Oskaloosa Care Center: Full Code Resident Dies Without CPR - IA
Federal inspectors classified what happened that morning as immediate jeopardy, the most serious category of nursing home violation, one reserved for situations where a facility's failures have placed residents in immediate risk of serious harm or death. The inspection, triggered by a complaint, was completed September 17, 2025.
The sequence of failures that morning involved at least four staff members, a paper chart that conflicted with the electronic health record, a code status sticker on the wrong side of a door, a crash cart nobody could find, and an ambulance that was never called until it was too late. At the center of it was a man whose name does not appear in the inspection report, whose wife learned by phone that her husband was dead, and who was then cleaned up and released to a funeral home before anyone realized the facility had let a Full Code resident die without attempting to save him.
The Director of Nursing arrived in the resident's room and found him displaying agonal breathing, the gasping, irregular pattern that signals the body is shutting down. He was diaphoretic. He was ashen. The DON asked Staff C to check the resident's code status and to call an ambulance. Staff C left the room to find the code status information, and when she came back with what she believed was the answer, she told the others he was a No Code. She called the time of death.
Nobody had called 911. Nobody had started CPR.
Staff C then called the resident's wife. When she opened the electronic health record to get the wife's phone number, she saw it. The EHR listed the resident as a Full Code. The paper chart in the room had said DNR. They were not the same document. They did not say the same thing. Staff C had read the paper chart. She had read it wrong.
"If she had known he was a Full Code," the inspection report states, "she would have started CPR."
Staff B, the nurse who had been asked to call 911 during the emergency, had not called. She told inspectors she had been flustered. She had gone to look for the crash cart instead. She did not know where the crash cart was. She had been told during orientation. She stated she was working on calling 911 when she retrieved the crash cart, but the ambulance call never happened. "She stated she forgot because she tried to find the crash cart," the report says. When Staff C turned to her after calling the wife and asked whether she had called the ambulance, Staff B said: "Oh, I forgot."
Staff B told inspectors she probably would have initiated CPR if she had known he was a Full Code. She stated she and Staff C had looked at the code status together and both misread it. "They were all flustered," she said.
A third nurse, Staff G, was at the medication cart when the call came over the two-way radio directing Staff B to call 911. Staff G said Staff B was closer to the radio and could hear the request. Staff B asked Staff G to locate the crash cart. After Staff G retrieved it, Staff B told her the resident was a DNR. That was not true. Staff B had misread the chart. Staff G had just handed over the crash cart for a man nobody was going to use it on.
The DON told inspectors that when she arrived in the room, the resident's condition was unmistakable. She said Staff C had asked her to meet in the room, and when she got there, she could see he was in agonal breathing, sweating, pale. She said she called the attending physician, Staff F, to report the resident was a No Code and received an order to release the body to the funeral home. The body was released.
Then Staff C called back. The EHR said Full Code.
The DON called Staff F again at 7:57 a.m. to correct what she had just reported. By then the resident was already dead, already cleaned up, and already turned over to the funeral home.
"She stated she did not believe if they had initiated CPR it would have changed things," the inspection report notes, "but stated they owed it to the family to do so."
That sentence sits in the middle of the report like a confession. The DON believed CPR would not have saved him. She also believed the facility owed it to the family to try. The family never got either the attempt or the honest conversation about why it didn't happen until after the body was gone.
The DON told inspectors she would have started CPR herself if she had known he was a Full Code, but said she thought she could trust a fellow nurse's read of the chart. She said that during the incident, the resident's door did not have the correct sticker indicating he was a Full Code, because of a room change. The Full Code sticker existed. It was on the wrong side of the door.
The administrator told inspectors the Full Code sticker had been on the chart but placed on the wrong side of the resident's door. After the incident, she said, staff checked all the door stickers across the facility and added a book at each nursing station listing code statuses.
The changes came after the man was dead.
The inspection report does not name the resident. It does not give his age. It does not describe how long he had lived at Oskaloosa Care Center, what he was being treated for, or what he had told the facility he wanted done if his heart stopped. It records only that he wanted to be a Full Code, that he had made that known and documented, and that when the moment came, the people responsible for honoring that choice were confused, flustered, and looking for a crash cart in the wrong place.
His wife learned he was dead in a phone call from a nurse who, at that moment, still believed he had chosen not to be resuscitated. She learned the truth later. The inspection report does not say how.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oskaloosa Care Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Oskaloosa Care Center in Oskaloosa, IA was cited for violations during a health inspection on September 17, 2025.
The inspection, triggered by a complaint, was completed September 17, 2025.
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.