Oelwein Health Care Center

In the surveyor’s words

From the most serious findings on record at Oelwein Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF580Mar 26, 2026

  Based on clinical record review, policy review, provider, family and staff interviews, the facility failed to notify the provider and family of a significant injury for 1 of 4 sampled residents (Resident #17). Staff identified an unexplained bruise to the resident's right eye on 3/15/26, but the facility didn't notify the medical provider or the family until 3/23/26, resulting in an 8-day delay. The facility identified a census of 51 residents.Findings include:Resident #17's Minimum Data Set (MDS) Assessment, dated 2/4/26, documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive loss. Resident #17 experienced memory problems, had moderately impaired decision-making, and was diagnosed with Alzheimer's Disease and Non-Alzheimer's Dementia. […]

• No harm, potential for more than minimal, isolatedF628Mar 26, 2026

  Based on record review and staff interview, the facility failed to ensure a complete medical record for 2 of 4 sampled residents (Resident #4 and Resident #8) by failing to maintain copies of hospital transfer documentation in the clinical records. The facility reported a census of 51 residents. Findings include:1. Resident #4's Minimum Data Set (MDS) Assessment, dated 12/3/25, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating she remained cognitively intact. […]

• No harm, potential for more than minimal, isolatedF640Mar 26, 2026

  Based on record review, document review, the Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Resident Assessment Instrument (RAI) Manual and staff interview, the facility failed to ensure the timely transmission of the Discharge Return Not Anticipated (DRNA) assessment for 1 of 2 sampled residents (Resident #34). The facility transmitted the assessment 118 days after the required completion date. The facility identified a census of 51 residents:Findings include:An Electronic Healthcare Record (EHR) Census Record showed Resident #34 discharged from the facility on 11/21/25.The Minimum Data Set (MDS) Summary Page documented the DRNA Assessment completion on 11/26/25 and locking on 3/24/26.An MDS Assessment History showed the iQIES (Internet Quality Improvement and Evaluation… […]

• No harm, potential for more than minimal, isolatedF641Mar 26, 2026

  Based on clinical record review, document review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Resident Assessment Instrument (RAI) Manual, provider and staff interviews, the facility failed to ensure an accurate picture of a resident's health status by coding a diagnosis that lacked a direct relationship to the resident's current status for 1 of 2 residents reviewed (Resident #7). The facility coded schizophrenia on the Minimum Data Set (MDS) (a resident assessment tool) based on 1990 medical records, despite a lack of supporting documentation from current providers. […]

• No harm, potential for more than minimal, isolatedF684Mar 26, 2026

  Based on record review, document review, family, staff, and physician interviews, and policy review the facility failed to ensure clinical monitoring and physician notification for critical lab values and significant injuries for 3 of 10 sampled residents (Resident #5, Resident #25, and Resident #17). Specifically, the facility failed to notify providers of dangerously high and low blood sugar readings and failed to perform neurological assessments for a resident with an unexplained head injury. The facility reported a census of 51 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) Assessment, dated 12/10/25, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating she remained cognitively intact. […]