Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northern Mahaska Specialty Care during CMS and state inspections, most recent first.
A dietary service failure occurred when residents on pureed and mechanical soft diets did not receive the planned portions and menu items during lunch service. Staff pureed the meat and vegetables, but pureed residents did not receive the wheat roll listed on the menu, and the DM stated bread should be included when the entree is pureed. Staff also used scoop sizes and extra portions for the mechanical soft meal. In a separate event, a resident with GERD, DM, and abdominal distention was placed on a clear liquid diet, but a dietary aide added applesauce to the tray after a cook said it was acceptable, even though the DM confirmed applesauce was not a clear liquid and the menu/manual listed only clear liquid items such as broth, juice, gelatin, popsickles, and tea.
The facility failed to follow infection control practices for COVID precautions and EBP. Staff were observed entering resident rooms with inconsistent PPE, with no N95s available outside some COVID rooms, and staff interviews showed confusion about isolation, exposure, testing, and masking. For a resident with an indwelling catheter, a CNA performed catheter emptying and handling without a gown and did not complete proper hand hygiene after the task.
A resident with spinal stenosis, neuropathy, and diabetes had multiple pain-related orders and documented complaints of back pain, spasms, and severe pain, including pain rated 10/10 and use of an electric wheelchair due to pain with ambulation. However, the resident’s care plan did not include pain or staff directives for pain management, and the MDS Coordinator confirmed that a pain focus area should have been included.
Inappropriate AED Use on a Conscious Resident: An LPN applied an AED to a resident with fever, altered MS, tachycardia, low O2 sat, and tremors, then delivered a shock even though the resident was conscious and breathing. EMS and hospital records stated the resident was not pulseless or unresponsive, and the ED noted the resident was awake and alert with baseline tremors. Facility policy and the AED guide stated the device is for suspected cardiac arrest with no pulse, no normal breathing, and unresponsiveness.
A resident with intact cognition and multiple diagnoses was found crying and upset, alleging that a staff member had thrown something at her. Despite being informed of the incident, the DON did not report the allegation to the state agency within the required two-hour timeframe, initially perceiving it as a customer service issue. The facility administrator later took steps to investigate, but the delay in reporting violated mandatory reporting requirements.
A cognitively impaired resident accessed an unsecured firearm brought into the facility by an LPN, who failed to report the incident. The resident, diagnosed with severe cognitive loss, moved a treatment cart to access the purse containing the gun. Other staff were aware but did not report the incident until much later, violating the facility's policy prohibiting firearms on the premises.
Incorrect Therapeutic Diet Portions and Inappropriate Clear Liquid Tray Item
Penalty
Summary
The facility failed to serve the appropriate portions for residents on pureed and mechanical soft diets during lunch meal service. The Cycle Day 4 Diet Spreadsheet identified a pureed lunch of deviled pork chop, squash, and a wheat roll, and a mechanical soft lunch of a 3 oz portion of deviled pork chop. During observation, dietary staff pureed six pork chop patties and squash, then used scoop sizes based on the amount pureed and the posted serving chart. At meal service, 3 of 3 residents on a pureed diet received pureed pork chop and pureed squash, but did not receive the wheat roll listed on the spreadsheet. The Dietary Manager stated the pureed residents should receive the correct portions of pureed meat, starch, fat, and vegetable, and that bread should be added when the entree is pureed. The manager also stated there were about 13 residents on a mechanical soft diet and extra portions were added so there would be enough, while the mechanical soft serving size was the same as the regular diet. The facility also served the wrong item to a resident on a clear liquid diet. Resident #84 had diagnoses of GERD, diabetes, and postprocedural complications and disorders of the digestive system, and the care plan identified risk for altered nutritional status related to GERD and diabetes. The resident had a new order for a clear liquid diet for abdominal distention after complaints of abdominal firmness and emesis, and after an abdominal x-ray was ordered. During tray preparation, a dietary aide asked whether applesauce could be given to the resident on a clear liquid diet, and the cook said yes. Applesauce was then placed on the resident’s tray and later observed at the bedside with the meal ticket indicating a clear liquid diet. Staff interviews showed the cook relied on experience and did not check the clear liquid list, while the Dietary Manager confirmed applesauce was not considered a clear liquid and referred to the Simplified Diet Manual for clear liquid items. The Daily Menu for a Clear Liquid Diet listed broth, apple juice, gelatin, popsickles, and tea, and the Simplified Diet Manual described clear liquids as see-through liquids and prohibited pulp-containing items. The report also noted the facility’s Pureed Food Preparation Policy required correct portions of pureed meat, starch, fat, and vegetable, and allowed bread and butter as planned on the menu, but the observed meal service did not match the planned pureed menu items.
Infection Control Failures During COVID Precautions and Catheter Care
Penalty
Summary
The facility failed to implement infection prevention and control practices consistent with CDC guidance for COVID precautions and Enhanced Barrier Precautions. Record review showed care plans for multiple residents with COVID-19 infection did not specify the type of isolation, even though the EHR contained orders for droplet or contact isolation precautions. During observations, staff entered and exited resident rooms with varying PPE use, and several rooms with COVID-related signage had supplies outside the door that included gowns, surgical masks, face shields, and gloves, but no N95 masks were present in the containers. The facility also had no signage on the front door indicating outbreak status during one observation, and later a COVID outbreak sign was observed at the entrance. For one resident with COVID-19, a CNA was observed donning gown, gloves, and a surgical mask to deliver a room tray, then exiting the room after removing PPE. In another observation, a CNA entered the resident’s room wearing a surgical mask, face shield, gown, and gloves, but no N95 mask, despite the presence of both EBP and droplet precaution signs outside the room. A separate observation showed a CMA entering the same resident’s room with a beverage cup, then leaving the room and walking down the hall and toward the dining room while still wearing a white hair covering. Staff interviews reflected confusion about COVID exposure, testing, masking, and the type of isolation being used, and the ADON stated the facility was not following CDC guidance for testing and masking as written in its policy. The facility also failed to perform hand hygiene after catheter care for a resident with an indwelling urinary catheter. The resident’s MDS identified renal insufficiency and diabetes, and the care plan and EHR indicated EBP due to the catheter. During observation, a CNA emptied the catheter into a graduate, handled the catheter equipment, rinsed the graduate, removed gloves, and used hand sanitizer before leaving the room, but did not wear a gown during the catheter care. The facility’s EBP policy identified urinary catheter care as a high-contact activity requiring gown and gloves, and the hand hygiene policy stated handwashing is the final step after removing PPE and that gloves do not replace handwashing.
Failure to Include Pain in the Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan that included pain management for one resident with spinal stenosis, neuropathy, and diabetes. The resident’s admission MDS comprehensive assessment documented that the resident took pain medication but had no pain in the past 5 days during the look-back period, and the CAA did not trigger pain. However, the care plan initiated on 8/20/25 did not include information about the resident’s pain or staff directives for pain management interventions, even though the EHR orders included pain-related monitoring and medications such as pain checks every shift, gabapentin, lidocaine patches, Biofreeze PRN, and later oxycodone and diazepam for pain and spasms. Progress notes documented multiple pain-related complaints and interventions after admission, including muscle spasms in the legs and abdomen, low back pain rated 5, intense sharp lower back pain radiating down the left leg, pain rated 10 out of 10 with follow-up pain still at 7, severe spinal stenosis pain that was especially intense in the morning, bilateral knee pain, and use of an electric wheelchair due to pain with ambulation. In interview, the MDS Coordinator stated she completed the MDS assessments and care plans and confirmed that a pain focus area should have been included on the care plan. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed for each resident and is developed within seven days of completion of the comprehensive MDS assessment.
Inappropriate AED Use on a Conscious Resident
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing interventions, including the use of an AED and administering a shock on a conscious, breathing resident. The deficiency involved one resident who had severe cognitive impairment and diagnoses including CAD, HF, dementia, COPD, anxiety, depression, and schizophrenia, and who also had shortness of breath when lying flat and was receiving antipsychotic, antidepressant, and anticoagulant medications. The resident developed a change in condition with fever, altered mental status, abnormal vital signs, shortness of breath, hypotension, tachycardia, and low oxygen saturation. Nursing documentation described worsening findings, including a pulse reported as high as 250 beats per minute and oxygen saturation in the 70s on room air. The nurse documented inability to auscultate an apical pulse or palpate a radial pulse, and an AED was applied. The AED advised a shock, and one shock was delivered even though the resident was conscious and breathing. After the shock, the nurse documented that the resident’s tremors slowed, breathing returned to normal, pulse and oxygen saturation improved, and the resident became more alert. Hospital and EMS records stated the resident was not reported to be pulseless or unresponsive and was awake and alert on scene. The ED physician documented that EMS reported the nursing home connected an AED to the resident and shocked him even though he was reportedly not unconscious. The resident was noted to have generalized intermittent shaking and tremors, and he reported that he always shakes. Interviews with staff showed that the nurse used the AED because she believed it would detect whether the resident needed a shock, despite the resident being responsive. The facility’s AED guide and policy stated the AED is for use when a victim is unconscious, not breathing normally, and has no pulse or signs of circulation, and that it should not be used when a patient is conscious, breathing, or has a detectable pulse.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe after staff became aware of the situation involving a resident. The resident, who had intact cognition and was diagnosed with Bipolar Disorder, End Stage Renal Disease, and atrial fibrillation, was found crying and upset in her room by a CNA. The resident alleged that a staff member had thrown something at her and treated her poorly. The incident occurred after lunch and before the resident was scheduled to leave for an appointment. The facility's Van Driver, who was present during the incident, reported the resident's distress to the Director of Nursing (DON). Despite being informed of the resident's upset state and the allegation, the DON initially perceived the situation as a customer service issue rather than a potential abuse case. The DON did not report the allegation to the State Department of Inspections, Appeals, and Licensing (DIAL) on the day of the incident or the following day, as required by facility policy. The facility administrator became aware of the situation two days later and took steps to investigate the allegation, including suspending the staff member involved pending investigation. However, the delay in reporting the allegation to the state agency constituted a failure to comply with the mandatory reporting requirements for abuse allegations, as the facility policy dictates that such allegations must be reported within two hours of staff becoming aware of them.
Resident Accesses Unsecured Firearm in Facility
Penalty
Summary
The facility failed to maintain a safe environment free from hazards when an employee brought a loaded handgun into the facility, which was left unsecured at the Nurse's Station. This lapse in safety protocol allowed a cognitively impaired resident, who had a history of fidgeting and seeking out objects, to gain access to the purse containing the firearm. The resident, who was diagnosed with non-Alzheimer's dementia and had severe cognitive loss, was able to move a treatment cart and access the purse, although the gun was not removed from the purse. The incident was not immediately reported to management, as the staff member involved, an LPN, did not disclose the event due to fear of getting into trouble. Other staff members, including a CNA and an RN, were aware of the situation but did not report it until much later. The RN had advised the LPN to report the incident, but it was only brought to the attention of the facility's administration after another staff member learned of it and contacted the Administrator. The facility's policy clearly prohibited firearms on the premises, and staff were instructed to report any such violations immediately. However, the failure to adhere to these policies and the delay in reporting the incident resulted in a significant safety breach. The resident's Power of Attorney was informed of the need to find a more suitable care setting for the resident but was not initially informed about the presence of a gun in the facility.
Removal Plan
- All Nursing Staff educated on: Firearms and weapons are not allowed on the premises, this includes in a vehicle in the parking lot.
- Keep your personal belongings in your vehicle or the breakroom, not in public areas accessible to residents.
- If the person being reported is your supervisor, please go to the next person in charge.
- If a person or staff member enters facility carrying a weapon, who is not required to carry a weapon (i.e., a law enforcement officer) they will be asked to remove the weapon from the premises. If they refuse to do so, police will be contacted. Staff will move residents and other staff away from situation. Staff will notify manager on duty.
- Education will be completed with new staff or contracted staff prior to the start of their next shift.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 93 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oskaloosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oskaloosa Care Center | 1.6 mi | ★★★★★ | 11 | 1 |
| Crystal Heights Care Center | 1.6 mi | ★★★★★ | 1 | 0 |
| The Cottages | 16 mi | ★★★★★ | 15 | 0 |
| Montezuma Specialty Care | 19.4 mi | ★★★★★ | 6 | 0 |
| Oakwood Specialty Care | 22.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Northern Mahaska Specialty Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.