Inspection Reports for Oskaloosa Care Center

A second revisit was conducted for the original visit ending September 17, 2025, and a first revisit for the survey ending November 13, 2025 to verify correction of previous deficiencies.

All deficiencies were corrected and the facility is in substantial compliance effective November 20, 2025.

The inspection visit was conducted as a revisit following a prior survey ending September 17, 2025, and an investigation of Facility Reported Incident #2644723-1.

The facility failed to meet the quality of care requirement related to the bowel regulatory program for four residents, including inadequate assessment, intervention, and monitoring of bowel movements. Documentation and nursing interventions were incomplete or missing for multiple residents.

The inspection was conducted as a result of complaint #2611557-C and facility reported incident #2613253-I between September 10, 2025 and September 17, 2025 to investigate alleged deficiencies related to cardiopulmonary resuscitation (CPR) and quality of care.

The facility failed to correctly identify and follow the resident's CPR code status, resulting in immediate jeopardy to the resident's health and safety. Additionally, the facility failed to carry out timely assessments and interventions for a resident with chest pain and failed to provide adequate staff training in multiple areas including infection control and quality assurance.

Complaint #2611557-C was investigated and did not result in a deficiency. Facility reported incident #2613253-I resulted in a deficiency related to failure in CPR procedures and resident care.

The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.

Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective June 26, 2025.

The inspection was conducted as the facility's Annual Recertification Survey and investigation of Facility Reported Incidents #127850-I, #129145-I, 129264-I and 128868-M from June 16, 2025 to June 19, 2025.

The facility was found deficient in several areas including failure to limit psychotropic drug use without appropriate diagnosis or documentation, failure to develop and implement comprehensive person-centered care plans, failure to meet professional standards during medication administration, and failure to maintain food safety standards including proper dishwasher sanitation. The facility also failed to implement adequate infection control practices.

The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.

The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective February 22, 2025.

The inspection was conducted as a result of investigations into multiple complaints (#122360-C, #125582-C) and facility reported incidents (#125465-I, #125951-I, #126072-I, #126117-I) between January 8 and January 23, 2025. The complaints and incidents were substantiated and involved concerns about resident rights and care.

The facility failed to treat residents with dignity, using excessive force to obtain a urine sample from Resident #1, and failed to meet professional standards in documentation, including falsification and removal of clinical records for residents #1 and #2. Additional findings included inadequate assessment accuracy, failure to ensure resident safety from physical aggression, and failure to provide appropriate supervision and care interventions.

The visit was complaint-related, investigating substantiated complaints #125582-C and facility reported incidents #125465-I, #125951-I, #126117-I. The complaints involved allegations of excessive force, improper care, falsification of records, and inadequate supervision.

The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.

The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective August 22, 2024.

The inspection was conducted as part of the facility's Annual Recertification survey and included investigation of multiple complaints and facility reported incidents.

The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments for physical restraints, failure to submit required PASARR evaluations, insufficient nursing staff on the Chronic Confusion or Dementing Illness Unit (CCDI), and inadequate restorative nursing program documentation and implementation.

Complaints #121815-C and #121985-C were substantiated. Facility Reported Incident #121663-I was substantiated.

The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility in compliance.

The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective February 8, 2024.

The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of complaints #114236-C, #114492-C, and #115395-C from January 7, 2024 to January 10, 2024.

The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments, failure to update care plans, inadequate respiratory care documentation, insufficient RN coverage, improper psychotropic medication management, and food safety violations. The facility reported a census of 78 residents during the survey.

The inspection included investigation of complaints #114236-C, #114492-C, and #115395-C.

A revisit of the survey ending May 18, 2023 and investigation of Complaint #113826-C was conducted on July 17-18, 2023.

All deficiencies were corrected and the facility is in substantial compliance effective May 25, 2023. Complaint #113826-C was not substantiated.

Complaint #113826-C was not substantiated.

The inspection was conducted as a result of investigation of Complaint #112523-A and Facility Reported Incidents #112230-I, #112233-I, and #112672-I between April 26, 2023 and May 18, 2023.

The facility was found to have failed to provide care in a respectful manner to residents, resulting in substantiated abuse complaints for three residents. Additionally, the facility failed to assess and provide timely intervention for catheter care and failed to notify the physician of critical blood glucose levels for one resident, resulting in an immediate jeopardy situation that was later abated.

Complaint #112523-A was substantiated. Facility Reported Incidents #112230-I, #112233-I, and #112672-I were substantiated.

The document is a plan of correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.

The facility will be certified in compliance effective February 23, 2023, based on acceptance of the plan of correction and credible allegation of compliance.

The inspection was conducted as a result of investigations into complaints #106366-C, #106474-C, and facility reported incidents #10911-I, #108911-I, and #109961-I. Complaints #106366-C and #106474-C, as well as incident #109961-I, were substantiated.

The facility failed to treat residents with respect and dignity during care and interactions for 2 of 4 residents reviewed, including inappropriate physical restraint and handling. Additionally, the facility failed to ensure staff were not under the influence of alcohol or intoxicating drugs while providing care, with evidence of a licensed practical nurse exhibiting impaired behavior during a night shift and suspected diversion of narcotic medications.

The visit was complaint-related, investigating complaints #106366-C and #106474-C, both substantiated, and facility reported incidents #10911-I, #108911-I, and #109961-I, with incident #109961-I substantiated.

The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.

The facility was found to be in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective July 28, 2022.

The inspection was conducted as part of the facility's annual health survey and investigation of complaints #100225-C, #101895-C, 101954-C, and a facility reported incident #100167-I from July 17, 2022 to July 27, 2022.

The facility failed to include all mental illness diagnoses on a Level 1 PASRR (Preadmission Screening and Resident Review) for one resident, which did not meet regulatory requirements. Interviews with staff and review of clinical records confirmed this deficiency.

The inspection was a Recertification Survey conducted from July 6 to July 13, 2021, to assess compliance with federal regulations for continued certification and licensure of the facility.

The facility was found deficient in multiple areas including failure to ensure staff completed mandatory Dependent Adult Abuse training, failure to coordinate PASRR assessments and referrals, failure to follow physician orders, failure to properly store and secure controlled substances, and failure to maintain an effective infection prevention and control program.

The inspection was conducted as an investigation of multiple complaints (#84865, #84872, #92916, #92956, #93729, #94005, #98123, and #98124) and facility reported incidents (#97613 and #97614) from May 10, 2021 to June 1, 2021.

The facility failed to provide bathing and oral hygiene services in accordance with professional standards for 4 of 4 sampled residents unable to carry out activities independently. Additionally, the facility failed to ensure residents received restorative therapies to increase range of motion and prevent further decline for 3 of 3 residents sampled.

Complaints #92916 and #92956 were substantiated. Complaints #84865, #84872, #93729, #94005, #98123, and #98124 were not substantiated. Facility reported incidents #97613 and #97614 were not substantiated.

The inspection was conducted as a Focused Infection Control Survey and complaint investigations related to complaints #94012, #94052, #94054, #94104, and #94315, all of which were substantiated.

The facility failed to administer medications as ordered by the physician for multiple residents, failed to provide adequate bathing services for dependent residents, and failed to properly utilize Personal Protective Equipment (PPE) to mitigate the spread of COVID-19. The facility had 36 out of 62 residents positive for COVID-19 and failed to meet infection prevention and control requirements.

Complaints #94012-C, #94052-C, #94054-C, #94104-C, and #94315-C were all substantiated.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on June 18, 2020, to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.

The facility failed to implement CMS recommended infection control practices to prevent the spread of disease for 2 of 3 sampled residents, including improper use of face masks by staff and failure to maintain social distancing of 6 feet among residents. The facility policy did not adequately address face mask usage.