Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Osage Rehab And Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide residents with a private space to make telephone calls, especially during non-business hours, resulting in calls being made at the busy nursing station where other residents and staff were present. One resident with moderate cognitive impairment was observed making a call at the nursing station while another resident yelled for help in the background and people walked by, and she later reported that it was often loud but was the only place available. Another cognitively intact resident without a personal phone reported there was no private place to use the facility phone and expressed dissatisfaction with the lack of privacy. The Administrator confirmed that while residents could use administrative offices for calls during business hours, there was no private area available for calls during evenings, weekends, or when management was not on-site.
A resident with moderate cognitive impairment, dementia, primary insomnia, and depression had repeated episodes of wandering the halls and entering other residents’ rooms, as documented in progress notes over an extended period. However, the resident’s care plan did not include these wandering or room-entry behaviors and contained no specific interventions to address them. The DON and ADON acknowledged awareness that the resident walked the halls at night but were not aware staff were documenting entry into other residents’ rooms, and they confirmed the behavior was not added to the care plan. This failure to revise the care plan was not consistent with the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident’s needs.
Two residents did not consistently receive or have documented scheduled bathing, despite facility expectations for twice-weekly showers. For one resident, multiple dates over several months showed bathing marked as not applicable or not documented, and the ADON could not confirm whether baths were provided. Another resident with moderate cognitive impairment, requiring substantial/maximal assistance for bathing, reported only two baths during a month and stated staff did not offer showers around medical appointments, leaving her feeling dirty and odorous with greasy hair, which was also observed by her representative. Facility records for this resident showed limited bathing entries and numerous days marked as not applicable, despite a policy stating showers would be provided per request or schedule with partial baths between showers.
A resident admitted from a hospital with peripheral vascular disease, diabetes, multiple venous and arterial ulcers, and moderately impaired cognition had hospital transfer orders for collagenase Santyl to the right heel, betadine to eschar on the right foot, and Juven twice daily. These orders were not entered on the January MAR/TAR, and thus were not implemented. The IDON acknowledged she failed to properly transcribe the admission orders, and the facility’s policy on physician-ordered services did not address the transcription and implementation of orders.
The facility did not ensure RN coverage for at least eight consecutive hours per day on several occasions and lacked a full-time DON for an extended period, as confirmed by schedule reviews and staff interviews. The census during this time was 25 residents.
The facility failed to complete required MDS and CAA documentation for two residents—one with unstageable pressure ulcers and another with severe cognitive impairment and significant weight loss. In both cases, the CAA worksheets lacked essential information on impact, rationale, risk factors, and referrals, as confirmed by staff interviews and record review.
A resident developed two unstageable pressure ulcers during their stay, and the facility did not implement detailed, resident-specific interventions to address these wounds. The care plan lacked specifics on treatments, medications, pain management, and input from the resident or external wound care providers, with only general interventions like an alternating air mattress and scheduled repositioning documented.
The facility did not include the resident census or facility name on daily nurse staffing postings over multiple days. The Administrator confirmed that overnight nurses complete the postings but do not include the census, and this omission was verified during a review of the postings.
Failure to document informed consent for psychotropic medications: A resident with moderate cognitive impairment and diagnoses including schizophrenia, dementia, anxiety, and depression received Paxil, buspirone, lorazepam, and trazodone without documentation that the resident or representative was informed of risks vs. benefits or offered alternatives before routine use. Another resident with moderate cognitive impairment and diagnoses including stroke, aphasia, and dementia received olanzapine without documented advance notification, discussion of alternatives, or consent from the resident or representative.
A resident with severe cognitive impairment, difficulty communicating, a seizure disorder, and limited ROM was using a wheelchair seat belt that was documented as a restraint/non-restraint. The record showed the PCP approved the seat belt, but the facility did not document release of the belt every 2 hours and had no informed consent or family/resident education for the seat belt order. The DON and ADON both stated they were not aware of any consent for the seat belt.
Inaccurate MDS coding affected two residents. One resident with schizophrenia, dementia, and other psychiatric diagnoses had a Level II PASRR requiring ongoing psychiatric medication management, but the MDS did not reflect the PASRR status. Another resident with 2 unstageable pressure ulcers had the wounds coded as facility-acquired on the MDS even though the resident, RN staff, and ADON stated the ulcers were present on admission and progress notes did not show new pressure ulcers during the stay.
A resident with diagnoses including schizophrenia, anxiety, depression, dementia, and neurocognitive disorder with Lewy bodies had a PASRR Level II that identified needed services, but the clinical record lacked the Level II documentation and the MDS was not coded correctly. The DON stated the PASRR Level II was not coded correctly, and the SW said she did not know the PASRR recommendations needed to be implemented into the care plan and had not been trained on which recommendations belonged in the care plan for PASRR Level II residents.
The facility failed to have the minimum required members present at quarterly QAA meetings. Record review showed the Infection Preventionist was absent from multiple meetings, the DON was absent from two meetings, and the Administrator missed one meeting. The Administrator stated she was unaware all required staff were not attending and noted staffing challenges; the QAPI committee document lacked direction on the required number of members needed at QAA meetings.
Failure to use EBP during routine suprapubic catheter care. A resident with a suprapubic catheter, neurogenic bladder, and dependence for toileting hygiene had catheter tubing positioned below the drainage bag with urine backflow noted and a strong urine odor in the room. A CNA emptied the catheter bag and then cleaned the catheter site without a gown, reused the same washcloth area on the skin and tubing, and did not change gloves or perform hand hygiene before redressing the resident. The ADON stated staff should wear gown and gloves for catheter care.
Lack of Qualified Infection Preventionist: The facility failed to have a qualified Infection Preventionist to oversee the infection prevention and control program. The DON reported that no qualified IP was in place, and the ADON had only started but not completed the required classes to become qualified. Facility policy states the program is to be coordinated and overseen by an Infection Prevention Specialist.
Failure to provide consented pneumococcal vaccinations for two residents was identified. Both residents had BIMS scores of 15, indicating intact cognition, and both had signed consent forms showing agreement to receive the vaccine, but the EHR lacked documentation that the vaccine was administered. The MDS noted the vaccines were not received because the facility was not offering them, and the interim DON confirmed neither resident got the pneumococcal vaccine as consented.
A resident with moderate cognitive impairment and significant physical needs was not provided transportation back to the facility after a neurology appointment. Although the resident left with a transport van and driver, the family was unable to confirm return transportation and ultimately transported the resident back themselves. Staff confirmed that a staff member was expected to accompany residents to appointments, but this did not occur, and there was no written policy in place.
Surveyors identified a deficiency related to unsanitary and non-homelike conditions, including mold buildup on heating/cooling pipes and persistent toilet leaks with standing water in multiple rooms. Staff and residents confirmed these issues had been ongoing for an extended period, affecting the comfort and safety of residents on one side of the building.
Two residents experienced significant delays in call light responses, with documented instances of waits exceeding 15 minutes and, in one case, up to two hours. Staff interviews confirmed that these delays were due to staffing shortages and agency staff not responding to call lights, in violation of facility policy.
A resident with severe cognitive impairment was allowed to have her cat in her room without staff verifying the animal's vaccination status or having a pet policy in place. The cat displayed aggressive behavior, and during an attempt to remove it, the resident was bitten, resulting in a wound infection that required antibiotic treatment.
A resident experienced repeated delays in call light response, sometimes waiting hours for assistance, due to a malfunctioning call system and insufficient staffing. Staff and maintenance confirmed the call system was inoperative for about a week, and alternative alert methods were ineffective, resulting in unmet resident needs and noncompliance with the facility's policy for timely response.
A resident with intact cognition and identified fall and incontinence risks did not receive timely responses to call light requests, despite care plan interventions requiring prompt assistance. The resident reported prolonged waits for help, including one instance lasting several hours overnight and another resulting in incontinence, reflecting the facility's failure to implement the care plan as directed.
A resident with multiple small cat bite wounds did not receive the prescribed wound care treatment, as the physician's orders for cleaning, antibiotic ointment application, and bandaging were not documented or carried out by staff. The required treatment was missing from the MAR and TAR, and this was confirmed by an LPN and the administrator.
A facility failed to provide a required Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNF/ABN) and Notice of Medicare Non-Coverage (NOMNC) to a resident or their legal representative. The resident, who had severe cognitive impairment and was receiving therapy treatments, was not notified of the discontinuation of Medicare Part A skilled services as required by the facility's policy. The administrator confirmed the notice was not given, and there was no documentation to prove it was done.
A facility failed to complete a baseline care plan for a resident admitted after a left knee replacement. The EHR showed the resident's admission and discharge dates, but lacked a completed baseline care plan. The facility's policy requires a baseline care plan within 48 hours of admission, but the DON mentioned a 72-hour timeframe, showing a policy-practice discrepancy. The Administrator confirmed the care plan was not completed, failing to meet the resident's immediate care needs.
The facility failed to conduct a criminal background check for a CMA, Staff A, who was hired conditionally in December 2022. A review in November 2024 revealed the absence of this check, despite facility policy requiring it before regular employment. The BOM confirmed the oversight and noted that the responsibility for background checks had just been transferred to her.
The facility failed to provide at least two baths/showers per week for two residents, as required. One resident with multiple sclerosis and intact cognition did not consistently receive scheduled showers, with missing documentation on specific dates. Another resident also had missing shower documentation. The ADON acknowledged inconsistent documentation and was unable to locate records, while the DON confirmed the expectation for scheduled showers and reporting deviations.
A facility failed to complete physician-ordered PICC line dressing changes for a resident with MS, who reported inconsistent dressing changes. The care plan required weekly sterile dressing changes and immediate provider contact for complications. However, the treatment administration record lacked documentation for two dates, with no rationale provided. The facility lacked a policy to ensure physician orders are followed.
A facility failed to conduct pre and post dialysis assessments for a resident with ESRD who required hemodialysis. The resident's care plan required immediate intervention for dialysis complications, but assessments were missing from the health record. The ADON acknowledged the oversight, and incomplete assessments were later provided, highlighting a deficiency in dialysis care.
A resident with a gastronomy tube suffered aspiration pneumonia and septic shock after a nurse failed to elevate the head of the bed during feeding, as required by the care plan. Despite the resident's history of pneumonia and dysphasia, the nurse administered the feeding with the bed lowered and did not elevate it when the resident vomited. The resident was found unresponsive with low oxygen saturation and was transferred to a hospital for further care.
A resident with a feeding tube was not properly positioned according to their care plan, leading to an incident where they vomited and became unresponsive. Staff interviews revealed that the resident was found with the head of the bed at an incorrect angle, and EMS was called to transport the resident to the hospital. This was not the first occurrence of improper positioning for this resident.
The facility failed to conduct thorough assessments for two residents following changes in their conditions. One resident experienced issues with a catheter, leading to a hospital transfer for septic shock and aspiration pneumonia, with inadequate documentation of assessments. Another resident's respiratory symptoms were not documented according to facility guidelines, highlighting deficiencies in care practices.
The facility failed to ensure that two staff members met the requirements for Dependent Adult Abuse Training. A CMA had not completed any further training since 1/9/19, and a CNA who started on 3/16/23 had no documentation of the required training. The facility's policy mandates training within six months of employment and every three years thereafter. The Administrator acknowledged the training was overdue.
The facility failed to maintain sanitary conditions during meal service, as staff did not change gloves or perform hand hygiene between tasks, increasing the risk of contamination and foodborne illness. Staff were observed handling various surfaces and food items without proper glove changes or hand hygiene.
A facility failed to ensure staff treated a resident with dignity and respect. A CNA reported that another CNA told the resident she 'smelled like piss' during a change, causing the resident to cry. The resident confirmed this comment was made frequently. The facility's policy lacked documentation on treating residents in a dignified manner.
Lack of Private Telephone Access for Residents
Penalty
Summary
The facility failed to ensure residents had reasonable access to privacy when using telephones, particularly during non-business hours, resulting in residents having to make calls at the nursing station in the presence of other residents and staff. Resident #6, who had a BIMS score of 11 indicating moderate cognitive impairment per an MDS dated 2/5/26, was observed on 3/31/26 at 6:40 PM making a phone call at the nursing station while another resident could be heard in the background yelling for help and multiple residents and staff walked past during the call. In an interview on 4/1/26 at 8:50 AM, Resident #6 stated it was often loud at the nursing station when she made phone calls, but that it was the only place available to her. Resident #15, who had a BIMS score of 15 indicating intact cognition per an MDS dated 1/7/26, reported during an interview on 3/31/26 at 6:55 PM that she did not have a personal phone and there was no private place to use the facility phone, and she expressed dislike of the lack of privacy when making calls. In an interview on 4/1/26 at 10:17 AM, the Administrator stated that residents could use her office or the DON’s office for calls during business hours, but confirmed that during off-hours, weekends, or when management was away, there was no designated private area for residents to make telephone calls.
Failure to Revise Care Plan for Resident Wandering and Room Entry Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a comprehensive, person-centered care plan to address a resident’s documented wandering behaviors. A comprehensive MDS assessment dated 2/5/26 showed the resident had a BIMS score of 8, indicating moderate cognitive impairment, and diagnoses including dementia, primary insomnia, and depression. Progress notes from 1/23/26 to 3/28/26 documented on several occasions that the resident wandered the hallways and required redirection out of other residents’ rooms. Despite this ongoing documentation of wandering and entry into other residents’ rooms, the care plan dated 2/17/26 did not include the resident’s wandering behavior or the behavior of entering other residents’ rooms. The care plan also lacked any interventions specifically aimed at managing the resident’s wandering or preventing entry into other residents’ rooms. During an interview, the DON and ADON stated they were aware the resident walked the halls at night because he could not sleep and believed he worked at the facility, but the DON reported she was not aware that staff were charting that the resident wandered into other residents’ rooms. Both the DON and ADON acknowledged that the wandering behavior was not included on the care plan and that no new interventions were added after the resident entered other residents’ rooms. This was inconsistent with the facility’s Comprehensive Care Plan policy, which required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet each resident’s medical, nursing, mental, and psychosocial needs.
Failure to Provide and Document Scheduled Bathing for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received scheduled bathing and to maintain accurate documentation of hygiene services for two residents. For one resident, review of Documentation Survey Report v2 forms for January through March 2026 showed multiple dates where bathing was marked as “not applicable” or not documented at all, including several specific dates in January, February, and March. Corresponding Visual Assessment forms for February and March were also incomplete, with missing entries on the same dates when bathing was not documented. During an interview, the ADON stated she was unsure why the resident’s baths were not charted on those dates and could not confirm whether the resident actually received the baths. For the second resident, the MDS dated early March 2026 showed a BIMS score of 12, indicating moderate cognitive impairment, and documented that the resident required substantial or maximal assistance for bathing. The resident reported receiving baths only on two specific dates in March and stated that on other days, when she had doctor appointments, staff did not offer a shower before or after the appointments and told her she had to wait until her next scheduled shower day. She reported feeling dirty and odorous, and her hair appeared greasy. The resident’s representative, who visited daily, also reported that the resident’s hair looked dirty and greasy. Documentation Survey Report v2 for March recorded bathing on only two dates and listed “not applicable” for multiple other dates. The Administrator stated she expected staff to complete showers twice a week, and the facility’s Resident Showers policy indicated residents would be provided showers per request or per facility schedule, with partial baths allowed between regular shower schedules.
Failure to Transcribe and Implement Admission Wound Care and Nutritional Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that admission orders were properly transcribed and implemented for a newly admitted resident. The resident was admitted from a short-term general hospital with documented diagnoses including peripheral vascular disease, diabetes, and atherosclerosis of native arteries of the extremities with ulceration. The resident’s MDS assessment identified moderately impaired cognition with a BIMS score of 12 and documented seven venous and arterial ulcers present at admission. The hospital transfer summary included specific admission orders for collagenase Santyl ointment to the right heel, betadine to eschar areas on the right foot daily, and Juven nutritional supplement twice daily. Record review showed that the January Medication Administration Record and Treatment Administration Record did not contain documentation of the Juven orders or the wound care treatment orders for the right foot and heel. During an interview, the Interim Director of Nursing acknowledged that she did not properly transcribe the admission orders and missed the wound care and Juven orders. The facility’s policy on Provision of Physician Ordered Services directed staff to provide a reliable process for the proper and consistent provision of physician-ordered services according to professional standards of quality, but the policy did not include guidance on how to transcribe and implement orders.
Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours per day as required by federal regulations, with documented absences of RN coverage on specific days in July and November 2025. Additionally, the facility did not have a full-time Director of Nursing (DON) in place from October 18, 2025, until December 1, 2025, as confirmed by both the Interim DON and the Administrator. These deficiencies were identified through review of facility schedules, new hire and termination lists, and staff interviews. The facility had a reported census of 25 residents during this period. No information regarding the medical history or condition of individual residents at the time of the deficiency was provided in the report.
Incomplete MDS and CAA Documentation for Pressure Ulcers and Nutrition
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) assessments and Care Area Assessment (CAA) worksheets for two residents. For one resident with no cognitive impairment, the MDS documented two unstageable pressure ulcers that developed during the stay. The CAA worksheet for pressure ulcers was incomplete, as it did not describe the impact, rationale for care planning, risk factors, or need for referral to other health professionals. Staff interviews confirmed that the resident had not developed new pressure ulcers since admission, and the MDS Coordinator responsible for completing the assessments worked offsite. For another resident with severe cognitive impairment and diagnoses including Parkinson's, dehydration, and depression, the CAA worksheet for nutrition was also incomplete. The resident experienced significant weight loss and was on hospice care, but the worksheet lacked documentation of the impact, rationale, risk factors, and referral needs. A weight/skin summary note indicated a meeting with the ADON and dietician regarding the weight loss, but the required CAA documentation was not completed. Attempts to contact the MDS Coordinator were unsuccessful.
Failure to Implement Resident-Specific Interventions for Pressure Ulcers
Penalty
Summary
The facility failed to implement appropriate and resident-specific interventions for a resident who developed two unstageable pressure ulcers during their stay. The resident, who had no cognitive impairment as indicated by a BIMS score of 15, was not admitted with these wounds, which were documented as acquired in the facility. The care plan, revised on 12/12/25, noted multiple pressure areas but lacked detailed interventions tailored to the resident's needs, such as specific treatments, medications, supplies, pain management strategies for wound care, and input from the resident or external wound care providers. The only interventions documented were the use of an alternating air pressure mattress and repositioning every two hours. Additionally, the facility's policy on pressure ulcers did not provide instructions on care planning or the assessment process.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information that includes both the resident census and the facility name. Observations on three consecutive days revealed that the daily staff posting was missing these required elements. During an interview, the Administrator confirmed that overnight nurses are responsible for completing the daily staff postings, which include the number of nurses and CNAs and their hours per shift, but acknowledged that the census was not being included. A review of the posting with the Administrator further confirmed the absence of both the resident census and the facility name on the daily staff posting.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to notify residents or their representatives in advance of the risks versus benefits of psychotropic medications, and failed to document discussion of treatment alternatives or other options before routine administration of the medications. Resident #1 had a BIMS score of 10 and diagnoses including schizophrenia, dementia, diabetes, heart failure, anxiety, depression, and adult failure to thrive. The MAR showed orders for Paxil, buspirone, lorazepam, and trazodone, and the progress notes from 12/1/23 to 12/15/25 lacked documentation that the resident or representative was informed about the medications' risks versus benefits or given alternatives before the medications were started on a routine basis. The December 2025 MAR documented repeated administration of these medications, and the interim DON stated the facility did not complete a consent form with the resident's representative before starting them. The facility also failed to document advance notification and consent for Resident #19 before routine administration of olanzapine. Resident #19 had a BIMS score of 12 and diagnoses including cerebral infarction, neuralgia, neuritis, aphasia, and dementia. The MAR listed olanzapine 5 mg daily for major depressive disorder, and the progress notes from 7/1/25 to 12/15/25 lacked documentation that the resident or representative was notified in advance of the risks versus benefits or offered treatment alternatives before the medication was given routinely. The interim DON stated the facility did not complete a consent form with the resident or representative prior to starting olanzapine, and the ADON stated the electronic record should include medication consents under Assessments.
Failure to Document Seat Belt Release and Obtain Informed Consent
Penalty
Summary
The facility failed to document the release of a resident’s seat belt every 2 hours and failed to obtain informed consent from the resident’s representative before using a seat belt in the wheelchair for Resident #8. Resident #8 was documented as severely impaired in decision-making, had difficulty making self understood and understanding others, had a functional limitation in range of motion, a seizure disorder, and was taking antianxiety medications. The care plan and orders reflected use of a wheelchair seat belt, including directions to release the seat belt every 2 hours, and the restraint/non-restraint assessment documented the seat belt as a physical restraint/non-restraint. The record showed the facility asked the PCP on 7/29/25 for approval to use a seat belt while the resident was in the wheelchair, and the PCP responded that it was okay. The facility lacked documentation of family or resident education or consent for the seat belt orders from 4/25/25 through 12/18/25. The interim DON stated on 12/17/25 that the facility did not have an informed consent for the seat belt and expected one to be obtained, and the ADON later stated she was not aware of any consents for the seat belt and also expected the facility to obtain one. On observation, Resident #8 was seen in the wheelchair wearing the seat belt.
Inaccurate MDS Coding for PASRR Level II Status and Pressure Ulcer Acquisition
Penalty
Summary
The facility failed to accurately code the PASRR Level II status on the MDS for Resident #2. The resident’s MDS assessment reflected that they did not have a state level II PASRR process for serious mental illness and/or intellectual disability or a related condition, even though the resident had a BIMS score of 10 indicating moderate cognitive impairment and diagnoses including schizophrenia, anxiety, depression, dementia, neurocognitive disorder with Lewy bodies, and heart failure. The resident’s Level II PASRR dated 9/18/25 indicated the need for ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP to evaluate response and effectiveness of psychotropic medications, modify medication orders, and assess the ongoing need for additional behavioral health services. The PASSAR dated 9/18/25 identified services required based on schizoaffective disorder, depressive. The interim DON stated on 12/18/25 that the MDS did not accurately reflect the PASSAR Level II status and should have been coded correctly. The facility also failed to accurately code that Resident #4’s pressure ulcers were not acquired at the facility. The resident’s MDS assessment documented a BIMS of 15 and identified 2 unstageable pressure ulcers, but coded them as not present on admission and acquired during the stay. The MDS CAA worksheet related to pressure ulcers showed the MDS Coordinator checked that the pressure ulcer areas needed to be implemented on the care plan, but did not complete the section describing impact, rationale for care planning, risk factors, or whether referral to other health professionals was needed. Resident #4 stated she did not have new pressure ulcers since admission, and RN staff and the ADON both stated the pressure ulcers were not new and had been present on admission. Progress notes from 9/24/25 to 9/28/25 did not document new acquired pressure ulcers during the resident’s stay.
PASRR Level II Recommendations Not Incorporated Into Assessment and Care Plan
Penalty
Summary
The facility failed to incorporate the recommendation from the PASRR Level II determination and evaluation report into the resident’s assessment and care plan for 1 of 2 residents with new mental health diagnoses. Resident #2’s MDS assessment reflected diagnoses including schizophrenia, anxiety, depression, dementia, neurocognitive disorder with Lewy bodies, and heart failure, and it indicated there was no state Level II PASRR process for serious mental illness and/or intellectual disability or a related condition. The resident’s PASARR dated 9/18/25 identified services required based on the diagnosis of schizoaffective disorder and depressive disorder, but the clinical record lacked the PASARR Level II documentation. During interview, the interim DON stated the PASARR Level II was not correctly coded on the MDS and said it should have been coded correctly. The SW stated she did not know until the previous week that the PASRR recommendations from the resident’s Level II needed to be implemented into the care plan, and she acknowledged the resident was seen by psychiatry services. She also stated the facility had not trained her since she became the SW over a year ago on which recommendations needed to be included in the care plan for PASRR Level II residents.
QAA Committee Lacked Required Members at Quarterly Meetings
Penalty
Summary
The facility failed to have the minimum required members present at Quality Assessment and Assurance (QAA) meetings to identify issues requiring quality assessment and assurance activities. Facility record review showed that, for a census of 25 residents, the Infection Preventionist was not present at the March, May, August, or November quarterly QAA meetings. The Director of Nursing was not present at the May or November quarterly meetings, and the Administrator did not attend the August quarterly meeting. During an interview on 12/17/25 at 10:30 AM, the Administrator stated she did not know the facility did not have all required staff at the QAA meetings and reported the facility struggled with staffing. Review of the facility's Quality Assurance and Performance Improvement Committee dated July 2016 showed it lacked direction on the required number of members needed at the QAA meetings.
Failure to Use EBP During Suprapubic Catheter Care
Penalty
Summary
The facility failed to use enhanced barrier precautions during routine catheter care for one resident who had a suprapubic catheter, neurogenic bladder, and was dependent on staff for toileting hygiene. The resident’s MDS documented a BIMS of 15 with no cognitive impairment. Her order summary directed that the catheter be changed every 30 days and that the suprapubic catheter site be cleaned daily. During observation, the catheter drainage bag was clipped to the bed with the tubing hanging below the bag, and urine was observed to backflow. The room also had a strong pungent urine odor. During catheter care, a CNA emptied the catheter bag, then changed gloves and began cleaning the suprapubic catheter site without wearing a gown. The CNA used a wet washcloth with foam soap to rub the skin around the site several times with the same part of the cloth, then used the same washcloth location to wash down and back up the catheter tubing. The CNA then used a new wet washcloth to wipe the area, but did not change gloves or perform hand hygiene before replacing the resident’s brief and covering her with the blanket. The CNA later confirmed she should have worn a gown when emptying the catheter bag and cleaning around the suprapubic catheter site. The ADON stated staff should wear EBP protective equipment, gown, and gloves when providing catheter care, and should change the site they wash and gloves after cleansing the site before rinsing the washcloth.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist to monitor and provide oversight for its infection prevention and control program. Based on facility policy and staff interviews, the Administrator reported on 12/15/25 that the facility did not have a qualified Infection Preventionist for the building, and stated that the Assistant Director of Nursing had started the required classes but had not completed them. On 12/18/25, the ADON reported that she was currently taking the classes to become a qualified Infection Preventionist. The facility policy titled Infection Prevention and Control Program states that the program is coordinated and overseen by an Infection Prevention Specialist.
Failure to Provide Consented Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide pneumococcal vaccination as requested for 2 of 5 residents reviewed, Resident #4 and Resident #15, despite documentation showing consent had been obtained. Resident #4’s MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident did not receive the pneumococcal vaccine because the facility was not offering it. A Pneumococcal Conjugate Informed Consent form signed by Resident #4 showed that information was provided and consent was given for the vaccine, but the EHR lacked documentation that the vaccine was administered. Resident #15’s MDS also documented a BIMS score of 15 and indicated the pneumococcal vaccine was not received because the facility was not offering it. A Pneumococcal Immunization Informed Consent form signed by Resident #15’s representative showed that information was provided and consent was given for the resident to receive the vaccine, but the EHR likewise lacked documentation of administration. The interim DON confirmed that both residents did not receive the pneumococcal vaccine as consented.
Failure to Provide Transportation for Resident After Off-Site Appointment
Penalty
Summary
The facility failed to provide transportation for a resident following an off-site neurology appointment. The resident, who had moderately impaired cognition (BIMS score of 9), required partial to moderate assistance with activities of daily living and used a wheelchair for mobility. The resident had diagnoses including hypertension, aphasia, cerebrovascular accident, hemiplegia, and anxiety. Documentation showed that the resident left the facility for the appointment with a transport van service and driver, and staff expected a staff member to accompany residents to appointments, although there was no formal policy in place. After the appointment, the resident's family member was unable to confirm with the facility that transportation would return to pick up the resident, as attempts to contact the facility's Social Worker went unanswered. As a result, the family member transported the resident back to the facility themselves. Staff interviews confirmed the expectation that a staff member should accompany residents to appointments, but this did not occur in this instance, and the facility lacked a written policy regarding transportation for such situations.
Deficiency Due to Mold and Persistent Plumbing Issues in Resident Rooms
Penalty
Summary
The facility failed to provide a clean, sanitary, and homelike environment for all residents residing on the East end of the building, as evidenced by a buildup of a black substance resembling mold on the pipes of the heating and cooling elements in all 16 resident rooms on that side. The heating and cooling system, installed in the 1960s, uses water that alternates between hot and cold depending on the season, leading to condensation and moisture buildup, which in turn has caused mold to develop on the pipes. Both the current and previous Maintenance Supervisors confirmed the ongoing presence of this issue, and staff interviews corroborated that the mold had been present for at least two years. Additionally, multiple rooms on the East end had active toilet leaks, resulting in standing water on bathroom floors. Residents confirmed that their toilets had been leaking for an extended period, and staff acknowledged that this was a long-standing problem despite various attempted interventions. Observations and interviews with residents and staff consistently identified these unsanitary conditions, which affected the comfort and safety of the residents in the affected rooms.
Failure to Respond to Resident Call Lights Within Required Timeframe
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by interviews with residents and staff, review of Alarm Response Report forms, and facility policy. One resident reported timing her call light and found it was not answered for over 15 minutes on multiple occasions, with documented delays ranging from 17 to 26 minutes over several days. Another resident reported her call light was left unanswered for up to two hours on an evening shift, particularly when agency staff were present, and the Alarm Response Report confirmed several instances where her call light was not answered within the required 15-minute timeframe. Staff interviews confirmed that call lights were not answered within 15 minutes due to staffing shortages and issues with agency staff refusing to respond to call lights. The facility's policy requires timely responses to call lights, but the documented delays and staff admissions indicate this standard was not met for at least two residents during the review period. The facility had a census of 28 residents at the time of the deficiency.
Failure to Prevent Accident Hazard Resulting in Resident Cat Bite and Infection
Penalty
Summary
Facility staff failed to maintain appropriate supervision and accident hazard prevention when a resident with severe cognitive impairment was allowed to have her cat brought into the facility. The resident, who had a history of cerebrovascular accident, anxiety, depression, disorientation, and mild cognitive impairment, was described as confused and exhibited exit-seeking behaviors. The cat was brought in by the resident's DPOA as a comfort measure, but staff did not obtain written proof of the cat's vaccination status, relying only on verbal confirmation. Multiple staff members reported the cat displaying aggressive behavior, including hissing and growling, and noted that the DPOA had difficulty catching the cat and was bitten in the process. Despite these warning signs, the cat remained in the resident's room. Staff attempts to remove the cat were unsuccessful at first, and the resident was not successfully redirected away from the situation. During the removal attempt, the resident tried to console the agitated cat and was bitten on the left wrist and palm, resulting in multiple puncture wounds. The wounds required cleaning, dressing, and antibiotic treatment, and a subsequent infection developed, necessitating a change in antibiotic therapy. Interviews with staff revealed that there was no facility policy or procedure regarding pets or animals in the building. Staff were unaware of the cat's vaccination status, and the decision to allow the cat to stay was based on the assumption that it was friendly and vaccinated. The lack of supervision, absence of a pet policy, and failure to verify vaccination status contributed to the resident sustaining a cat bite and subsequent wound infection.
Failure to Provide Timely Call Light Response Due to Staffing and Equipment Issues
Penalty
Summary
The facility failed to provide adequate nursing staff and ensure timely response to a resident's call light, resulting in multiple instances where a resident's needs were not met within the regulated 15-minute timeframe. The resident reported that on several occasions, her call light remained unanswered for extended periods, including one instance where it was on from approximately 1:30 AM to 5:30 AM. The resident described feeling ignored, angry, and unhappy, and recounted an episode where a delayed response led to incontinence. Documentation from the Alarm Response Report confirmed numerous occasions over several days where the call light was not answered within the required timeframe, with delays ranging from over 15 minutes to nearly two hours. Staff interviews corroborated the resident's account, revealing that the facility's call light system was nonfunctional for about a week, during which residents were given bells that staff often could not hear, especially when staffing levels were low. Staff confirmed that with only one nurse and one CNA on duty, and with some residents requiring assistance from two or three staff members, it was not possible to consistently monitor or respond to call lights or bells within the required timeframe. Maintenance staff confirmed that the call system had been inoperative on two separate occasions in the past two months. The facility's policy required timely responses to call lights, but this was not achieved during the period in question.
Failure to Implement Care Plan for Timely Call Light Response
Penalty
Summary
The facility failed to implement a comprehensive care plan for one resident, as evidenced by the lack of timely response to call lights and unmet care needs. Clinical record review showed that the resident had intact cognition and was identified as being at risk for falls due to gait and balance problems, as well as incontinence. The care plan required that the call light be kept within reach and that staff respond promptly to all requests for assistance. However, the resident reported multiple instances where her call light was not answered for extended periods, including one occasion where it remained on for approximately four hours overnight, and another where it was unanswered for 45 minutes, resulting in loss of bowel control. These events caused the resident to feel ignored, angry, and unhappy, and were directly related to the facility's failure to implement the care plan interventions as specified.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
Facility staff failed to follow physician orders for a resident who sustained six small cat bite marks on her left arm. The physician had ordered staff to clean the affected areas with normal saline, apply triple antibiotic ointment, and cover with a bandage twice daily and as needed until healed. However, a review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January and February showed that the prescribed treatment orders were not documented or completed as ordered. Staff confirmed that the treatment order was missing from the MAR and TAR during this period. Facility policy required that medications and treatments be administered only upon written order and in accordance with safe and effective order writing principles.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNF/ABN) and Notice of Medicare Non-Coverage (NOMNC) to a resident or their legal representative, documenting an appeal decision and the date of notification of Medicare non-coverage. This deficiency was identified for one of the three residents sampled, specifically Resident #10, who was admitted for Medicare Part A skilled services and discharged on 8/16/24. The resident's medical record lacked documentation of notification regarding the discontinuation of Medicare Part A skilled services. The facility's policy required notification 48 hours prior to the termination of skilled coverage, but the administrator confirmed that the notice was not given, and there was no proof of it being done. Resident #10 had severe cognitive impairment and was receiving speech-language pathology and physical therapy treatments at the time of the deficiency.
Failure to Complete Baseline Care Plan for Resident
Penalty
Summary
The facility failed to complete a baseline care plan for one of the two residents reviewed, specifically for a resident who was admitted following a left knee replacement. The Electronic Health Record (EHR) documented the resident's admission and discharge dates, but lacked a completed baseline care plan. The facility's policy, revised in December 2016, requires a baseline care plan to be developed within 48 hours of admission to address the resident's immediate needs. However, the Director of Nursing stated that the baseline care plan should be completed within 72 hours of admission, indicating a discrepancy between the policy and practice. The Administrator confirmed that the baseline care plan for the resident was not completed, highlighting a failure to adhere to the facility's policy and meet the resident's immediate care needs within the required timeframe.
Failure to Conduct Background Check for Staff Member
Penalty
Summary
The facility failed to conduct a criminal background check for one of the five staff members reviewed, specifically a Certified Medication Aide (CMA) referred to as Staff A. Staff A was offered conditional employment on December 5, 2022, but a review of her file on November 13, 2024, revealed the absence of a background check. The Business Office Manager (BOM), Staff B, confirmed that the facility did not have a criminal background check for Staff A and had attempted to contact the Human Resources personnel responsible for conducting these checks, but they were unavailable. The BOM had recently assumed responsibility for conducting background checks on the same day of the review. The facility's policy, revised on May 20, 2024, mandates that every employee must successfully complete a background check before being granted regular employment, which was not adhered to in this case.
Failure to Provide Scheduled Baths/Showers
Penalty
Summary
The facility failed to ensure that residents received the required number of baths or showers per week, as evidenced by the cases of two residents. Resident #6, who has intact cognition and a diagnosis of multiple sclerosis, was not consistently receiving showers as scheduled. The care plan for Resident #6, revised in May 2022, indicated a need for assistance with bathing due to limited mobility. However, the electronic health record (EHR) lacked documentation of showers or baths being offered or provided on specific dates in October 2024. The facility's policy required documentation of any refusals and notification to supervisors if a shower was not given as scheduled, but this was not adhered to. Similarly, Resident #4, who required assistance with bathing, also had missing documentation for showers on several dates in October and November 2024. The Assistant Director of Nursing (ADON) acknowledged the inconsistency in documentation and was unable to provide further information regarding the missing records. The ADON mentioned that documentation was supposed to be on daily sheets, but these were not found, and it was unclear if they had been shredded. The Director of Nursing (DON) confirmed the expectation that residents receive their showers on scheduled days and that any deviations should be reported to nursing leadership.
Failure to Complete Physician-Ordered PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure the completion of physician-ordered treatments for a resident with multiple sclerosis (MS), who had intact cognition and required assistance with bathing. The resident reported that the dressing for her peripherally inserted central catheter (PICC) line was not consistently changed as ordered by the physician. The care plan for the resident, initiated in September 2021, directed staff to change the PICC line dressing using sterile technique weekly and to contact the provider if signs or symptoms of PICC line complications were noticed. However, a review of the treatment administration record for October 2024 showed a lack of documentation for the dressing change on two specific dates, with no rationale provided for the omission. The facility did not have a policy ensuring that physician orders are followed, and the Assistant Director of Nursing stated that staff should document if a treatment was not completed as ordered and provide a reason for the omission.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre and post dialysis assessments for a resident with End Stage Renal Disease (ESRD) who required hemodialysis. The resident, who had moderate cognitive impairment, was admitted to the facility and had a care plan directing immediate intervention for any complications from dialysis. However, during an electronic record review, it was discovered that these assessments were missing from the resident's health record. The facility's Administrator and Assistant Director of Nursing (ADON) were unable to locate the assessments, and the ADON acknowledged that the assessments should have been completed. The ADON later provided three incomplete Dialysis Communication assessments and admitted that many more assessments were missing. The facility's policy on dialysis communication and shunt care was highlighted and annotated, indicating it was intended as a guide for nurses. Despite this, the necessary documentation was not completed, leading to a deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Elevate Head During Tube Feeding Leads to Aspiration
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a gastronomy tube, leading to a serious health incident. The resident, who had a history of pneumonia, dysphasia, and other medical conditions, required his head of bed to be elevated during and after tube feedings to prevent aspiration. However, during a feeding, the nurse administered the feeding with the resident's head of bed lowered, and when the resident began to vomit, the nurse did not elevate the bed as required. This failure to follow proper procedure resulted in the resident developing aspiration pneumonia and septic shock. The resident's care plan clearly indicated the need for the head of bed to be elevated to 45 degrees during and after feedings, yet this was not adhered to. Staff interviews revealed that the resident was often left in a supine position, contrary to the care plan. On the day of the incident, the resident was found unresponsive with tube feeding formula draining from his nose, and his oxygen saturation was critically low. Despite these alarming signs, the nurse failed to perform a thorough assessment or take immediate corrective action. The situation was further exacerbated by the lack of communication and proper response from the nursing staff. The nurse involved did not recall the events accurately and failed to inform other staff members of the resident's true condition. The resident was eventually transferred to a hospital, where he was diagnosed with aspiration pneumonia and septic shock, conditions that were preventable had the proper care procedures been followed.
Failure to Follow Care Plan for Tube Feeding
Penalty
Summary
The facility failed to follow the care plan for a resident who required a feeding tube due to a swallowing problem. The care plan specified that the resident was dependent on staff for tube feedings and water flushes, and required monitoring for aspiration, shortness of breath, abnormal breath/lung sounds, and nausea and vomiting. Additionally, the care plan directed that the head of the bed (HOB) should be elevated 45 degrees during and thirty minutes after a tube feeding. However, during an incident, the resident was found with the HOB at approximately 15 degrees after vomiting, which was not in accordance with the care plan. Staff interviews revealed that a CNA and an RN found the resident lethargic and responsive after vomiting, with the HOB improperly positioned. Later, an LPN observed the resident in a supine position with tube feeding formula draining from his nose and found him non-responsive. The facility called EMS, who found the resident unresponsive with a high temperature and transported him to the hospital. The EMS crew noted that this was not the first time they found the resident in a supine position, indicating a recurring issue with following the care plan for this resident.
Failure to Conduct Thorough Assessments Following Condition Changes
Penalty
Summary
The facility failed to complete thorough assessments and interventions for two residents following a change in their conditions. For one resident, the progress notes indicated a catheter change due to discomfort, with blood noted in the catheter drainage bag. However, there were no assessments documented between the catheter change and the subsequent observation of blood, nor were there additional assessments after the blood was noted until the resident was discharged to the hospital. The resident was later found unresponsive with a high fever and was transferred to the emergency department, where he was diagnosed with septic shock and aspiration pneumonia. The hospital records indicated a blocked catheter and significant medical interventions were required, including intubation and administration of antibiotics. Another resident's assessment noted a non-productive cough and wheezing, but the facility's documentation guidelines for such symptoms were not followed. The guidelines required detailed documentation of vitals, symptom descriptions, and notifications, which were not present in the records. This lack of thorough assessment and documentation for both residents following changes in their conditions represents a deficiency in the facility's care practices.
Failure to Ensure Staff Completed Dependent Adult Abuse Training
Penalty
Summary
The facility failed to ensure that two of six staff members met the requirements for Dependent Adult Abuse Training. Specifically, Staff A, a Certified Medication Aide (CMA), had completed the required training on 1/9/19, which was valid for five years, but had not completed any further training since then. Staff B, a Certified Nursing Assistant (CNA) who started on 3/16/23, had no documentation of having completed the required Dependent Adult Abuse Training. The facility's policy, revised in April 2023, mandates that each employee complete two hours of training on the identification and reporting of dependent adult abuse within six months of initial employment and an additional two hours every three years. The Administrator acknowledged that both staff members were completing the training but confirmed it was overdue.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to serve food under sanitary conditions, increasing the risk of contamination and foodborne illness. During an observation, Staff D, a cook, was seen washing her hands and applying gloves before starting the supper service. However, Staff D did not change her gloves throughout the process of serving meals to 15 residents. She touched various surfaces, including containers, menus, plates, bowls, utensils, and food, without changing gloves or performing hand hygiene. Additionally, Staff E, a dietary aide, was observed adjusting his ballcap and then handling glasses and drinks without performing hand hygiene. Staff E delivered drinks to 12 residents by carrying the glasses by the rim, further compromising sanitary conditions. Staff D continued to use the same gloves to open the refrigerator and handle food items, including chicken salad sandwiches and cookies, without changing gloves or performing hand hygiene between tasks. The facility's sanitation policy, revised in June 2015, directed staff to change gloves with each new task but lacked specific instructions on hand hygiene between glove changes and between surfaces. The Dietary Manager confirmed that staff were expected to use utensils when serving food and not to use gloves when handling food during serving.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure staff treated residents with dignity and respect, as evidenced by an incident involving a resident with intact cognition and multiple diagnoses, including hypertension, diabetes, schizoaffective disorder, borderline personality disorder, anxiety, and traumatic brain injury. During an interview, a CNA reported that another CNA told the resident she 'smelled like piss' while assisting with a change, causing the resident to cry. The resident confirmed that this comment was made almost every time she was changed. The Director of Nursing stated that all staff are expected to treat residents with dignity and respect. The facility's policy on Residents Rights and Responsibilities lacked documentation of residents being treated in a dignified manner by staff.
What surveyors are citing around you — mapped
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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 62 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Osage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Faith Lutheran Home | 0.4 mi | ★★★★★ | 0 | 0 |
| Good Samaritan - Saint Ansgar | 8.5 mi | ★★★★★ | 0 | 0 |
| Stacyville Community Nursing Home | 10.9 mi | ★★★★★ | 2 | 0 |
| Nora Springs Care Center | 13.7 mi | ★★★★★ | 4 | 0 |
| Riceville Family Care And Therapy Center | 14.2 mi | ★★★★★ | 5 | 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.