correct size Hoyer lift sling was used for a resident with right-sided paralysis, contracture, neglect syndrome, and dementia. The resident's care plan and medical record specified the use of a medium (purple) sling for all mechanical lift transfers, in accordance with the manufacturer's guidelines and the resident's weight. However, during observation, the resident was found seated in a broda chair with a green (large) sling in use, contrary to the care plan instructions. The Certified Nursing Assistant (CNA) involved confirmed the care plan required a medium sling and expressed surprise at the error, despite recent education and skill checks provided to staff. The facility's policy mandates that resident handling and transfers be performed according to each resident's individual plan of care to minimize injury risk. The deficiency was identified when the surveyor observed the incorrect sling in use and verified the care plan documentation with the CNA. The Nursing Home Administrator confirmed that all other residents requiring Hoyer lifts were checked and found to have the correct sling size, with the exception of this resident.
Resident Subjected to Unwanted Catheterization
Penalty
Summary
The facility failed to protect a resident from mental abuse by staff, which resulted in immediate jeopardy. The incident involved a resident with Parkinson's disease who was cognitively intact and her own decision-maker. The resident was subjected to a straight catheterization procedure against her will, despite her clear verbal objections and physical resistance. The procedure was carried out by an RN with the assistance of two CNAs, who held the resident down while she cried and pleaded for them to stop. The resident had been experiencing urinary discomfort, and a physician had ordered a urine sample. However, the facility's criteria for obtaining a urine culture required the presence of a fever, which the resident did not have. Despite this, the RN proceeded with the catheterization, claiming not to have heard the resident's objections. The CNAs involved expressed discomfort with the situation but followed the RN's instructions, later reporting the incident to the Director of Nursing. The incident was reported to law enforcement and Adult Protective Services, and the resident expressed feeling unsafe in the facility. The resident's family noted a decline in her condition following the incident, and she was eventually transferred to a hospital. The facility's failure to respect the resident's right to refuse treatment and protect her from abuse led to the finding of immediate jeopardy.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to establish an effective Infection Control Program, which led to several deficiencies in infection prevention and control practices. The facility did not have a proper surveillance system in place to track and monitor infections among residents and staff. The infection control logs were incomplete, lacking critical information such as symptom onset and resolution dates, diagnostic results, and analysis of infections. The Director of Nursing (DON) acknowledged the absence of a consistent documentation procedure for infection surveillance prior to November 2024 and admitted that no written improvement plan was in place. In one instance, a resident was placed on contact precautions after a single episode of vomiting, despite negative COVID-19 tests and no further symptoms. The facility's surveillance data was inaccurately completed, and the resident remained on precautions longer than the recommended 48-hour period for gastrointestinal symptoms. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter upon admission, as required by their policy. The facility also demonstrated improper use of Personal Protective Equipment (PPE). A Certified Nursing Assistant (CNA) with a full beard was observed wearing an N95 mask without a proper seal, and contaminated PPE was disposed of in non-COVID positive resident rooms. Furthermore, another CNA failed to practice proper hand hygiene during personal care for a resident, continuing to use the same gloves throughout various tasks without washing or sanitizing hands. These actions indicate a lack of adherence to infection control protocols, potentially affecting all residents and staff in the facility.
Failure to Develop Person-Centered Care Plan for Resident's Smoking Preferences
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, identified as R35, which did not address the resident's preference for smoking. Despite R35's intact cognition and expressed desire to smoke, the comprehensive care plan lacked specific interventions to accommodate this preference. The facility's policy allows residents deemed safe to smoke in designated areas, yet R35's care plan did not reflect his smoking preferences, leading to frustration and negative behaviors. R35, who has diagnoses including dementia, anxiety, and depression, expressed a desire to smoke regularly, but reported being able to smoke only once a week. The resident's cigarettes were stored in a locked medication cart, and staff were reportedly unable to supervise R35's smoking due to time constraints. Interviews with staff revealed that while R35 frequently requested to smoke, the staff could not consistently accommodate these requests, leading to R35's frustration and feelings of being ignored. The surveyor observed that R35's care plan was updated to reflect risks associated with smoking-related injuries but did not include interventions to address his smoking preferences. Despite the facility's policy to accommodate smoking requests, staff interviews indicated that scheduled smoking times were not consistently applied, and R35's requests were only met when staff were available. This lack of a person-centered approach in the care plan potentially impacted R35's quality of life and care.
Failure to Document and Implement ROM Care Plan
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase or maintain ROM, as outlined in the resident's care plan. The resident, who was admitted with diagnoses including hemiplegia, rheumatoid arthritis, and a right shoulder contracture, had a care plan that included specific ROM exercises. However, there was no documentation in the resident's electronic medical record indicating that these exercises were completed, despite the care plan's requirements. Interviews with facility staff revealed that ROM exercises were reportedly performed by a Certified Nursing Assistant (CNA) during morning care, but no documentation was found to support this claim. The Director of Nursing (DON) acknowledged that the facility's restorative binder contained only care plans and lacked documentation of completed exercises. The Nursing Home Administrator (NHA) noted a change in leadership and identified gaps in the restorative programs, indicating that the facility was working on addressing these issues.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to use a gait belt during the transfer of a resident, identified as R9, which is a violation of their policy on safe resident handling and transfers. R9, who has diagnoses including anxiety disorders, osteoarthritis, a right artificial knee, abnormalities of gait and mobility, and generalized muscle weakness, requires assistance with activities of daily living (ADLs) and is at risk for falls. The care plan for R9 specifies the need for assistance from one staff member during transfers but does not explicitly mention the use of a gait belt. During an observation, a Certified Nursing Assistant (CNA) assisted R9 with transfers without using a gait belt, instead holding onto R9's pant waist band and underarms. Interviews with the CNA and other staff, including Occupational Therapy (OT) and Physical Therapy (PT) personnel, revealed that the expectation is to use a gait belt for any assistive transfers unless the resident declines its use. The Director of Nursing (DON) confirmed that the transfer assessment should be documented in the care plan and that the use of a gait belt is expected during transfers. The CNA admitted to not using a gait belt with R9 and stated that she was not instructed to do so, indicating a gap in communication and adherence to the facility's policy.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. Upon admission, one resident was identified with a suspected deep tissue injury (DTI) from the coccyx to the peri area, but the physician, Director of Nursing (DON), or wound nurse were not notified. No care plan or interventions were put in place, and pressure injury assessments were not completed. This oversight led to the development of an unstageable pressure injury and sepsis, requiring hospitalization and surgical intervention. Another resident was admitted with a pressure injury on the left heel, but the care plan interventions, such as floating the heels, were not consistently implemented. Observations by the survey team noted that the resident's heels were not floated during multiple instances, and there was a lack of documentation regarding the assessment and resolution of the pressure injury. The staff, including CNAs and RNs, were not aware of the necessary interventions or the current status of the resident's pressure injury. The facility's failure to implement pressure injury interventions and assess the residents' conditions created a finding of immediate jeopardy. The lack of communication and documentation regarding the residents' pressure injuries and the absence of individualized care plans contributed to the deficiency. The facility did not ensure that each resident received care consistent with professional standards of practice to prevent pressure injuries.
Removal Plan
- Facility in-house residents had their skin inspected by RN and no unidentified pressure injuries were discovered, current interventions were reviewed and verified in place as per care plan, and treatment orders are in place, accurate, and completed as ordered.
- Re-education to licensed nursing staff (RNs and LPNs) for aggressive pressure injury prevention including visually inspecting resident's skin upon admission or readmission to identify skin impairments, notifying physician to obtain orders for treatment, notifying responsible party of resident, and interdisciplinary team (IDT) re-educated on pressure injury and non-pressure injury, need to review new or worsening skin impairments to ensure interventions are reviewed and care plan updated.
- Re-education to nursing staff to monitor skin for injuries or changes with cares to ensure current he nurse if noted.
- DON or designee to review facility charting to ensure new admissions, readmissions, and current residents have skin impairments properly documented, orders implemented, and notifications completed and documented. This review will then be completed 5 days per week for 6 weeks or until substantial compliance maintained.
- Audits will be completed by DON or IDT to ensure in house residents with pressure injuries have established wound process in place including care plan review and evaluation.
- Quality Assurance Performance Improvement (QAPI) meeting held to review pressure injury incident, discuss implementation of actions items as stated above.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician about a change in condition, specifically for a resident who developed a deep tissue injury (DTI) and experienced changes in vital signs. The resident, who was admitted with diagnoses including malnutrition, multiple myeloma, and a left hip fracture, was assessed with a Braden Scale score indicating no risk for skin breakdown. However, a weekly skin assessment revealed a DTI on the coccyx, but there was no documentation of physician notification regarding this injury. Additionally, the resident experienced tachycardia and a drop in blood pressure, which are potential signs of sepsis, yet there was no documentation of physician notification for these changes either. The resident expressed concerns about her heart, and despite regular auscultation, the facility did not notify the physician until the resident was sent to the emergency room. The physician confirmed that they were not informed of the DTI or the changes in heart rate and blood pressure until the transfer to the hospital was requested.
Inadequate Infection Control Leads to Scabies Outbreak
Penalty
Summary
The facility failed to establish an effective Infection Control Program, which led to an outbreak of scabies affecting both staff and residents. The facility did not have a tracking program in place for the early detection of infected and exposed individuals, resulting in multiple nursing staff members working while infected and subsequently exposing residents across different units. The outbreak timeline revealed that several staff members, including CNAs and an RN, developed symptoms and were treated for scabies, but continued to work on various halls, spreading the infection further. The facility's response to the outbreak was inadequate, as evidenced by the lack of documentation and timely implementation of contact precautions. For instance, a resident on Cedar Hall developed a rash but was not placed on contact precautions until two weeks later. Additionally, there was no documentation of skin scrapings to confirm scabies, and the facility did not conduct skin assessments on all units, despite the presence of symptomatic staff and residents. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) only conducted a full body review on Aspen Hall, neglecting other potentially affected areas. Interviews with facility leadership revealed a lack of awareness and timely action regarding the outbreak. The DON admitted to not taking action when initially informed about staff members with scabies, and the facility only began surveillance efforts after the outbreak was deemed active. Furthermore, there was no resident line list or monitoring for rashes on certain halls, and the facility failed to treat all exposed residents promptly. The report highlights the facility's failure to implement necessary infection control measures, resulting in the spread of scabies among residents and staff.
Failure to Provide Adequate Bowel Management for Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident (R2) to promote regular bowel movements in accordance with the resident's preferences, goals for care, and professional standards of practice. R2 was admitted to the facility with a history of constipation and was dependent on staff for toileting and transfers. Despite being on medications such as MiraLAX and Senna Plus for constipation, and having standing orders for Milk of Magnesia, Bisacodyl suppository, and Fleets enema, there was no documentation of R2 receiving these as-needed medications during their stay. R2 expressed feeling constipated and refused the option of using a bedpan, preferring other options like Milk of Magnesia and a suppository, which were not documented as administered. The facility lacked a policy or procedure on bowel management and did not conduct a formal bowel assessment for R2. The medical record review showed no documentation of a bowel movement during R2's stay, and the Director of Nursing and a Registered Nurse confirmed the absence of a bowel assessment and documentation of administered as-needed medications. The expectation was for nurses to provide Milk of Magnesia and prune juice, and if no bowel movement occurred by the next day, to administer a suppository. The facility's failure to adhere to these expectations and lack of documentation led to R2's transfer to the hospital after not having a bowel movement for four days.
Failure to Monitor Fluid Intake for High-Risk Resident
Penalty
Summary
The facility failed to calculate the fluid intake for one of three sampled residents, identified as R2, who was at high risk for dehydration. The facility's policy on hydration requires offering sufficient fluid to each resident to maintain proper hydration and health, with a minimum fluid intake of 1500 cc per day recommended by guidelines. However, R2's fluid intake records showed significantly lower amounts on several days, with no assessments completed to monitor for dehydration or to recommend appropriate fluid intakes. R2 was admitted with a diagnosis of compression fracture and a history of constipation, and was receiving Furosemide, a diuretic that increases fluid loss, further increasing the risk of dehydration. Interviews with the Director of Nursing and a Registered Nurse confirmed the absence of assessments to ensure R2 was receiving the recommended fluid intake. Additionally, the Dietary Manager acknowledged that an assessment of R2's nutritional and fluid needs was not completed, although it would have recommended a daily intake of 2100 to 2500 cc. The facility's failure to assess and monitor R2's fluid intake, despite the resident's high risk for dehydration, constitutes a deficiency in providing adequate hydration to maintain health.
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All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Altoona
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 | 0.1 mi | ★★★★★ | 3 | 0 |
| Dove Healthcare - South Eau Claire | 2 mi | ★★★★★ | 0 | 0 |
| Dove Healthcare - West Eau Claire | 4.2 mi | ★★★★★ | 0 | 0 |
| Chippewa Manor Nursing And Rehabilitation | 8.1 mi | ★★★★★ | 6 | 0 |
| Wi Veterans Home At Chippewa Falls | 9.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.