Above 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 Onalaska Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions experienced several syncopal episodes and a fall, but the family was not notified of each incident as required by facility policy. Staff interviews revealed that although the resident had expressed a preference for family notification, there was no documentation confirming that the family was informed after each event. The family only became aware of the situation when the resident was transferred to the hospital for a hip fracture.
A resident with multiple falls and complaints of pain did not receive comprehensive head-to-toe, skin, respiratory, or pain assessments as required by facility policy and professional standards. Despite repeated incidents and escalating symptoms, staff failed to document thorough assessments, and interviews with nursing staff and the DON confirmed these omissions. The resident was later found to have multiple fractures and complications upon hospital transfer.
The facility failed to maintain sanitary conditions in food preparation, affecting all residents. Dietary aides were observed not following proper hand hygiene protocols, such as turning off faucets with clean hands and handling ready-to-eat foods with contaminated gloves. Despite training, these practices did not align with the facility's handwashing policy.
The facility failed to maintain an effective infection prevention and control program, as evidenced by inadequate surveillance of illness symptoms, improper hand hygiene practices, and failure to implement Enhanced Barrier Precautions. Staff did not consistently follow hand hygiene protocols, and shared equipment was not sanitized between uses, increasing the risk of infection spread among residents.
The facility's admission packet included a 'Personal Property Notice' requiring residents to waive liability for losses of personal property, which could affect all 53 residents. The Nursing Home Administrator confirmed that residents sign this notice upon admission, acknowledging the facility's lack of responsibility for lost or damaged items, except for dentures. The NHA recognized the potential issue and planned to address it with the QAPI team.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's family or representative of significant changes in the resident's condition, as required by facility policy. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, hypotension, and syncope, experienced multiple syncopal episodes and a fall over several days. Documentation showed that after an unwitnessed fall, the resident declined family notification, but during subsequent syncopal episodes—one resulting in a skin tear and another in moderate leg pain—there was no documentation that the provider or family/HCPOA were notified. Only after a further decline, when the resident exhibited loss of range of motion and was found to have a hip fracture, were the provider and family notified and the resident sent to the hospital. Interviews with staff confirmed that the charge nurse is responsible for notifying the provider and family after significant changes, and that if a resident is their own decision maker, they are asked about family notification. The Director of Nursing stated that the resident had expressed a preference for family notification, but there was no documentation to confirm that the resident was asked or that the family was notified after each incident. The resident's family member also reported not being notified of the earlier incidents, only learning of the situation when the resident was being transferred to the hospital for evaluation.
Failure to Complete Comprehensive Post-Fall and Pain Assessments
Penalty
Summary
A deficiency occurred when staff failed to provide care and treatment in accordance with professional standards of practice for a resident who experienced multiple falls and subsequent complaints of pain. Despite facility policy and professional guidelines requiring comprehensive head-to-toe, skin, respiratory, and pain assessments after each fall, documentation revealed that these assessments were not consistently completed. Specifically, after several falls, there was no documentation of head-to-toe skin assessments, and when the resident later complained of rib and hip pain, comprehensive pain and respiratory assessments were not performed or documented as required. The resident involved had a history of atrial fibrillation, congestive heart failure, hypotension, and syncope, and was cognitively intact according to the admission assessment. The resident experienced multiple falls, after which staff documented vital signs, musculoskeletal, and neurological assessments, but repeatedly omitted thorough skin and focused respiratory assessments. When the resident reported symptoms such as rib pain, shortness of breath, and increased pain intensity, staff did not complete or document comprehensive pain assessments that included quality, functional impairment, onset, and duration, nor did they perform focused respiratory assessments as indicated by the resident's complaints. Interviews with nursing staff and the DON confirmed that facility expectations and professional standards required these assessments and documentation, but acknowledged that they were not completed in this case. The resident was eventually transferred to the hospital, where imaging revealed multiple healing rib fractures, a left hip fracture, and other complications, indicating that injuries may have gone unrecognized due to the lack of comprehensive assessments following the falls and pain complaints.
Improper Hand Hygiene in Food Preparation
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation and distribution, potentially affecting all 53 residents. Observations revealed that dietary aides did not adhere to proper hand hygiene protocols. Dietary Aide E was seen washing hands, applying gloves, and then touching various surfaces and food items without changing gloves or washing hands in between tasks. This included touching a bread bag, toaster knobs, and ladles, and then handling ready-to-eat foods like toast and dinner rolls with the same contaminated gloves. Similarly, Dietary Aide F was observed washing hands but turning off the faucet with clean hands instead of using a paper towel, which compromised hand hygiene. DA F then proceeded to handle meal plates and drinks without proper hand hygiene. The Nutrition Services Director confirmed that staff had received training on proper hand hygiene, yet the observed practices did not align with the facility's handwashing policy, which emphasized the importance of turning off faucets with a paper towel and maintaining clean hands when handling food.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. The facility did not have an adequate surveillance system in place to track the onset and resolution of illness symptoms, leading to premature lifting of a Norovirus outbreak. The infection control line list continued to show residents and staff with symptoms after the outbreak was lifted, indicating a lack of proper monitoring and documentation. Additionally, the facility failed to document and track infections such as Clostridioides difficile and herpes zoster on the surveillance log, which could have led to potential harm to residents. Staff did not adhere to proper hand hygiene protocols during resident care, as observed in multiple instances. Certified Nursing Assistants (CNAs) were seen not performing hand hygiene between glove changes and between caring for different residents. This lack of compliance with hand hygiene policies increases the risk of cross-contamination and infection spread among residents. The facility's policy clearly states the need for hand hygiene before and after resident care and between glove changes, but this was not consistently followed by the staff. Enhanced Barrier Precautions (EBP) were not properly implemented or followed for residents with specific medical conditions requiring such precautions. For instance, a resident with a stage 3 pressure ulcer did not have EBP signage or personal protective equipment readily available, and another resident with an indwelling catheter did not have staff wearing the required gown during care. Additionally, shared equipment such as mechanical lifts were not sanitized between uses, further compromising infection control measures. These deficiencies highlight significant lapses in the facility's infection prevention and control practices.
Facility's Admission Packet Requires Waiver of Liability for Personal Property
Penalty
Summary
The facility failed to ensure that its admission packet did not require residents to waive potential facility liability for losses of personal property. This deficiency was identified during a policy review and interview with the Nursing Home Administrator (NHA). The facility's document titled 'Personal Property Notice' stated that residents could possess personal property within reason, but the facility would not be responsible for any loss, damage, or maintenance of these items. Residents were advised not to bring items of significant monetary or sentimental value, and staff were instructed not to accept responsibility for residents' personal property. During an interview, the NHA confirmed that residents are given the Personal Property Notice upon admission and are asked to sign it, acknowledging the facility's lack of responsibility for lost or damaged items. The NHA also mentioned that there is no specific policy outlining the facility's responsibility for high-value items, except for dentures. The NHA recognized that this policy could be problematic and intended to bring the concern to the Quality Assurance Performance Improvement (QAPI) team for review. This failure had the potential to affect all 53 residents residing in the facility.
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What surveyors actually found near you
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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 Onalaska
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Crescent Health Services | 6.2 mi | ★★★★★ | 25 | 1 |
| Mulder Health Care Facility | 6.8 mi | ★★★★★ | 8 | 0 |
| Riverside | 7 mi | ★★★★★ | 12 | 0 |
| Benedictine Manor Of Lacrosse | 7.2 mi | ★★★★★ | 1 | 0 |
| Hillview Health Care Ctr | 7.2 mi | ★★★★★ | 15 | 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.