Oskaloosa Care Center
Oskaloosa Care Center in Oskaloosa, IA — inspection on September 17, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
chart.
Staff C told Staff B it was under Advanced Directives and Staff B stated the resident was a
jeopardy to resident health or and when she opened the resident's EHR to obtain the phone number for the resident's wife, she saw safety 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
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] 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] 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] 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] 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.
165589 09/17/2025
Oskaloosa Care Center 605 Highway 432 Oskaloosa, IA 52577
She stated when she heard about the situation with Staff B and Resident #9, she was upset.
She
stated she was not in the building at the time of the situation with Resident #9 but stated staff came
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.
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Oskaloosa Care Center 605 Highway 432 Oskaloosa, IA 52577
members.
facility failed to implement training for multiple topics for 6 of 6 staff reviewed (Staff B, M, N, O, P, Q).
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.
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Oskaloosa Care Center 605 Highway 432 Oskaloosa, IA 52577
Improvement Program.
facility failed to ensure staff completed training in Quality Assurance and Performance
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.
165589 09/17/2025
Oskaloosa Care Center 605 Highway 432 Oskaloosa, IA 52577
written standards, policies, and procedures for the program.
facility failed to ensure staff completed training in infection control for 4 of 6 staff reviewed (Staff
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.
165589 09/17/2025
Oskaloosa Care Center 605 Highway 432 Oskaloosa, IA 52577
reviewed(Staff B, M, N, O, P, Q).
The facility reported a census of 76 residents.
Findings included: An
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.