Oskaloosa Care Center
605 Highway 432, Oskaloosa, IA 52577 · Mahaska County · 83 certified beds · avg 80 residents/day · certified since Sep 4, 2008
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 17, 2025 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 29, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 17, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 29, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 11, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jun 11, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jun 11, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 15, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Apr 15, 2026 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 13, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 17, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Sep 17, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 17, 2025 | D · Potential for harm, one-off | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint |
| Sep 17, 2025 | D · Potential for harm, one-off | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · from a complaint |
| Sep 17, 2025 | D · Potential for harm, one-off | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · from a complaint |
| Sep 17, 2025 | D · Potential for harm, one-off | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. · from a complaint |
| Jun 19, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 23, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 23, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jan 23, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Jan 23, 2025 | D · Potential for harm, one-off | The facility did not make sure resident assessments were done by a qualified health professional. Assessments guide all of a resident's care, so the person doing them must be properly trained. · from a complaint |
| Jan 23, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 1, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Aug 1, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (4 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 9 | 0 | E |
| 2025 | 17 | 2 | J ▲ |
| 2026 | 7 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $45,354.
| Date | Type | Amount / length |
|---|---|---|
| Sep 17, 2025 | Fine | $45,354 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.37 | 4.37 | 3.95 | top 45% in Iowa; top 27% in the U.S. |
| Registered Nurse hours | 0.37 | 0.85 | 0.69 | bottom 3% in Iowa; bottom 17% in the U.S. |
| Weekend total nurse staffing | 3.95 | 3.86 | 3.50 | top 41% in Iowa; top 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.27 | 0.51 | 0.48 | bottom 12% in Iowa; bottom 27% in the U.S. |
| Total nursing staff turnover (%) | 62.6 | 44.0 | 45.8 | bottom 9% in Iowa; bottom 13% in the U.S. |
| RN turnover (%) | 100.0 | 42.1 | 42.9 | bottom 1% in Iowa; bottom 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.66, RN 0.31, weekend 3.31. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 3/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Barbara S. Donohue, Revocable Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2016 |
| Carlson, Kenneth | Individual | 5% or Greater Indirect Ownership Interest | — | 05/19/2008 |
| Donohue, Barbara | Individual | 5% or Greater Indirect Ownership Interest | — | 03/22/2016 |
| Oskaloosa Care Center INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/19/2008 |
| Reitmeier, Ronald | Individual | 5% or Greater Indirect Ownership Interest | — | 05/19/2008 |
| Theobald, Michael | Individual | 5% or Greater Indirect Ownership Interest | — | 05/19/2008 |
| Barbara S. Donohue, Revocable Trust | Organization | ADP of the SNF | NOT APPLICABLE | 03/22/2016 |
| Carlson, Kenneth | Individual | Corporate Director | NOT APPLICABLE | 05/19/2008 |
| Carlson, Kenneth | Individual | Corporate Officer | NOT APPLICABLE | 05/19/2008 |
| Carlson, Kenneth | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/19/2008 |
| Carlson, Kenneth | Individual | ADP of the SNF | NOT APPLICABLE | 05/19/2008 |
| Donohue, Barbara | Individual | ADP of the SNF | NOT APPLICABLE | 03/22/2016 |
| Donohue, Richard | Individual | Corporate Director | NOT APPLICABLE | 05/19/2008 |
| Donohue, Richard | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/19/2008 |
| Donohue, Richard | Individual | ADP of the SNF | NOT APPLICABLE | 05/19/2008 |
| Frymoyer, Cisley | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/28/2025 |
| Frymoyer, Cisley | Individual | ADP of the SNF | NOT APPLICABLE | 01/28/2025 |
| Kdcllc | Organization | ADP of the SNF | NOT APPLICABLE | 05/19/2008 |
| Mahaska County Hospital | Organization | ADP of the SNF | NOT APPLICABLE | 05/19/2008 |
| Mahaska Drug INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/19/2008 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Crystal Heights Care Center | 0.4 mi | Oskaloosa, IA | ★★☆☆☆ | 2/5 | |
| Northern Mahaska Specialty Care | 1.6 mi | Oskaloosa, IA | ★★☆☆☆ | 2/5 | |
| The Cottages | 15.5 mi | Pella, IA | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165589.