Casa De Paz Health Care: Missed Treatments - IA
The patient, identified as Resident #10 in federal inspection records, suffered from dementia, schizophrenia and respiratory failure. Her care plan noted she was on hospice services due to her terminal condition and had potential for impaired skin integrity.
Federal inspectors found that nurses at Casa De Paz Health Care Center routinely failed to complete ordered treatments for multiple residents during a complaint investigation in August. The missed care affected residents with conditions including dementia, heart failure and terminal illnesses.
Resident #10's treatment failures were extensive. On August 3rd, 16th and 17th, nurses skipped applying lotion to areas affected by incontinence despite a doctor's order dating back to February. They also missed applying lotion to dry areas on both feet those same days, according to a June order.
The woman's wound care proved equally inconsistent. A July order required Steri-strip application to her left forearm skin tear twice daily, but nurses completed the treatment only once on August 3rd, 10th, 16th and 17th.
Another resident with multiple chronic conditions experienced similar treatment gaps. Resident #9, who suffered from kidney disease, heart failure, dementia, seizure disorder and anxiety, had a care plan updated in April noting potential for impaired skin integrity and risk for edema, swelling and pain.
His August treatment record showed three separate medication orders that nurses repeatedly failed to complete. A June order for methol-zinc oxide ointment to the gluteal crease went undone on August 3rd, 16th and 17th. Compression hose application and leg elevation, ordered in June, was skipped the same days.
The resident's pain management suffered as well. Nurses failed to apply Biofreeze gel to his back and knee twice daily as ordered in March, missing treatments on August 3rd, 16th and 17th.
Inspection records show the facility's medication administration records contained blank spaces with no explanation for why treatments were missed. Staff C, a licensed practical nurse, demonstrated to inspectors that the electronic charting system provided multiple options for nurses to indicate reasons when treatments or medications weren't given.
"The choices then transferred over into the nursing notes," the nurse explained to inspectors on August 21st. "With those options, the space on the MAR/TAR should never be left blank with no explanation."
The Director of Nursing acknowledged problems with treatment documentation during the inspection. She told investigators she suspected a new nurse didn't understand proper documentation procedures for treatments.
"She had a charge nurse that was responsible for supervising the new staff member and she would be providing some education to the nurses," according to inspection records.
The missed treatments violated facility policies requiring consistent medication and treatment orders following principles of safe and effective care. The nursing home's own indwelling catheter policy emphasized the importance of reviewing residents' records and verifying physician orders before procedures.
Resident #10's case proved particularly concerning given her terminal diagnosis and total dependence on staff. The woman required complete assistance with dressing, hygiene, toileting and transfers. She had an indwelling catheter and her care plan specifically called for catheter care per facility policy.
Her moderate cognitive deficit, documented through standardized testing, meant she couldn't advocate for herself when treatments were missed or recognize when her care fell short of doctor's orders.
Resident #9 faced similar vulnerabilities with his combination of dementia and multiple chronic conditions requiring careful monitoring and consistent treatment to prevent complications like skin breakdown and increased pain.
The inspection found that treatment failures affected "some" residents at the facility, suggesting the documentation and care problems extended beyond the two detailed cases. Federal investigators classified the violations as causing minimal harm or potential for actual harm to residents.
The missed treatments occurred despite clear physician orders and facility policies requiring proper documentation when care couldn't be provided. The electronic charting system's built-in options for explaining missed treatments made the blank documentation spaces particularly problematic, according to nursing staff.
Casa De Paz Health Care Center's treatment failures highlight ongoing challenges with medication and treatment administration in nursing homes, particularly for residents with complex medical needs who depend entirely on staff for basic care and cannot monitor their own treatment compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casa De Paz Health Care Center from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Casa De Paz Health Care Center in Sioux City, IA was cited for violations during a health inspection on August 21, 2025.
The patient, identified as Resident #10 in federal inspection records, suffered from dementia, schizophrenia and respiratory failure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.