Oskaloosa Care Center

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident's room and he was slumped over in his recliner, almost sliding out. She stated he was very diaphoretic and had had a bowel movement. She stated he was warm but not so warm he was feverish.

She stated they were not able to get him up and he was not responsive. She called over the two-way radio for the DON and told Staff B to call 911. She stated they placed him on the ground and stated outside the resident's room, there was not a sticker present so that meant the resident was a DNR. Staff B stood at the doorway and Staff C directed her to double check the Code Status. The DON opened the resident's airway and they were ready to start compressions but Staff B took a long time and had not returned with the verification of the Code Status. Staff C left the room and at the nursing station, Staff B was fumbling and could not find the resident's code status in the paper chart. Staff C told Staff B it was under Advanced Directives and Staff B stated the resident was a DNR. It was at this time that they called the time of death.

Staff C stated the aides got him cleaned up and when she opened the resident's EHR to obtain the phone number for the resident's wife, she saw that the resident was a Full Code. Staff C asked Staff B why the EHR stated Full Code when the paper chart said DNR. Staff C stated if she had known he was a Full Code,

she would have started CPR. She stated after she spoke with the wife, she thought she should call and cancel the ambulance and she looked at Staff B and stated you called the ambulance, right? Staff B stated oh, I forgot because she tried to find the crash cart. On [DATE REDACTED] at 11:18 a.m., Staff B stated she and the DON were summoned to the resident's room and he sat in the chair and was purple. She stated she was asked to call 911 and the DON asked her to check the resident's Code Status. She stated she looked for

the crash cart and she did not know where it was at first. She stated she and Staff C looked at the resident's code status and stated the resident was a No Code but this was incorrect and they both misread it. She stated they were all flustered. She stated she was working on calling 911 when she retrieved the crash cart. She stated she was flustered and should have called 911. She stated she probably would have initiated CPR(if she had known he was a Full Code). On [DATE REDACTED] at 12:24 a.m., the DON stated Staff C asked her to meet her in the resident's room. She stated when she arrived, the resident displayed agonal breathing and was diaphoretic and ashen in color. Staff C asked Staff B to check the resident's code status and to call an ambulance. Staff C left the room because they did not have his Code Status and when she found out he was a No Code, she called the time of death. She stated she called Staff F and informed her

the resident was a No Code and she gave an order to release the body to the funeral home. She stated Staff C called the family and stated the resident's EHR stated he was a Full Code. She stated she called Staff F back to tell her and it was 7:57 a.m. The DON stated she did not believe if they had initiated CPR it would have changed things but stated they owed it to the family to do so. She stated Staff B stated she forgot to call the ambulance and had gone to look for the crash cart which was not her assignment. She stated Staff B did not know where the crash cart was but they educated her on this during orientation. The DON stated she would have started CPR if she had that information but thought she could trust a fellow nurse. She stated during the incident, the resident's door did not contain the correct sticker to indicate he was a full code due to room changes. On [DATE REDACTED] at 3:22 p.m., the Administrator stated the Full Code sticker was on the chart but on the wrong side of the resident's door. She stated after the incident they checked all

the door stickers and added another book at each nursing station which contained code statuses. On [DATE REDACTED] at 9:16 a.m Staff G stated she was at the medication cart and someone directed Staff B on the two-way radio to call 911. She stated Staff B was closer to the radio than she was and that she(Staff B) could hear the request. She stated Staff B asked her to locate the crash cart. After she retrieved the crash cart, Staff B told her that the resident was a DNR.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oskaloosa Care Center

605 Highway 432 Oskaloosa, IA 52577

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

said she was super tired but that she was fine and was just playing possum. Staff H stated that Staff B acted like it was no big deal and did not report to her that the resident had chest pain. After Staff B left, staff reported to her that she needed to come and look at the resident. Staff H stated normally the resident was talkative, busy and pacing but at this point she was not herself and extremely lethargic. She stated the resident was slumped over and did not respond much. She had to carry out a sternal rub and the resident opened her eyes but closed them again. She stated she called Staff F and they sent her to the hospital for evaluation. On 9/17/25 at 10:03 a.m., the Director of Nursing (DON) stated if a resident complained of chest pain, staff should carry out an assessment and notify the provider. She stated if a resident had chest pain,

they could not rule out that it was a cardiac event. She stated when she heard about the situation with Staff B and Resident #9, she was upset. She stated Staff L was the DON at the time of the incident.On 9/17/25 at 4:00 p.m., via phone, Staff L stated she was not in the building at the time of the situation with Resident #9 but stated staff came to her the next day. Staff reported to her that they told Staff B the resident had chest pain but she just told the resident to sit down. Staff L stated the aides should have reported this to her if the nurse did not listen. Staff L stated Staff B should have notified the provider and had her sent out for evaluation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oskaloosa Care Center

605 Highway 432 Oskaloosa, IA 52577

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or potential for actual harm

Based on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to implement training for multiple topics for 6 of 6 staff reviewed (Staff B, M, N, O, P, Q). The facility reported a census of 76 residents.Findings included: An Employee Face Sheet listed the hire date for Staff B Licensed Practical Nurse(LPN) as 1/8/25. The facility's Hired List By Date listed the following hire dates:Staff O Certified Nursing Assistant(CNA) 4/16/25Staff P CNA 7/16/25Staff Q CNA 8/28/25The facility lacked documentation that new hires Staff B, Staff O, Staff P and Staff Q completed training in Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and infection control upon hire and lacked documentation that non-new hires Staff M CNA and Staff N CNA completed training in QAPI and compliance and ethics on an annual basis.An undated, untitled facility document stated the facility training program was for all departments including new hires and existing staff. The facility Inservice Attendance calendar listed infection control as a topic but did not include QAPI or compliance and ethicsOn 9/17/25 at 12:41 p.m., the DON stated she did not see any additional education in the staff's files and stated they would work to building their training program.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oskaloosa Care Center

605 Highway 432 Oskaloosa, IA 52577

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Based on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in Quality Assurance and Performance Improvement(QAPI) for 6 of 6 staff reviewed(Staff B,M, N, O, P, Q). The facility reported a census of 76 residents.Findings included: An Employee Face Sheet listed the hire date for Staff B Licensed Practical Nurse(LPN) as 1/8/25. The facility's Hired List By Date listed the following hire dates:Staff O Certified Nursing Assistant(CNA) 4/16/25Staff P CNA 7/16/25Staff Q CNA 8/28/25The facility lacked documentation that new hires Staff B, Staff O, Staff P and Staff Q and non-new hires Staff M and Staff N completed training in Quality Assurance and Performance Improvement(QAPI) upon hire/annually. An undated, untitled facility document stated the facility training program was for all departments including new hires and existing staff. The facility Inservice Attendance calendar did not list QAPI as a training topic.On 9/17/25 at 12:41 p.m., the DON stated she did not see any additional education in the staff's files and stated they would work to building their training program.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oskaloosa Care Center

605 Highway 432 Oskaloosa, IA 52577

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Based on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in infection control for 4 of 6 staff reviewed (Staff B,O, P, Q). The facility reported a census of 76 residents.Findings included: An Employee Face Sheet listed the hire date for Staff B Licensed Practical Nurse(LPN) as 1/8/25. The facility's Hired List By Date listed the following hire dates:Staff O Certified Nursing Assistant(CNA) 4/16/25Staff P CNA 7/16/25Staff Q CNA 8/28/25The facility lacked documentation that new hires Staff B, Staff O, Staff P and Staff Q completed training in infection control.An undated, untitled facility document stated the facility training program was for all departments including new hires and existing staff. The facility Inservice Attendance calendar listed infection control as a training topic.On 9/17/25 at 12:41 p.m., the DON stated she did not see any additional education in the staff's files and stated they would work to building their training program.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oskaloosa Care Center

605 Highway 432 Oskaloosa, IA 52577

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946

Provide training in compliance and ethics.

Level of Harm - Minimal harm or potential for actual harm

Based on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in compliance and ethics for 6 of 6 staff reviewed(Staff B, M, N, O, P, Q). The facility reported a census of 76 residents.Findings included: An Employee Face Sheet listed the hire date for Staff B Licensed Practical Nurse(LPN) as 1/8/25. The facility's Hired List By Date listed the following hire dates:Staff O Certified Nursing Assistant(CNA) 4/16/25Staff P CNA 7/16/25Staff Q CNA 8/28/25The facility lacked documentation that new hires Staff B, Staff O, Staff P and Staff Q and non-new hires Staff M and Staff N completed training in compliance and ethics upon hire/annually. An undated, untitled facility document stated the facility training program was for all departments including new hires and existing staff. The facility Inservice Attendance calendar did not list compliance and ethics as a training topic.On 9/17/25 at 12:41 p.m., the DON stated she did not see any additional education in the staff's files and stated they would work to building their training program.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet