Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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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Illustrative
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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 August 2026) and official state health department websites.