Osage Beach Rehabilitation and Health Care Center

Inspectors wroteBased on interview and record review, facility staff failed to report an allegation of a physical altercation between two residents (Resident #1 and #2) to the State Survey Agency (SSA) within the required two hour timeframe. The facility census was 80.1. Review of the facility's Administrative Procedure Manual, Reporting policy, dated 11/28/16, showed any partner with either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately. All alleged violations and all substantiated incidents will be reported immediately to the administrator or her/his designated representative and to other officials in accordance with State and Federal law (including to the State survey and certification agency). 2. [...]

Inspectors wrote1. Review of the facility's Administrative Procedures Manual policy, dated 11/28/16, showed patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow-through designed to minimize the risk of conduct. Review of the facility's policies, undated, did not contain a policy to direct staff on the Care Plan process and instead staff were directed to refer to the RAI Manual. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/25/26, showed staff assessed the resident with severe cognitive impairment. Review of the resident's progress notes, dated 06/23/2026, showed staff documented the resident was seen holding hands and kissing with Resident #2 on the lips reported by a Certified Nurse Aide (CNA). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure one resident (Resident #2) remained free from sexual abuse, when a resident (Resident #1) entered Resident #2's room and touched his/her chest. The facility census was 81. The administrator was notified on 06/22/26 of Past Non-Compliance which occurred on 06/17/26. The Administrator and Director investigated, notified the residents' responsible parties, and in-serviced staff regarding abuse, sent Resident #1 to the hospital for evaluation, and initiated one on one monitoring. Resident #2 had additional therapy services initiated as a result of this. Staff corrected the deficient practice on 06/18/26. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when the lift hit a television mounted on the wall and the television fell and struck the resident and he/she sustained an injury to his/her head and arm. The facility census was 77. 1. Review of the Electric Portable Patient Lift owner's operator and maintenance manual, undated, showed the guide recommends two persons transfer in circumstance of combativeness, obesity, contracture etc. It is the responsibility of each facility or medical professional to determine if a one or two person transfer is more appropriate. Review of the facility's Transfers and Lifts policy, undated, showed the lift must be used with two staff members. 2. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to notify the physician in a timely manner of an injury to one resident (Resident #1) when a television fell from the wall and struck the resident in the arm and head. The facility census was 77. 1. Review of the facility's change in patient status Policy, revised 3/2024, showed the charge nurse is to notify the physician. Review of the facility's Accidents and Untoward Occurrences Policy, reviewed May 2025, showed staff are directed to notify the physician and document content of discussion. 2. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool, dated 6/5/25, showed staff assessed the resident as follows: -Cognitively intact; -Guillain-Barre syndrome (immune system attacks the nerves), Paraplegia (muscle weakness or paralysis on the lower half of the body). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a barrier for the glucometer (a device for monitoring blood sugars) supplies for seven residents (Resident #7, #26, #52, #55, #61, #74, and #79) out of seven sampled residents. Facility staff failed to wear gloves while administering insulin to three residents (Resident #52, #61, and #74) out of seven sampled residents. Facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness). The facility census was 75. 1. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to meet professional standards of care when staff did not document an order for code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) for one Resident #9, did not document a clear order for code status for one Resident #37, and did not document clinical condition or symptoms for use of medications for three Residents (#75, #79, and #80) out of 18 sampled residents. The facility's census was 75. 1. Review of the facility's policy titled, Code Status/Advance Directives Procedure, dated [DATE], showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain consents for side rails and failed to complete side rail assessments for five residents (Resident #18, #43, #64, #76 and #77), out of seven sampled residents. The facility census was 75. 1. Review of the facility's Proper use of Side Rails Policy, 12/2016, showed: -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; -When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility; -Ability to change positions, transfer to and from bed or chair, and stand and toilet; -Risk of entrapment from the use of side rails; -That the beds dimensions are appropriate for the resident's size and weight. [...]

Inspectors wroteBased on observation and interview, facility staff failed to ensure residents' personal information was protected when staff left the computer screen open in public areas for six residents (Resident #7, #26, #31, #61, #74 and #79) of nine sampled residents. The facility's census was 75. 1. Review of the facility's policy titled, National Healthcare Corporation (NHC) Health Insurance Portability and accountability Act (HIPAA) Privacy Program, dated 12/2024, showed: -NHC is committed to complying with the HIPAA Privacy Rule and maintaining the confidentiality of patient's Protected Health Information (PHI) through appropriate, authorized access, uses, and disclosures; -NHC creates, stores, maintains, uses, transmits, collects and disseminates PHI in an environment that promotes confidentiality and integrity without compromising PHI. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document an accurate Minimum Data Set (MDS), a federally mandated assessment, when staff did not accurately code section A of the MDS for two residents (Residents #9 and #41), and section B of the MDS for one resident (Resident #43) out of 18 sampled residents. The facility's census was 75. 1. Review of the facility's policies showed staff did not provide a MDS policy. 2. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, a guideline for staff to complete each resident's MDS, dated [DATE], showed federal regulations require the assessment accurately reflects the resident's status, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. [...]

Inspectors wroteBased on observation and interview, facility staff failed to post, in a form and manner accessible to residents, resident representative, visitors and staff the required telephone number to the Department of Health and Senior Services (DHSS) elder abuse and neglect hotline. The census was 75. 1. Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, showed the names, addresses, and telephone numbers of all pertinent State client advocate groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network are available to all patients and their families and will be posted prominently in the center. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care to meet basic hygiene needs for three (Resident #5, #24, and #80) out of five sampled residents. The facility census was 75. 1. Review of the facility's policies showed the staff did not provide a bath policy. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/30/25, showed staff assessed the resident as follows: -Brief Interview for Mental Status ((BIMS) - a short cognitive screening tool) score not conducted as the resident is rarely/never understood; -Did not reject care; -Required substantial/max assist from staff with personal hygiene and to shower/bathe. Review of the resident's care plan, dated 02/12/25, showed staff are directed to assist the resident with dressing, personal hygiene, transfers, and showers. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 being transported to the hospital after an adverse reaction. The facility census was 76. The administrator was notified on 5/6/24 of past Non-Compliance, which occurred on 4/21/24 when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 4/23/2024. 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for it's residents competently during both day-to-day operations and emergencies as required. The facility census was 73. 1. Review of the facility's Facility Assessment Report, dated September 2022 through August 2023, showed the assessment did not contain information on staffing for day-to-day operations and emergencies as required. During an interview on 5/6/24 at 1:14 P.M., the administrator said he/she did not have a full facility assessment completed and is aware it is required to be done annually. He/She said he/she staffs by census.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. Facility staff also failed to store food in a manner to prevent contamination and out-dated use. The facility census was 71. 1. Review of the facility's Machine Warewashing policy, dated November 2017, showed the policy directed staff to air dry all items and ensure all items are completely dry before stacking to prevent wet-nesting. Observation on 12/11/23 at 9:54 A.M., showed Dietary Aide (DA) I removed sanitized plates from the clean side of the mechanical dishwashing station while wet and stacked them together upside down in the plate heater. [...]

Inspectors wroteBased on observation, record review and interview, facility staff failed to update three residents (Resident #20, #59, and #68) care plans to include the use of oxygen. The facility census was 71. 1. Review of the facility's policies showed staff did not provide a policy for care plans. 2. Review of Resident's #20's admission Minimum Data Set (MDS), a federally mandated assessment, dated 10/16/23, showed staff assessed the resident as follows: -Cognitively intact; -Oxygen therapy; -BiPAP therapy (a device that helps with breathing which provides distinct air pressure levels for inhalation and exhalation); -Diagnoses of chronic lung disease, respiratory failure, anxiety, and heart failure. Review of the resident's care plan, dated 10/18/23, showed the care plan did not contain information for the resident use of his/her BiPAP or oxygen therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection when staff failed to clean a suction machine for one resident (Resident #8), during perineal care and staff applied oxygen tubing directly from the floor on one resident (Resident #11). Staff failed to change and date respiratory tubing for three residents (Resident #15, #20, and #59). The facility census was 71. 1. Review of the facility's Suction Machine, Care and Use of policy, dated 2006, showed the suction machine bottle should be emptied, washed with soapy water and rinsed after each use. 2. Review of Resident #8's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/18/23 showed staff assessed the resident: -Required artificial intake of greater than 51 percent (%) of fluid and calories; [...]

Inspectors wroteBased on interviews and record review, facility staff failed to report a missing gift card for one resident (Resident #45) to the Department of Health and Senior Services (DHSS) within the required time frame. The facility census was 71. 1. Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/23, showed abuse, neglect, misappropriation of patient property and exploitation will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors or any other individual in this center. Review showed: -The patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation; [...]

Inspectors wroteBased on observation, record review and interview, facility staff failed to ensure one resident (Resident #20) had a physician order for oxygen usage. The facility cenus was 71. 1. Review of the facility's Oxygen for Patient Use policy, revised November 2022, showed the policy did not contain direction on orders required for oxygen therapy. 2. Review of Resident's #20's admission Minimum Data Set (MDS), a federally mandated assessment, dated 10/16/23, showed staff assessed the resident as follows: -Cognitively intact; -Oxygen therapy; -Diagnoses of chronic lung disease, respiratory failure, anxiety, and heart failure. Review of the resident's Physicians Order Sheet (POS), dated 12/01/23, showed the record did not contain an order for the use of oxygen. Observation on 12/11/23 at 01:04 P.M., showed the resident with his/her oxygen on per a nasal cannula. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of Covid-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for Covid-19. The facility failed to separate three positive Covid-19 residents (Resident #1, #3 and #8) from residents who had tested negative for Covid-19 or had only been exposed to Covid-19 for five residents (Resident #2, #4, #5, #6 and #7) at an increased risk of contracting Covid-19 due to prolonged exposure. The facility census was 71. The Administrator was notified on 10/02/23 at 1:43 P.M., of an Immediate Jeopardy (IJ) which began on 09/19/23. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the resident environment remains as free of accident hazards as is possible, when staff failed to maintain the hot water temperature of plumbing fixtures accessible to residents on corridors A and B in a manner to prevent serious burns or scalding in a short amount of time. Additionally, facility staff failed to ensure razors and hazardous chemicals were stored in a safe manner, and failed to lock an unattended treatment cart. Facility staff also failed to propel four residents (Residents #14, #30, #57 and #59) in wheelchairs in a manner to prevent accidents. The facility census was 68. The administrator was notified on 09/20/22 at 12:45 P.M. of an Immediate Jeopardy (IJ) which began on 09/19/22. The IJ was removed on 09/20/22, as confirmed by surveyor onsite verification. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to allow sanitized dishes to air dry before stacking in storage and use to prevent cross-contamination and the growth of food-borne pathogens. Facility staff failed to perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff failed to store food in a manner to prevent contamination and out-dated use. Facility staff also failed to maintain the kitchen physical environment and equipment in a sanitary condition. The facility census was 68. 1. Review of the facility's Machine Warewashing policy, dated 11/2017, showed the policy directed staff to air dry all items and make sure all items are completely dry before stacking to prevent wet-nesting. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). Additionally, the facility staff failed to use hand hygiene and provide perineal care and catheter (a tube inserted into the bladder) care in a manner to reduce the risk of infection for two residents (Resident #23 and Resident #35). Facility staff failed to ensure all employees were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per policy for four out of ten sampled employees. [...]

Inspectors wroteBased on interview and record review, facility staff failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances; failed to establish a grievance policy that identified a current grievance official, included the right to file a grievance anonymously and that required the facility to maintain evidence demonstrating the result of all grievances for a period of no less than three years; and failed to educate and review guidelines on how to file a grievance with the residents. The facility census was 68. 1. Review of the facility's Resident Rights Grievance Procedure, dated 2009, showed: If at any time you are not being treated fairly, or if you feel that an employee has mistreated you in any way, please take the following steps: -Notify the social worker for assistance in resolving the problem. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to accurately identify care areas for 10 residents (Residents #6, #7, #14, #29, #35, #42, #58, #59, #60, and #65) in the resident's comprehensive care plans (CP). The facility census was 68. 1. Review of the facility's Patient Care policies, dated 2022 showed: -Patients are assessed initially and at regular intervals using a Federal/State specified, standardized, comprehensive resident assessment instrument to identify functional capacity and health status; -The process involves the entire Interdisciplinary Team (IDT); -Decision making/planning is based on identified needs/problems and builds on patients strengths while taking into account the patients preferences; -The care plan serves a guide for care decisions and is made available to use by all patient care personnel. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to meet professional standards of quality when staff failed to provide consistent documentation in regard to residents' Physician Orders for Life-Sustaining Treatment (designed to improve patient care by creating a medical order form that records residents' treatment wishes so staff know what treatments the resident wants in the event of a medical emergency) for three residents (Resident #9, #30 and #65). Additionally, facility staff failed to follow scope of practice by allowing a Certified Nurse Aide (CNA) to administer medication without an order to two residents (Residents #23 and #40). The facility census was 68. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure residents that were unable to complete their own activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene when staff failed to provide hair care and nail care to eight residents (Residents #6, #14, #25, #29, #42, #59, #62, and #65). The facility census was 68. 1. Review of the facility's Activity of Daily Living (ADL) policy, undated, showed: -Resident self-image is maintained; -Equipment and instruction for mouth care, shaving, makeup, and hair care are provided; -Frequent showers or baths are scheduled and assistance provided when required. Review of the facility's Quality of Life-Dignity policy, dated August, 2009, showed: -Residents shall be treated with dignity and respect at all times; [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to use alternatives prior to bed rail installation, assess for risk of entrapment, or obtain informed consent for bed rails for eleven residents (Resident #6, #24, #25, #35, #41, #42, #47, #51, #52, #60, #62). The facility census was 68. 1. Review of the facility's Bed Safety policy, dated December 2007, showed: -The resident's sleeping environment shall be assessed by the interdisciplinary team (IDT), considering the resident's safety, medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habit and bed environment; -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of bedrails as part of a regular maintenance program by failing to measure and assess all possible entrapment zones for 12 residents (Residents #6, #24, #25, #35, #37, #40, #41, #42, #47, #48, #52, and #62). The facility census was 68. 1. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure resident's personal information was protected when staff left residents' protected health information on top of the medication cart and left the Electronic Health Record (EHR) open and unattended in public hallways. The facility census was 68. 1. Review of the facility's Quality of Life-Dignity Policy, revised August 2009, showed staff shall maintain an environment in which confidential clinical information is protected. Review of the facility's Administration Procedures for All Medications Policy, dated 1/1/19, showed staff are directed to secure records containing protected health information. Observation on 9/19/22 at 11:00 A.M., showed paper documentation on top of the computer cart, unattended on Hallway A with residents' information exposed. [...]

Inspectors wroteBased on record review and interview, the facility staff failed to complete an admission and a Significant Change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, within the timeframes directed by the Centers for Medicaid and Medicare Services (CMS) for two residents (Residents #7 and #65). The facility census was 68. 1. Review of the CMS, Long-Term Care (LTC) Facility, Resident Assessment Instrument (RAI) User's Manual, dated October 1, 2019, provides the following instruction for LTC staff. The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day one. Review of Resident #65's admission MDS, dated [DATE], showed as of 9/22/22 the MDS had not been finalized or accepted. 2. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete and implement a baseline care plan within 48 hours of admission and failed to document the baseline care plan was reviewed with the resident or responsible party for three residents (Residents #25, #66, and #88). The facility census was 68. 1. Review of the facility's Nursing Services policy, dated February 2022, showed: -A baseline care plan is developed to address the immediate needs of the patient within 48 hours of the patient's admission; -A summary of the baseline care plan will be shared with the patient and the representative. 2. Review of Resident #25's Annual Minimum Data Set, (MDS), a federally mandated assessment tool, dated 3/22/22, showed staff assessed the resident as: -admitted on [DATE]; -Required supervision of one staff member for bed mobility, transfers, locomotion, eating, and toilet use; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5%, when staff administered medications late to one resident (Resident #26) and failed to prime an insulin pen before administration for one resident (Resident #15). Out of 25 opportunities observed, six errors occurred, resulting in a 24% error rate. The facility census was 68. 1. Review of the facility's Medication Error Report Form, undated, identified incorrect time and incorrect dose as a type of medication error. 2. Review of Resident #26's Physician's Order Sheet (POS), dated 8/22/22, showed staff were directed to administer the following medications at 7:00 A.M.: -Levetiacetam (used to treat seizures) 500 Milligrams (mg), one tablet (tab) orally; -Senna Plus (used to treat constipation) 50/8.6 mg, two tabs orally; [...]

Inspectors wroteBased on interview and record review, facility staff failed to annually and as necessary, conduct, document, review and update their Facility-wide Assessment, an assessment completed by facility staff to determine what resources are necessary to care for its residents competently during day-to-day operations and emergencies. The facility census was 68. 1. Review of the facility's Facility Assessment Tool, dated 8/18/17, showed nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The tool is organized into three parts: -Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care; [...]