Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Oaknoll Retirement Residence during CMS and state inspections, most recent first.
A facility failed to follow professional standards for insulin administration for two residents. An RN did not prime the insulin pen with the required 2 units and did not keep the needle under the skin for the recommended time, as per the manufacturer's instructions and facility policy. This resulted in a deficiency in medication administration practices.
The facility failed to complete neurological assessments for a resident with a history of falls and did not ensure safe wheelchair transport for several residents. Additionally, the facility did not provide appropriate dietary care for a resident requiring pudding-thickened liquids.
The facility failed to maintain secure medication storage when a medication cart was left unlocked and unattended, and Schedule 4 medication was not kept under double lock in two medication storage rooms. Various residents, visitors, and staff were present during these lapses, posing a risk of unauthorized access to medications.
The facility failed to complete a baseline Care Plan within the first 48 hours of admission for a resident with significant cognitive impairments. Despite being admitted with diagnoses of hypertension, non-Alzheimer's dementia, and a depressive episode, the resident's immediate needs were not addressed in a timely manner. Staff interviews revealed confusion and lack of clarity regarding responsibility for care plans, indicating systemic issues in the care planning process.
The facility failed to comprehensively review, revise, or follow Care Plans for two residents, resulting in significant weight loss for one resident and unmanaged anxiety for another. Observations and staff interviews confirmed that the Care Plans lacked necessary updates and interventions.
The facility failed to document behavioral triggers and implement comprehensive care plans for two residents prescribed psychotropic medications. One resident with Alzheimer's and depression exhibited various behaviors, but the care plan lacked specific interventions. Another resident with depression had no documented behavioral symptoms, yet was prescribed psychotropic drugs. The facility's policy on medication review was not adequately followed.
The facility failed to document and coordinate hospice care for two residents. For one resident, the MDS assessment did not document hospice care, and the Care Plan lacked hospice certification and a plan of care. For another resident, the facility did not have a medical order for hospice in the resident's file, despite documentation of hospice care in the Admission Summary. The facility's policy requiring a coordinated plan of care with the hospice provider was not followed.
Failure to Follow Insulin Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for two residents, specifically in the administration of insulin using a flex pen. During observations, a registered nurse (RN) was seen administering insulin to two residents without following the correct procedure. For the first resident, the RN did not prime the insulin pen with the required 2 units before setting it to the prescribed dose of 16 units, and also failed to keep the needle under the skin for the recommended count of 6 seconds to ensure the full dose was delivered. Similarly, for the second resident, the RN primed the pen with only 1 unit instead of the required 2 units before setting it to the prescribed dose of 3 units, and again did not maintain the needle under the skin for the necessary duration. The manufacturer's instructions for the Novolog flex pen clearly state that the pen should be primed with 2 units of insulin before selecting the dose to be administered, and the needle should remain under the skin for a slow count to 6 to ensure the full dose is received. The facility's policy on insulin pen usage, which was reviewed and in place since 2017, aligns with these instructions, emphasizing the need for priming with 2 units and maintaining the needle under the skin for 6-10 seconds. Despite these guidelines, the RN's actions during the medication pass task did not comply with the established procedures, leading to the deficiency noted in the report.
Failure to Ensure Neurological Assessments and Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure neurological assessments were completed for residents with a known history of falls and failed to ensure residents were safely transported via wheelchair. Resident #49, who had cognitive impairments and a history of falls, experienced unwitnessed falls on two occasions. Despite the facility's protocol requiring neurological checks for 24 hours post-fall, no such assessments were documented for these incidents. Additionally, the Director of Nursing was unaware of one of the falls, indicating a lapse in communication and adherence to protocol. Several residents were observed being transported in wheelchairs without foot pedals, which is against safety protocols. Resident #48 was pushed in a wheelchair without pedals, causing her to hold her feet up off the ground. Similarly, Resident #21 was found with her feet trapped under the pedals, unable to move her wheelchair. Other residents, including Resident #4, Resident #8, and Resident #16, were also transported without foot pedals, leading to unsafe conditions where their feet skimmed the floor or were improperly positioned. The facility also failed to provide appropriate dietary care for Resident #8, who required pudding-thickened liquids due to dysphagia. Despite clear instructions and recommendations from the Speech Therapist, the resident was observed with liquids of incorrect consistency on multiple occasions. The care sheets in the resident's wardrobe were outdated and did not reflect the current dietary requirements, leading to staff confusion and improper care. This lack of adherence to dietary protocols posed a significant risk to the resident's health and safety.
Failure to Maintain Secure Medication Storage
Penalty
Summary
The facility failed to maintain secure medication storage when one of three medication carts remained unlocked without staff supervision. On two separate occasions, the South hallway medication cart was observed left unattended and unlocked, with keys hanging from the lock. During these times, various residents, visitors, and staff were present in the area, posing a risk of unauthorized access to medications. Additionally, an ambulatory resident was seen wandering near the unattended cart, further highlighting the potential for a security breach. Staff A, an LPN, was observed leaving the cart unlocked on both occasions before eventually returning to secure it after several minutes. The facility also failed to keep Schedule 4 medication (lorazepam concentrate solution) under double lock in two of three medication storage rooms observed. During a tour of the North hall medication storage room, an open bottle of liquid lorazepam was found in a medication refrigerator without an additional locking system. Similarly, in the South hall medication storage room, another open bottle of liquid lorazepam was found in a medication refrigerator without a double lock. Staff B and Staff C confirmed the absence of additional locking systems for these controlled substances, and the Director of Nursing acknowledged the deficiency and indicated that the facility would address the requirement for double locks on these medications.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline Care Plan within the first 48 hours of admission for one resident. Resident #48, who had diagnoses of hypertension, non-Alzheimer's dementia, and a depressive episode, was admitted on 6/27/23. The Quarterly Minimum Data Set (MDS) for the resident dated 1/31/24 revealed that a Brief Interview for Mental Status (BIMS) could not be administered due to memory problems, disorganized thinking, and inattention. Despite these significant cognitive impairments, the facility did not document the development of a baseline Care Plan or discuss it with the resident's power of attorney within the required 48-hour timeframe. The Care Plan was only updated with various focus areas weeks and months after the resident's admission, indicating a delay in addressing the resident's immediate needs. Observations and interviews with staff revealed systemic issues in the care planning process. The resident's paper chart, located on a different floor from where the resident resided, did not contain a baseline Care Plan. Staff interviews indicated confusion and lack of clarity regarding responsibility for completing care plans. The Director of Nursing confirmed that nursing was not responsible for care plans, and the MDS Coordinator and Assistant Director of Nursing (ADON) were tasked with this duty, with assistance from the Director of Nursing as needed. However, a Licensed Practical Nurse (LPN) stated she had spoken to the ADON about care plans but did not know why the baseline Care Plan for Resident #48 was not completed, highlighting a breakdown in communication and accountability within the facility's care planning process.
Failure to Update and Follow Care Plans for Nutrition and Behavioral Health
Penalty
Summary
The facility failed to ensure the Care Plan was comprehensively reviewed, revised, or followed for two residents. For Resident #35, who had diagnoses including coronary artery disease and hypokalemia, the Care Plan was not updated to address significant weight loss. Despite documented weight loss and a physician's note indicating the resident's inability to understand the importance of nutrition, the Care Plan lacked additional interventions or modifications. Observations revealed that staff did not consistently assist or encourage the resident to eat, as required by the Care Plan, leading to further weight loss and nutritional decline. For Resident #42, who had diagnoses including unspecified dementia and anxiety, the Care Plan was not updated to reflect new diagnoses and behavioral health needs. Despite a referral to a behavioral health provider and new orders to increase medication, the Care Plan lacked documentation of triggers, new diagnoses, and resident-specific behaviors with associated interventions. Observations and interviews with staff confirmed that the resident exhibited increased anxiety and restlessness, but the Care Plan did not include suggested interventions from a psychiatry intake note. The deficiencies in the Care Plans for both residents indicate a failure to comprehensively review, revise, and follow the Care Plans as required. This resulted in inadequate management of the residents' nutritional and behavioral health needs, as evidenced by significant weight loss for Resident #35 and unmanaged anxiety for Resident #42.
Lack of Documentation for Behavioral Triggers and Comprehensive Care Plans
Penalty
Summary
The facility failed to document behavioral triggers related to the use of psychotropic medication and did not implement a comprehensive care plan for two residents. Resident #33, who has Alzheimer's disease and depression, was prescribed Zoloft, Trazadone, and Risperidone. The care plan for Resident #33 lacked specific behaviors or triggers associated with these medications. Behavioral monitoring documented various behaviors such as wandering, kicking, hitting, grabbing, and abusive language, but the care plan did not include potential interventions or triggers for these behaviors. Progress notes indicated that the resident had challenges expressing needs due to dementia, but these triggers were not documented in the care plan. Resident #36, diagnosed with congestive heart failure, type 2 diabetes, and an unspecified mood disorder, was prescribed Wellbutrin and Cymbalta for depression. The care plan for Resident #36 also lacked documentation of specific triggers and associated behaviors to support the need for psychotropic drug use. Behavioral monitoring indicated that Resident #36 did not display any behavioral symptoms during the review period. The facility's policy on medication regimen review emphasized the need for adequate monitoring and indications for drug use, but this was not reflected in the care plans for the residents reviewed. The facility administrator reported that the team focuses on medication reviews and gradual dose reductions, and staff are educated on documenting behaviors and interventions. Non-pharmacological interventions such as music therapy, massage, redirection, and distraction are utilized. However, the care plans for the residents reviewed did not include specific behavioral triggers or interventions, leading to the administration of unnecessary medications without adequate documentation and monitoring.
Failure to Document and Coordinate Hospice Care
Penalty
Summary
The facility failed to document an agreement and collaboration between the facility and hospice for two residents receiving hospice care. For Resident #12, the Quarterly Minimum Data Set (MDS) assessment dated 3/20/2024 did not document that the resident was on hospice care, despite a pharmacist note from 12/27/2023 indicating hospice enrollment. Additionally, the Care Plan dated 6/12/2019 and revised on 3/20/2024 did not include hospice certification and a plan of care. For Resident #107, the Admission MDS assessment dated 3/25/2024 documented hospice care, but the facility did not have a medical order for hospice in the resident's file. The Admission Summary from 3/14/2024 noted hospice care and other relevant details, but the facility failed to document a coordinated plan of care with the hospice provider. During interviews, the facility Administrator and Director of Nursing (DON) acknowledged that new orders for medication, treatment, or symptom management would be documented in hospice notes entered by the hospice provider via Interdisciplinary Communication. However, they also noted that only the DON and the facility Social Worker had access to this communication. The facility's policy dated 2/26/2024 required the hospice provider to furnish the facility with a copy of the Hospice Provider Plan of Care, identifying the services to be provided by both the facility and the hospice provider. This policy was not followed, leading to the deficiency in documentation and coordination of hospice care for the two residents reviewed.
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What surveyors actually found near you
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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.
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Nursing homes near Iowa City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarwood Healthcare Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Iowa City Rehab & Health Care | 4 mi | ★★★★★ | 27 | 0 |
| Lantern Park Specialty Care | 4.2 mi | ★★★★★ | 0 | 0 |
| Windmill Manor | 4.8 mi | ★★★★★ | 12 | 0 |
| Crestview Specialty Care | 10.7 mi | ★★★★★ | 15 | 1 |
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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.