Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Oelwein Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia developed an unexplained bruise above the right eye that staff observed and documented, but the provider and family were not notified for 8 days. Multiple staff members saw the bruise over several shifts and described it as worsening, while the resident’s sister later reported the injury to the DON. Interviews confirmed that nurses were expected to document the injury, complete an incident report, and notify the MD and family promptly.
Incomplete hospital transfer documentation was found for two residents whose records lacked copies of transfer paperwork. One resident was cognitively intact, dependent for transfers, and had diagnoses including malnutrition, a pressure ulcer, and paraplegia; the other was cognitively intact with paraplegia, diabetes, and anxiety and was transferred for sepsis and a UTI. The DON stated the nurse failed to copy the paperwork sent with both residents, and staff identified required transfer documents such as the Resident Transfer Sheet/Record, MAR, TAR, immunization records, advance directives, and pertinent lab or x-ray results.
The facility failed to timely transmit a DRNA assessment for a resident who had discharged from the facility. The assessment was completed and later accepted in iQIES, but an LPN said she believed it remained marked not to submit because the resident had Medicare Advantage coverage and that she usually waited for DON sign-off before weekly transmission. The CMS LTC RAI Manual required transmission within 14 days of completion, but the record was sent far later than required.
A resident’s MDS was coded with schizophrenia based on old records rather than current documentation. The resident had intact cognition and current diagnoses of GAD, depression, agoraphobia with panic disorder, PTSD, and major depressive disorder, while the PMHNP stated she had not diagnosed schizophrenia or schizoid personality disorder and did not view those old diagnoses as relevant to the resident’s current condition. The LPN and DON both relied on the historical 1990 diagnosis when entering/coding quetiapine and schizophrenia, even though current provider notes did not support schizophrenia.
The facility failed to document provider notification for repeated critical blood glucose values for two residents with diabetes, including severe hypo- and hyperglycemia. The facility also failed to complete timely neuro assessment after an unexplained bruise was found on a resident’s head/face; staff noted the injury over several days, but the record lacked prompt follow-up documentation. The DON confirmed the chart lacked physician notification for one resident’s abnormal blood sugars, and staff stated a neuro exam would be expected for a new head bruise.
A resident with dysphagia, a mechanically altered diet, and documented coughing during meals was allowed to be fed by PNAs even though the care plan and swallow study identified aspiration concerns and safe-swallow precautions. Staff interviews showed PNAs assisted the resident routinely, one PNA reported coughing after every drink, and the DON stated the facility did not have residents PNAs could not assist, despite policy limiting residents with recurrent aspiration or difficulty swallowing to licensed or certified staff.
Failure to Perform Hand Hygiene and Proper Commode Cleaning: A CNA assisted a resident with a commode and handled a pan with visible BM without consistent hand hygiene. The CNA removed gloves multiple times without washing hands, carried the contaminated pan to the dirty utility room, left visible BM on the rim after rinsing, and completed only a brief hand wash. The resident reported staff often did not wash hands or use sanitizer after emptying the commode bucket, and an LPN and the DON verified the hand hygiene concerns.
A facility failed to complete a Significant Change Status Assessment (SCSA) MDS in a timely manner for a resident who elected hospice services. Despite the resident's admission to hospice care, the facility did not document hospice as the primary payer, and the SCSA MDS was not completed within the required timeframe. Interviews revealed a lack of awareness and communication among staff regarding the completion of the SCSA MDS.
A facility failed to update a resident's Care Plan to include hospice services, despite the resident being on hospice care. The resident had moderate cognitive impairment and other health conditions. The MDS Coordinator acknowledged the oversight, and the DON confirmed the MDS Coordinator's responsibility for Care Plan updates.
Improper food handling practices were observed during the preparation of pureed meals, where a dietary staff member used a single gloved hand to handle buttered bread slices, risking cross-contamination. The Dietary Manager confirmed the staff member should have used tongs and acknowledged the facility lacked a specific food handling policy, relying instead on the Iowa Food Code.
A facility failed to accurately complete the MDS for a resident, incorrectly documenting the use of a feeding tube. Observations and staff interviews confirmed the resident did not have a feeding tube, and the MDS coordinator admitted the error. The facility lacked a specific policy for MDS completion, relying on the RAI 3.0 User's Manual.
The facility inaccurately reported staffing information to CMS for FY Quarter 1, as the PBJ report indicated low weekend staffing despite daily sheets and schedules showing over 2.0 hours per resident per day. Observations confirmed residents were well cared for. The Administrator, DON, and HR stated that the corporate office handles PBJ data submission without a preliminary review.
Delayed Notification of Significant Facial Bruising
Penalty
Summary
The facility failed to notify the provider and family of a significant injury for Resident #17 after staff identified an unexplained bruise to the right eye. Staff first documented the bruise on 3/15/26, describing it as approximately 2 cm by 2 cm above the right eye, but the clinical record did not show notification to the medical provider or family until 3/23/26, creating an 8-day delay. The resident’s record showed severe cognitive loss, Alzheimer’s disease and non-Alzheimer’s dementia, hallucinations, rejection of care, and physical and verbal behaviors toward others, with no documented upper or lower extremity range-of-motion impairments and independence with sit-to-stand transfers and walking. Interviews showed multiple staff members observed the bruising over several days, with some describing it as worsening and moving around the right eye. The resident’s sister stated she noticed the bruise during a visit and reported it to the DON on 3/23/26. An ARNP stated staff should notify her immediately when unexplained bruising is found on the face or head and said the 8-day delay was inappropriate. Staff interviews indicated nurses should document the bruise, complete an incident report, and notify the doctor and family, while the DON stated she first became aware of the situation when the sister reported it. The facility policy directed immediate notification of the resident, physician, and legal representative or family member when an accident results in injury with potential for physician intervention.
Incomplete Hospital Transfer Documentation in Resident Records
Penalty
Summary
The facility failed to maintain a complete medical record for 2 of 4 sampled residents by not keeping copies of hospital transfer documentation in the clinical records. Resident #4 had a BIMS score of 15 on the MDS, indicating she was cognitively intact, and required staff dependence for transfers, did not walk, and had diagnoses including malnutrition, a pressure ulcer, and paraplegia. A progress note documented that an ambulance transported Resident #4 to the hospital, and the resident later stated she required a mechanical sling lift with two-person assistance for all transfers and that her last hospitalization was for an infection. Resident #8 also had a BIMS score of 15 and diagnoses of paraplegia, diabetes, and anxiety. A health status note documented that Resident #8 entered the local hospital for sepsis and a UTI. The DON stated the nurse on shift failed to copy the transfer paperwork sent with Resident #4 and Resident #8 during their hospitalizations, and staff interviews identified the documents that should accompany a resident to the hospital, including the Resident Transfer Sheet/Record, MAR, TAR, immunization records, advance directives, and pertinent lab or x-ray results. During interview, the DON reported she could not locate the hospital transfer paperwork for either hospitalization and noted the hospital retained some documentation from Resident #4's transfer.
Delayed Transmission of DRNA Assessment
Penalty
Summary
The facility failed to ensure timely transmission of the Discharge Return Not Anticipated (DRNA) assessment for Resident #34. Record review showed the resident discharged from the facility on 11/21/25, the DRNA assessment was completed on 11/26/25, and it was not locked until 3/24/26. The MDS Assessment History showed iQIES accepted the DRNA record on 3/24/26, and a Batch Report dated 3/25/26 documented the acceptance of the assessment. During interview, an LPN stated she believed the discharge record remained marked not to submit because the resident used a Medicare Advantage plan, and she normally waited for the DON to sign off on MDS records before transmitting them each week. The CMS LTC RAI Manual directed that the DRNA be transmitted within 14 days of the completion date, but this assessment was transmitted 118 days after the required completion date.
Inaccurate MDS Diagnosis Coding
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when it coded schizophrenia on the MDS without current supporting documentation showing the diagnosis was active or directly related to the resident’s current status. Resident #7’s admission MDS documented intact cognition with a BIMS score of 15/15 and listed active diagnoses of generalized anxiety disorder, depression, and agoraphobia with panic disorder, along with antianxiety and antidepressant medications. The record also included a 1990 hospital discharge summary showing schizophrenia, residual type, and schizoid personality disorder, but that document did not show current treatment with quetiapine at that time. Later behavioral health notes documented quetiapine prescribed for major depressive disorder, PTSD, and GAD, and a therapist visit note listed GAD, schizoid personality disorder, and agoraphobia with panic disorder. Facility provider visit notes listed an active problem list but did not include a current diagnosis of schizophrenia or schizoid personality disorder, even though quetiapine remained ordered. The quarterly MDS documented a new diagnosis of schizophrenia and antipsychotic medication use, but it lacked documentation of active delirium, behaviors, hallucinations, or delusions. During interviews, the PMHNP stated she had started quetiapine for panic-type anxiety, agoraphobia, and PTSD, had seen the old 1990 schizophrenia documentation, but had not diagnosed the resident with schizophrenia or schizoid personality disorder and did not consider those diagnoses relevant to the resident’s current condition. The LPN stated she coded schizophrenia on the MDS after receiving the old records and did not verify whether the diagnosis remained current. The DON stated she entered the quetiapine order using the 1990 schizophrenia diagnosis, later confirmed there was no documentation supporting schizophrenia, and identified the MDS entry as a coding error.
Failure to Notify Providers of Critical Blood Sugars and Assess Unexplained Head Injury
Penalty
Summary
The facility failed to ensure clinical monitoring and physician notification for critical blood glucose values for Resident #5. The resident’s MDS documented a BIMS score of 15, indicating she was cognitively intact, and noted diagnoses including diabetes, fracture, and long-term insulin use. Her blood sugar summary showed multiple readings below 60 mg/dL and above 450 mg/dL, including values of 58, 461, 483, 55, 43, 457, and 515 mg/dL. The record review found no documentation in the progress notes that the provider was notified of these abnormal results. Resident #25 also had repeated severe hyperglycemia without documented physician notification. The resident’s MDS documented diagnoses including type 2 diabetes mellitus with diabetic neuropathy, schizoaffective disorder, chronic kidney disease, heart failure, and obesity. The EHR progress notes lacked documentation that the physician was notified of blood glucose readings above 450 mg/dL, including 480, 483, 510, 539, 522, and 533 mg/dL. During interview, the DON stated that staff were expected to notify the physician when blood sugars were outside parameters, and later confirmed the chart lacked documentation of physician notification. The facility also failed to perform neurological assessment and timely follow-up for Resident #17 after an unexplained bruise was found on the head/face. The resident’s MDS documented severe cognitive loss, hallucinations, behaviors toward others, rejection of care, and diagnoses of Alzheimer’s disease and non-Alzheimer’s dementia. Staff discovered a bruise to the right eyebrow and documented it in a progress note, but the record lacked documentation of further assessment or neurological assessment for 8 days. Multiple staff later reported seeing the bruise over several days, and the DON stated the normal process was to measure the area, document an incident report, and place the resident on alert charting for observation and vital signs, but those steps were not documented at the time the bruise was first identified.
PNA Assisted Resident With Dysphagia and Coughing During Meals
Penalty
Summary
The facility failed to ensure that a resident with dysphagia and a high risk for aspiration was fed only by licensed or certified staff. Resident #20’s MDS identified a mechanically altered diet, and the care plan directed assistance with eating and monitoring for signs and symptoms of aspiration or difficulty swallowing. A video swallow study documented coughing during meals, a diagnosis of dysphagia, and recommendations for pureed food with mildly thick liquids and strict safe swallow precautions, including small bites and sips and a slow rate of intake. Despite these findings, the PNA-Resident Dining assessment determined that Resident #20 could eat with the assistance of a PNA. Staff interviews showed PNAs assisted the resident with meals on a regular basis, and one PNA reported the resident coughed after every drink and that she did not report the coughing to the nurse. The DON stated the facility did not have residents that PNAs could not assist, and later stated a PNA may assist if Speech Therapy approved, while also expecting the PNA to get a nurse if the resident started choking or coughing. The facility policy stated residents with recurrent lung aspiration or difficulty swallowing are to be fed only by nurses, nurse aides, or other licensed health professionals.
Failure to Perform Hand Hygiene and Proper Commode Cleaning
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during the cleaning of a commode for Resident #3. Resident #3 had a BIMS score of 15 out of 15 on the MDS dated 1/13/26, indicating intact cognition, and the care plan identified a risk of chronic urinary disturbance with interventions to encourage commode use and assist as needed. During an initial interview, Resident #3 stated that only one CNA washed hands after emptying her commode bucket, that only 2 to 3 CNAs wore gloves to clean the bucket, and that she did not see staff wash hands or use hand sanitizer afterward. She also reported that staff sometimes refilled her water pitcher immediately after handling the commode. During observation, Staff D, a CNA, assisted Resident #3 with the commode and removed a pan containing visible bowel movement. Staff D placed the dirty pan half-tipped on the roommate’s toilet seat, removed gloves, and opened a drawer to get a plastic bag without performing hand hygiene. Staff D then put on new gloves, placed the dirty pan in the bag, returned it to the commode, changed gloves again without hand hygiene, and carried the commode more than 60 feet to the dirty utility room. There, Staff D rinsed the pan but visible bowel movement remained in three places on the rim, removed gloves and left the room without hand hygiene to get cleaning chemical, returned with a glove on only one hand without washing hands, sprayed the pan, and then washed hands for about five seconds. An LPN verified that Staff D left the utility room without washing hands and that visible bowel movement remained on the pan, and the DON stated that best practice is hand hygiene after glove removal and that the facility policy required a 15 to 20 second hand wash.
Failure to Timely Complete SCSA MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) Assessment in a timely manner for a resident who elected hospice services. The resident was referred for hospice care services, and the family agreed to a hospice consultation. The hospice care provider scheduled an onsite visit, and the resident was admitted to hospice care services. However, the facility did not document hospice as the primary payer in the Electronic Healthcare Record (EHR) census detail page, and the SCSA MDS was not completed within the required timeframe. Interviews with facility staff revealed a lack of awareness and communication regarding the completion of the SCSA MDS. The MDS Coordinator, responsible for completing all required MDS assessments, acknowledged the oversight and stated that the SCSA MDS should have been completed by a specific date. The Director of Nursing (DON) was unaware of the required completion timeframe and needed to consult with the MDS Coordinator. The failure to complete the SCSA MDS within the required timeframe was acknowledged by the MDS Coordinator, who admitted the oversight.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to revise and implement interventions on the comprehensive Care Plan to include hospice services for a resident who was on hospice care. The resident, identified with moderate cognitive impairment, non-traumatic brain dysfunction, heart failure, diabetes mellitus, and non-Alzheimer's dementia, had a Hospice Election Packet signed by a family member with a start of service date. However, the Care Plan initiated for the resident did not include a focus area for a terminal prognosis with the election of hospice care services, nor did it provide interventions directing staff on the care to be provided. During an interview, the MDS Coordinator acknowledged that the Care Plan should have been updated to reflect the election of hospice care services. The Director of Nursing (DON) confirmed that the MDS Coordinator is responsible for updating and revising the Care Plan.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to utilize proper food handling procedures to prevent potential cross-contamination of food, which could lead to foodborne illness. During the preparation of pureed meals, Staff B, a dietary staff member, was observed using a single glove on her left hand to remove a green lid from a container holding buttered bread slices. Staff B then reached into the container with the same gloved hand to remove four slices of buttered bread, which were placed into a food processor with green beans. This action did not adhere to proper food handling practices, as it posed a risk of cross-contamination. During an interview, Staff C, the Dietary Manager, acknowledged observing Staff B's actions and confirmed that Staff B should have used tongs to handle the bread, as previously instructed. It was also revealed that the facility lacked a specific policy for food handling and instead followed the current Iowa Food Code. The Iowa Administrative Code mandates that food must be processed, stored, and distributed in a manner that protects it from contamination, including cross-contamination and allergen cross-contact.
Inaccurate MDS Assessment for Resident's Feeding Tube Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the health status of a resident. The MDS for this resident incorrectly documented the use of a feeding tube, despite observations and staff interviews confirming that the resident did not have a feeding tube. The Director of Nursing confirmed that the resident had never had a feeding tube, and the MDS coordinator acknowledged the error in coding. Additionally, the facility lacked a specific policy for completing MDS assessments, relying instead on the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual.
Inaccurate Staffing Reporting to CMS
Penalty
Summary
The facility failed to completely and accurately report the required staffing information to the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 1. The Payroll Based Journal (PBJ) report, compiled by CMS, indicated excessively low weekend staffing. However, a review of daily staffing sheets and nursing department schedules showed staffing levels over 2.0 hours per resident per day. Observations from March 24 to March 27, 2025, revealed that residents were well cared for, being out of bed, dressed, clean, and well kempt, with no odors and made beds. During an interview, the Administrator, Director of Nursing (DON), and Human Resources explained that the PBJ data is submitted by their corporate office, and they do not receive a preliminary report to review for accuracy.
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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 Oelwein
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grandview Healthcare Center | 0.2 mi | ★★★★★ | 5 | 0 |
| Maple Crest Manor | 12.8 mi | ★★★★★ | 0 | 0 |
| Rehabilitation Centers Of Independence West Campus | 13.8 mi | ★★★★★ | 14 | 1 |
| Buchanan County Health Center | 14 mi | ★★★★★ | 4 | 0 |
| Hillcrest Home | 16.1 mi | ★★★★★ | 0 | 0 |
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