Oskaloosa home cited for series of alleged errors in resident death

The Oskaloosa Care Center in Mahaska County. (Photo via Google Earth)

by Clark Kauffman, Iowa Capital Dispatch
October 23, 2025

State officials have cited an Oskaloosa nursing home where a resident died after the staff couldn’t locate a crash cart, forgot to summon an ambulance and failed to realize the resident had standing orders in place for CPR to be administered.

The Oskaloosa Care Center, a 76-resident nursing home in Mahaska County, has been cited by the Iowa Department of Inspections, Appeals and Licensing with failing to carry out cardiopulmonary resuscitation, or CPR, in accordance with a resident’s wishes, and for workers’ inability to locate the facility’s crash cart, which had a defibrillator on board for restoring a patient’s heartbeat in cases of cardiac arrest.

According to the state agency, these failures placed residents of the home in immediate jeopardy.

State inspectors allege that on the morning of Sept. 8, 2025, a certified nursing assistant and registered nurse entered a male resident’s room and found the man slumped over in his recliner and in distress – gasping, sweating profusely and stating he needed to sit.

According to the inspectors’ reports, one of the workers left the room to obtain equipment to check the man’s vital signs, at which point the man’s eyes rolled back in his head as if he was having a seizure.

The director of nursing arrived in the room and instructed a licensed practical nurse to call an ambulance and verify the resident’s “code status,” which would indicate whether the resident either had a do-not-resuscitate, or DNR, order in place, or wished to have potentially lifesaving measures, such as CPR, administered.

After one worker left the room to check the resident’s code status, a nurse communicated over a two-way radio that the resident had a do-not-resuscitate order in place. The staff then concluded the resident was dead and began to clean and clothe the body for the family’s viewing, according to inspectors.

While one worker began the process of contacting the resident’s family, she noticed in the resident’s chart that the man was listed as “full code” — indicating life-saving procedures were to have been performed. She then reviewed other records and confirmed that information.

According to state inspectors, the staff elected not to perform CPR at that point due to the man’s lack of responsiveness, ashen color, blotchy skin and lack of a pulse.

A certified nursing assistant later told inspectors that shortly after the resident was found in distress, two of her co-workers began looking for the home’s crash cart but could not find it. The aide told inspectors she was able to locate the cart, noting that it was marked with a sign that read “AED,” for automated external defibrillator.

According to the inspectors, the CNA noted that for residents designated “full code,” there was supposed to be a green sticker on the outside of their door — adding that there was such a sticker in this case, but it was located on the roommate’s side of the door, so the staff presumed the resident who died had a DNR order in place.

The director of nursing allegedly told inspectors the resident’s door did not contain the correct sticker due to a recent room change, adding that she would have started CPR had she known the man was “full code” but believed she could trust the information given to her by the nurse.

It was later determined that no one had ever called the ambulance and, according to inspectors, the worker who was tasked with that responsibility explained she “forgot to call” while searching for the crash cart.

As a result of the incident, the inspections department proposed, but then held in a suspension, a $10,000 fine. The state fine is being held in suspension so that the Centers for Medicaid and Medicare Services can determine whether a federal penalty should be imposed in its place.

Fine proposed for separate incident

The inspections department also proposed, and held in suspension, a fine for a separate incident involving the staff’s failure to adequately respond to a lethargic female resident’s complaints of chest pain. The resident was later taken to a hospital where it was determined she had suffered a heart attack.

Workers at the home allegedly told inspectors they had reported the resident’s worsening condition to a nurse. The nurse, they said, “dismissed” their concerns, “acted like it was no big deal,” and then asserted the resident was merely “playing possum.”

According to inspectors, when they later interviewed the nurse and asked whether she thought she should have notified the woman’s physician of the situation, the nurse refused to answer.

State records provide conflicting information as the size of the suspended fine stemming from that incident, with some of the records stating $9,000 and some stating $9,500.

Iowa Capital Dispatch is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Iowa Capital Dispatch maintains editorial independence. Contact Editor Kathie Obradovich for questions: info@iowacapitaldispatch.com.