Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Heritage Gardens Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not consistently provide scheduled activities on weekends, as shown by activity calendars and confirmed by resident and staff interviews. While occasional church services, music, or movies were provided, there was no structured weekend activity program, despite facility policy requiring ongoing activities to support residents' well-being, including those with cognitive impairments.
Dietary staff did not follow approved recipes when preparing pureed meals for eight residents on a puree-textured diet, instead adding extra gravy to pureed pork chops, which altered the nutritional content. Facility policy required adherence to ordered diet texture and consistency.
Two residents' BIPAP masks and nasal cannulas were not stored in a sanitary manner, with equipment found on bedside tables, in wheelchairs, and wrapped around oxygen canisters, contrary to facility protocols requiring storage in dated, labeled bags. Staff interviews confirmed the correct procedures were not followed.
Several residents did not have documentation showing that the PCV20 vaccine was offered or declined, nor records of prior administration or contraindications. Nursing staff reported that immunization status was checked on admission and information was sent to the pharmacy, but records did not consistently reflect that the PCV20 vaccine was addressed as required by facility policy.
A resident with multiple medical conditions and dependent on staff for care was transferred to the hospital three times, but the facility did not provide the required written transfer/discharge notifications or bed-hold notices to the resident's legal representative, as confirmed by staff interviews and record review.
A resident with multiple chronic conditions, including CHF and on diuretic therapy, did not consistently have daily weights obtained or documented as ordered by the physician. Staff interviews revealed unclear follow-through on responsibilities for obtaining and documenting weights, and the EMR showed multiple missed entries without consistent documentation of refusals.
A resident with severe cognitive impairment, limited mobility, and incontinence was observed seated in a wheelchair without a pressure redistribution cushion, despite documented risk for pressure ulcers and care plan instructions requiring such interventions. Staff interviews confirmed the absence of the cushion, and facility policy mandated preventative measures for residents at risk.
Two residents with cognitive and physical impairments experienced repeated falls due to staff not consistently implementing fall prevention interventions as outlined in their care plans. Despite care plans requiring education on call light use and ensuring call lights were within reach, observations and interviews showed these measures were not reliably followed, resulting in continued fall risks.
A resident with multiple chronic conditions requiring oxygen therapy and BIPAP support had their respiratory equipment, including a BIPAP mask and nasal cannula, improperly stored on a bedside table and in a wheelchair seat instead of in dated, labeled bags as required by facility policy and physician orders. Staff interviews confirmed the expected storage procedures were not followed, and the resident's care plan lacked specific instructions for equipment care.
A resident with severe dementia and multiple care needs did not receive consistent dementia-related care services. The care plan lacked specific interventions for aggressive behaviors, and staff did not consistently use non-pharmacological approaches during episodes of aggression or wandering. The resident was observed entering peers' rooms and experiencing non-injury falls, with staff reporting challenges in keeping him engaged and redirecting him, contrary to the facility's dementia care policy.
Failure to Provide Consistent Weekend Activities for Residents
Penalty
Summary
The facility failed to consistently provide scheduled activities for residents on weekends, as evidenced by a review of the activity calendars for April and May 2025, which showed no listed activities during weekends. Interviews with residents during a council meeting confirmed that there were no consistent or regular weekend activities provided by staff. Further interviews with staff, including a CNA and a licensed nurse, revealed that while church groups or visitors occasionally provided services or music, and movies were sometimes played, there was no structured or scheduled activity program in place for weekends. The activity staff confirmed the absence of scheduled weekend activities and noted that although administrative staff were assigned on weekends and could initiate activities, this was not consistently done. The facility's own policy required an ongoing program of activities tailored to residents' assessments, care plans, and preferences, designed to support their physical, mental, and psychosocial well-being. At the time of the deficiency, the facility had 28 residents with moderately or severely impaired cognition, who were at risk of decline due to the lack of consistent weekend activities.
Failure to Follow Approved Puree Diet Recipes
Penalty
Summary
The facility failed to follow nutritionally approved recipes during the preparation of pureed meals for eight residents on a puree-textured diet. Specifically, a dietary staff member was observed placing cooked pork chops into a food processor, adding several scoops of gravy, checking the consistency, and then adding more gravy before finalizing the pureed pork chops. The staff member stated that a total of four cups of gravy were added to the pork chops. Another staff member confirmed that the recipe for pureed pork chops was not followed, and acknowledged that the additional gravy increased the calorie content but did not diminish the nutritional value. The facility's policy required the food and nutrition services department to prepare and serve diets as ordered, including adhering to the specified texture and fluid consistency.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically BIPAP masks and nasal cannulas, were stored in a sanitary manner for two residents. One resident was observed lying in bed with a nasal cannula in use, while her BIPAP mask was placed directly on the bedside table and an oxygen nasal cannula was left in the seat of her wheelchair. Another resident's oxygen nasal cannula was found wrapped around the handle of an oxygen canister in the room. These storage practices did not meet sanitary standards. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expected protocol was to store BIPAP masks and nasal cannulas in a dated and labeled plastic bag when not in use. The facility's own infection prevention and control program required maintaining a safe and sanitary environment to prevent the transmission of communicable diseases, as per national standards and guidelines. The observed practices were inconsistent with these established protocols.
Failure to Document Consent or Declination for PCV20 Vaccination
Penalty
Summary
The facility failed to obtain and document consent or declination for the Pneumococcal Conjugate Vaccine (PCV20) for several residents. Specifically, clinical records for four residents lacked evidence that the PCV20 vaccine was offered or declined, and there was no documentation of prior administration or physician-documented contraindications. In some cases, records showed that other pneumococcal vaccines (such as PCV13 or PCV23) were pending or had been administered, but there was no follow-up or documentation regarding the PCV20 vaccine as required. Interviews with nursing staff revealed that immunization status was typically assessed on admission and that the process involved the nurse in charge, the DON, and the pharmacy. However, the records did not reflect that the required steps for offering or documenting the PCV20 vaccine were consistently followed. The facility's policy stated that pneumococcal immunizations would be offered in accordance with CDC guidelines, but the lack of documentation for these residents indicated that the policy was not fully implemented.
Failure to Provide Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge as soon as practicable and did not issue a bed-hold notice with the required information for a resident who experienced three facility-initiated transfers to the hospital. The resident, who had diagnoses of diabetes mellitus, congestive heart failure, and seizure disorder, was documented as having intact cognition and was dependent on staff for dressing and transfers. The resident's care plan and assessments consistently indicated a need for staff assistance with activities of daily living. Despite multiple hospital transfers, the facility did not send the required written notifications or bed-hold notices to the resident's legal representative. Interviews with administrative and social service staff confirmed that these notifications were not provided as required by facility policy. The facility's own policy stated that written notice specifying the duration of the bed-hold policy and information about the resident's return should be given at the time of transfer, but this was not followed for the resident in question.
Failure to Consistently Obtain and Document Daily Weights per Physician Order
Penalty
Summary
The facility failed to consistently follow a physician's order for obtaining daily weights for a resident with multiple complex medical conditions, including congestive heart failure, diabetes mellitus, obesity, repeated falls, hypertension, chronic obstructive pulmonary disease, edema, and dementia. The resident's care plan specifically required daily weights due to diuretic therapy and the potential for weight fluctuations, with instructions to notify the physician if certain weight gains occurred. Despite these orders, review of the resident's Treatment Administration Record (TAR) revealed numerous dates where weights were not documented, and there was a lack of consistent documentation regarding refusals of daily weights. Interviews with staff indicated that CNAs were responsible for obtaining daily weights and were to notify the nurse if unable to do so, while nurses were responsible for ensuring weights were obtained or refusals documented. However, the EMR showed multiple missed entries for daily weights and lacked consistent documentation of refusals. The facility's policy required maintaining a schedule of diagnostic tests and a reliable process for providing physician-ordered services, but this was not consistently followed for the resident in question.
Failure to Provide Pressure Redistribution Cushion for At-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, limited mobility, and a history of incontinence and falls was not provided with a pressure redistribution cushion in his wheelchair, as required by his care plan and facility policy. The resident's medical records indicated diagnoses of dementia, benign prostatic hyperplasia, and acute kidney failure, and assessments consistently documented his risk for pressure ulcers due to incontinence and reduced mobility. The care plan specifically instructed staff to use pressure redistribution surfaces for the resident's bed and wheelchair if indicated, and the Braden Scale assessment confirmed his risk for developing pressure ulcers. Despite these documented risks and care plan instructions, observations on multiple occasions revealed that the resident was seated in his wheelchair without any cushion or pressure-reducing padding. Interviews with nursing staff and aides confirmed that the resident previously had a pressure-relieving cushion, but it was not present at the time of the observations, possibly due to issues with incontinence or falls. The facility's policy required implementation of preventative interventions, including pressure redistribution, for residents at risk, but this was not followed for the resident in question.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for two residents with significant cognitive and physical impairments. One resident with diagnoses including multiple sclerosis, epilepsy, and a history of falls had a care plan directing staff to educate and re-educate him on the use of his call light and to ensure needed items were within reach. Despite these interventions, the resident experienced multiple falls, and documentation showed that staff did not implement new interventions following these incidents. Staff interviews confirmed that while care plans and updates were accessible, there was a lack of consistent follow-through on implementing and updating fall prevention measures. Another resident with a history of encephalopathy, dementia, fractures, and multiple falls had a care plan requiring staff to keep her call light within reach and to respond promptly to requests for assistance. Observations revealed that the resident's call light was repeatedly placed out of reach, both hooked to the wall and on the bedside table, making it inaccessible. Staff interviews corroborated that call lights should be within reach, but this was not consistently practiced, directly contradicting the care plan directives. The facility's policy required maintaining an environment free of accident hazards and providing adequate supervision and assistive devices to prevent accidents. However, the failure to ensure that fall interventions, such as accessible call lights and updated care plans, were consistently implemented for these residents resulted in a deficiency. These lapses placed the residents at risk for further falls and injuries, as evidenced by the repeated incidents and lack of effective intervention.
Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The facility failed to ensure the proper and sanitary storage of a resident's respiratory equipment, specifically a BIPAP mask and nasal cannula. During observation, the resident's BIPAP mask was found placed directly on the bedside table, and the oxygen nasal cannula was left in the seat of the resident's wheelchair, rather than being stored in a dated, labeled bag as required by facility policy and staff instructions. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expected practice was to store these items in a dated plastic bag to maintain sanitation. The resident involved had multiple medical conditions, including COPD, congestive heart failure, diabetes, obesity, and dementia, and required both oxygen therapy and a BIPAP device as part of their care. The care plan documented the need for oxygen therapy and BIPAP use, but lacked specific instructions for the care and storage of the oxygen cannula and BIPAP mask. Physician orders were in place for regular changing and dating of respiratory equipment, but these were not followed in practice, as evidenced by the unsanitary storage observed during the survey.
Failure to Provide Consistent Dementia Care Services
Penalty
Summary
The facility failed to provide consistent dementia-related care services for a resident diagnosed with dementia, benign prostatic hyperplasia, and acute kidney failure. The resident had severe cognitive impairment, as indicated by a BIMS score of zero, and required substantial to maximal assistance with daily activities, including dressing, hygiene, and mobility. The care plan identified risks such as cognitive loss, incontinence, falls, and skin breakdown, and instructed staff to keep the resident engaged in activities, calmly communicate, and anticipate his needs. However, the care plan lacked specific interventions for managing aggressive behaviors, and staff documentation did not reflect the use of non-pharmacological interventions during episodes of aggression or wandering. Observations and interviews revealed that the resident frequently wandered into peers' rooms and attempted to self-toilet, resulting in non-injury falls. Staff reported difficulty keeping the resident engaged and redirecting him from unsafe areas, but there was no evidence of consistent implementation of individualized behavioral interventions. The facility's dementia care policy required strategies to address triggers and behaviors, but the documentation and staff actions did not demonstrate adherence to these approaches, resulting in a failure to promote the resident's highest practicable level of well-being.
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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 Oskaloosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| F W Huston Medical Center | 8 mi | ★★★★★ | 24 | 0 |
| Valley Health Care Center | 11.5 mi | ★★★★★ | 0 | 0 |
| Easton Health Care Center | 13.7 mi | ★★★★★ | 14 | 0 |
| Nortonville Health Care Center | 14 mi | ★★★★★ | 49 | 4 |
| Tonganoxie Terrace | 14.6 mi | ★★★★★ | 31 | 0 |
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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.