Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Oakwood Health Services during CMS and state inspections, most recent first.
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.
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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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) |
|---|---|---|---|---|
| Grace Lutheran Communities - River Pines | 0.1 mi | — | 0 | 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 |
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