Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Osceola Senior Living during CMS and state inspections, most recent first.
A resident receiving CPAP therapy had no routine cleaning schedule for the CPAP equipment, and staff did not have current CPAP settings available. The resident reported the equipment had not been cleaned since admission and was unsure whether the settings were correct. Orders listed nightly CPAP use, but the settings were not documented, and the care plan did not include cleaning, maintenance, or setting instructions.
The facility did not update physician orders in the electronic health records for two residents with severe cognitive impairment. One resident's PRN lorazepam order was not updated with the correct end date, and another resident's order was similarly mishandled. The facility's policy requires orders to be entered into the computer and notifications made, but these steps were not followed.
A resident with moderate cognitive impairment and heart-related diagnoses did not receive oxygen therapy as per the physician's order to maintain oxygen saturation levels at or above 92%. Despite low oxygen levels during activities, the facility's documentation lacked evidence of appropriate interventions, and the resident's oxygen saturation frequently fell below the prescribed threshold.
A facility failed to include necessary dementia care in the care plan of a resident with Alzheimer's Disease, severe cognitive impairment, stroke, and hypertension. The care plan lacked details on the resident's physical, mental, and psychosocial needs. The DON acknowledged the omission and reported the absence of a policy for dementia care planning.
The facility failed to manage and document psychotropic medications for two residents, omitting these medications from care plans and not specifying targeted behaviors or non-pharmacological interventions. Additionally, a discontinued medication remained in a care plan, and an indefinite prescription lacked an end date. The DON acknowledged these issues and the lack of a policy on unnecessary medications.
The facility failed to follow proper infection control practices for catheter care, as observed with two residents whose catheter bags were hung from garbage receptacles. A CNA did not perform proper hand hygiene during catheter care, using soiled gloves to handle the catheter bag and touching surfaces without removing gloves or sanitizing hands. The facility's policies on catheter care and hand hygiene were not adhered to, as confirmed by the DON.
The facility failed to develop comprehensive care plans for several residents, including those with severe cognitive impairment and multiple diagnoses. Key issues included lack of communication about medication side effects to CNAs, incomplete care plans for high-risk medications, and failure to address specific needs related to dementia and pressure ulcers.
The facility failed to ensure proper infection control practices for a resident on contact precautions, appropriate hand hygiene during feeding assistance, and an annual review of infection control policies. Trash and linen receptacles were incorrectly placed outside a resident's room, and a CNA did not perform hand hygiene between assisting two residents. The facility also lacked a policy for the annual review of infection control procedures.
The facility failed to screen and offer a COVID-19 vaccination to a resident upon admission, as required by their policy. The resident had previously received COVID-19 vaccinations but there was no documentation indicating that the resident was screened or offered a booster dose upon admission.
CPAP Equipment Not Cleaned and Settings Not Available
Penalty
Summary
The facility failed to implement and follow appropriate infection control measures for a resident using CPAP therapy by not establishing or following a routine cleaning schedule for the CPAP equipment and by not providing staff with current CPAP machine settings. Resident #17 had diagnoses including anemia, coronary artery disease, and dementia, and the MDS documented use of a non-invasive mechanical ventilator with a BIMS score of 15. The resident reported that staff had not cleaned the CPAP equipment since admission and stated they did not know whether the CPAP settings were correct. The physician orders showed CPAP use every night but did not include the settings, and the care plan for CPAP therapy did not include instructions for cleaning, maintenance, or settings. The Infection Preventionist and DON confirmed that CPAP and BiPAP equipment should have a regular cleaning schedule and that settings should be available for staff to ensure correct use.
Failure to Update Physician Orders in Electronic Records
Penalty
Summary
The facility failed to adhere to professional standards of care by not updating physician orders in the electronic health records for two residents. Resident #3, who has severe cognitive impairment due to Alzheimer's Disease, stroke, and hypertension, had a physician order for PRN lorazepam updated on February 13, 2025, for a duration of 12 months. However, the electronic record showed the last update on January 5, 2025, with an indefinite end date, indicating a failure to enter the updated order and correct end date. Similarly, Resident #31, diagnosed with dementia, psychotic disorder, and acute kidney disease, also exhibited severe cognitive impairment. The physician reordered PRN lorazepam for this resident on December 31, 2024, for three months, but the electronic record was last updated on September 5, 2025, with an indefinite end date. The facility's policy requires that orders be noted, entered into the computer, and the resident and family notified, but these steps were not followed. The Director of Nursing acknowledged the oversight and indicated that the pharmacy is responsible for entering orders into the electronic health records.
Failure to Administer Oxygen Per Physician's Order
Penalty
Summary
The facility failed to ensure a resident received oxygen therapy as per the physician's order. The resident, who had moderate cognitive impairment and diagnoses including atrial fibrillation, heart failure, and pulmonary hypertension, experienced low oxygen saturation levels during activities. Despite the Certified Nurse Practitioner (CNP) advising to administer oxygen as needed to maintain saturation levels at or above 92%, the resident's oxygen levels frequently fell below this threshold. The clinical records showed that the resident's oxygen saturation levels were consistently below 92% on room air and even while on 2 liters of oxygen via nasal cannula. The facility's documentation lacked evidence of appropriate interventions to maintain the resident's oxygen saturation at the prescribed level. The Director of Nursing acknowledged that the oxygen should have been titrated to meet the order's requirements. The facility's oxygen policy required a physician's order specifying the route and liter flow, and the nurse was expected to monitor and document the resident's oxygen status. However, the records did not reflect adherence to these guidelines, resulting in the deficiency.
Failure to Address Dementia Care in Resident's Care Plan
Penalty
Summary
The facility failed to address the care needs of a resident diagnosed with Alzheimer's Disease in their care plan. The resident, identified as having severe cognitive impairment with a BIMS score of 5, also had diagnoses of stroke and hypertension. Despite these conditions, the care plan did not include information regarding the physical, mental, and psychosocial needs necessary to support the resident's highest practical level of well-being. The Director of Nursing acknowledged the omission and noted that the facility lacked a policy for incorporating Alzheimer's Disease or dementia care into the care plan.
Deficiencies in Psychotropic Medication Management and Care Planning
Penalty
Summary
The facility failed to properly manage and document the use of psychotropic medications for two residents, leading to deficiencies in care planning and medication management. Resident #3, who has severe cognitive impairment due to Alzheimer's Disease, stroke, and hypertension, was prescribed lorazepam, quetiapine, and trazodone. However, the facility did not include these medications in the resident's care plan, nor did it document specific targeted behaviors for their use or non-pharmacological interventions to be attempted prior to medication administration. Similarly, Resident #9, who has no cognitive impairment but suffers from peripheral vascular disease, diabetes mellitus, and stroke, was prescribed lorazepam and trazodone. The facility also failed to include these medications in the care plan and did not document targeted behaviors or non-pharmacological interventions. Additionally, the care plan for Resident #9 still listed sertraline, an antidepressant that had been discontinued, and the facility did not specify an end date for the lorazepam prescription. The Director of Nursing acknowledged these oversights and noted the absence of a policy related to unnecessary medications.
Improper Infection Control Practices in Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices concerning the handling of catheter bags for two residents. Observations revealed that the catheter bags for both residents were improperly hung from garbage receptacles, which is against the facility's infection control policy. Additionally, during the process of emptying a catheter bag, a CNA did not perform proper hand hygiene. The CNA was observed using soiled gloves to handle the catheter bag and then touching various surfaces, including the resident's door, without removing the gloves or performing hand hygiene immediately after removing them. The facility's policy on catheter care and hand hygiene was not followed, as evidenced by the CNA's actions. The policy requires washing hands before and after handling catheters and emphasizes the importance of not allowing the drain tube to touch any surfaces. However, the CNA exited the resident's room with soiled gloves, used hand sanitizer improperly, and failed to maintain a sterile environment. The Director of Nursing confirmed that catheter bags should not be hung from garbage receptacles and that staff should not exit resident rooms without removing PPE and performing hand hygiene.
Deficiencies in Care Plan Development
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. For Resident #9, who had severe cognitive impairment and was prescribed high-risk medications such as Buspirone and Seroquel, the care plan included monitoring for side effects but did not ensure that Certified Nurse Assistants (CNAs) were informed of these side effects. This gap in communication was acknowledged by the Director of Nursing (DON), who confirmed that CNAs do not have access to the Medication Administration Record (MAR) where side effects are listed. Resident #27, who had intact cognition and multiple diagnoses including cancer, heart failure, and diabetes, was prescribed Furosemide, insulin aspart, and morphine sulfate. The care plan only included information about Furosemide and lacked any focus areas or interventions for the insulin and narcotic pain medication, as well as for pain management. This omission was contrary to the facility's policy of developing comprehensive, person-centered care plans. Resident #31, with severe cognitive impairment and diagnoses of dementia and Alzheimer's disease, did not have a care plan that addressed her specific needs related to these conditions. The care plan failed to include proactive measures for identifying symptoms of distress or basic needs such as pain, hunger, and toileting. Additionally, Resident #29, who had multiple diagnoses and a documented stage 2 pressure ulcer, did not have the pressure ulcer included in the care plan. Staff A attributed this to a malfunction in the Electronic Health Records (EHR) system, which had not been resolved at the time of the survey.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control practices for a resident on transmission-based precautions, proper hand hygiene during assistance with feeding, and an annual review of infection control policies by the medical director. One resident, who had ulcerative colitis and C-diff, was placed on contact precautions and required to stay in her room for 10 days. However, trash and linen receptacles were placed outside the resident's room, contrary to the facility's policy, which required these items to be inside the room for proper disposal of personal protective equipment (PPE). Both the Director of Nursing (DON) and the Infection Preventionist (IP) acknowledged this error during the surveyor's observation. Additionally, a Certified Nurse Assistant (CNA) was observed assisting one resident with lunch and then another without performing hand hygiene in between, which is against the facility's hand hygiene guidelines. The DON confirmed that staff should not assist multiple residents with eating without performing hand hygiene in between. Furthermore, the facility did not perform an annual review of their infection prevention and control policies and procedures, as confirmed by the DON and the new IP. The DON admitted that the facility lacked a policy for the annual review of these procedures.
Failure to Screen and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to screen and offer a COVID-19 vaccination to a resident upon admission, as required by their policy. Resident #5 was admitted to the facility and had previously received COVID-19 vaccinations on 3/8/21 and 4/8/21. However, there was no documentation in the clinical record indicating that the resident was screened or offered a COVID-19 vaccination upon admission, nor was there any record of a booster dose being offered, despite the HHS directive allowing booster doses starting on 9/25/21. The facility's COVID Vaccine Policy, dated 5/3/23, mandates that vaccination preferences be inquired about on admission, with a consent form completed for acceptance or refusal. Additionally, the policy requires that COVID immunizations be offered to each resident per the consulting pharmacist's recommendations, and that the pharmacist document the vaccination in the electronic health record (PCC). The lack of documentation for Resident #5 indicates a failure to adhere to these policies, resulting in the deficiency noted in the report.
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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 Sibley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sibley Specialty Care | 1.2 mi | ★★★★★ | 1 | 0 |
| Good Samaritan - George | 13.5 mi | ★★★★★ | 19 | 0 |
| The Shores Of Worthington | 15.4 mi | ★★★★★ | 21 | 1 |
| Parkview Manor Nursing Home | 15.7 mi | ★★★★★ | 10 | 0 |
| Sanford Senior Care Sheldon | 16.3 mi | ★★★★★ | 8 | 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.