Oskaloosa Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Sep 17, 2025

  Based on clinical record review, policy review, and staff interview, the facility failed to carry out cardiopulmonary resuscitation(CPR) in accordance with the resident's wishes, and follow the physician's orders for 1 of 1 residents reviewed for cardiopulmonary resuscitation status(Resident #1). The facility failed to correctly identify that Resident #1 desired CPR related to discrepancies in code status listed in multiple locations and a staff member incorrectly reading the resident's chart. Approximately 7 minutes after Resident #1 was last seen alive, the Advanced Registered Nursing Practitioner(ARNP) issued an order to withhold CPR due to the facility staff's delays. The facility staff also lacked knowledge of how to locate the facility's crash cart. […]

• Immediate jeopardy, isolatedF684May 18, 2023

  Based on clinical record review, staff interviews and policy review, the facility failed to assess and provide a timely intervention for 3 of 3 residents reviewed for catheter care (Resident #1, #4, #5). Resident #1 had little to no urinary output for 3 days without intervention. Residents #4 & #5 clinical records for urinary output lacked documentation. The facility failed to notify the attending physician of blood glucose levels greater than 400 for 1 of 1 resident reviewed (Resident #1). This failure resulted in possible distress for the resident, therefore causing an immediate Jeopardy (IJ) to the health, safety, and security of the resident. […]

• Actual harm, isolatedF684Sep 17, 2025

  Based on interviews, clinical record review, and facility policy review, the facility failed to carry out timely assessments and interventions after a resident complained of chest pain for 1 of 3 residents reviewed for a change in condition(Resident #9). The facility reported a census of 76 residents.Findings included:The Minimum Data Set(MDS) assessment tool, dated 6/8/25 listed diagnoses for Resident #9 which included hypertension(high blood pressure), nonrhematic aortic stenosis(a condition where the aortic valve, which controls blood flow from the heart to the body, becomes narrowed or obstructed), and weakness and listed her Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. […]

• Actual harm, isolatedF600May 18, 2023

  Based on observation, clinical record review, resident and staff interviews, the facility failed to talk to residents with respect and provide care in a respectful manner in an environment that enhanced his or her self-esteem and self-worth for 3 of 5 residents reviewed (Resident # 2, #3, and #6). The facility staff and temporary agency staff failed to incorporate the resident's goals, preferences and choices. The facility reported a resident census of 76. Findings include: 1. […]

• No harm, potential for more than minimal, patternF658Apr 15, 2026

  Based on record review, staff interview, and facility policy review, the facility failed to provide services that met professional standards regarding following physician's treatment orders (Resident #4) and monitoring for adverse reactions to immunizations (Resident #1, #2, #3, #5, #6, #7, #9, #11, #13, #14) for 11 of 13 residents reviewed. The facility reported a census of 75 residents. Findings include:1. Review of Minimum Data Set (MDS) dated [DATE], revealed Resident #4's Brief interview for Mental Status (BIMS) of 14 indicating cognitively intact. […]