Osage Healthcare & Wellness Centre

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Provide continuous supplemental oxygen (a medical treatment delivering oxygen enriched air to people with breathing problems) at two liters per minute (lpm, unit of measurement the rate of oxygen flow delivered to the resident) through nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as ordered by the physician for one of three sampled residents (Resident 2). 2. Ensure the oxygen tubing (a flexible, latex-free tubing, to deliver oxygen from a source) was labeled and dated for one of three sampled residents (Resident 22). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident food brought from outside was labeled, dated and stored in the designated resident's refrigerator in the activity room for one of one sampled resident (Resident 30). 2. Ensure 1 week old lettuce in a clear container was labeled and dated in the vegetable refrigerator in the kitchen. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (an infection or irritation of the gastrointestinal tract caused by eating or drinking food or beverages contaminated with harmful bacteria, viruses, parasites, or chemicals).

Inspectors wroteBased on interview and record review, the facility failed to:1. Obtain a written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from interdisciplinary team (([IDT] - team members from different disciplines who come together to discuss resident care) before initiation of a psychotropic drug (Any drug that affects brain activities associated with mental process and behavior) for resident with diagnosis of dementia (a progressive state of decline in mental abilities) for one of six sampled residents (Resident 39). This deficient practice placed Resident 39 at risk for sustaining adverse effects (undesired effect of a drug) from psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure that one of five residents, Resident 35, was provided a call device within their reach. This failure had the potential to result in Resident 35's inability to notify staff when in need of care or in distress.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Notify the physician for one of one sampled resident (Resident 30) refusing Bilevel Positive Airway Pressure ([BIPAP] - a noninvasive, mask-based ventilation device that assists with breathing by delivering two distinct levels of pressure) treatment. This failure had the potential for Resident 30 to experience severe shortness of breath that would likely require hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Inform a resident of how to file a grievance for missing glasses for one of four sampled residents (Resident 32). This deficient practice had the potential to violate the resident's right to have a grievance filed and ensure resident was comfortable at the facility.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one of two residents (Resident 2) Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 screening (a mandatory preliminary screening required for all individuals seeking admission to a Medicaid-certified nursing facility) indicated diagnosed mental illnesses. This failure had the potential for Resident 2 not being appropriately identified for further evaluation of serious mental illness leading to resident not receiving necessary specialized services, treatment planning interventions, or appropriate placement.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for one of 17 sampled residents (Resident 30) by failing to: 1. Develop a comprehensive care plan addressing Resident 30's refusal to use Bilevel Positive Airway Pressure ([BIPAP] - a noninvasive, mask-based ventilation device that assists with breathing by delivering two distinct levels of pressure). This deficient practice had the potential to place Resident 30 at risk for delay of care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure missing eyeglasses were replaced for one of four sampled residents (Resident 32). This deficient practice had the potential to violate the resident's right to have a grievance filed and ensure resident was comfortable at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure a Stage 4 pressure ulcer wound care treatment was provided for 4 days for one of four sampled residents (Resident 6). This deficient practice had the potential to result in further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure two of three residents' (Resident 2 and Resident 22) oxygen concentrator (machine that converts normal air to a more concentrated oxygen) was turned off when not in use. This failure had the potential to create an oxygen enriched environment, increased risk of fire hazards, equipment malfunction, and compromised resident safety.

Inspectors wroteBased on interview and record review, the facility failed to: 1. ensure employee performance, competency validation, initial orientation validation, and orientation activities checklist were completed for 3 of 6 employees, RN1, LVN 2, and CNA 2. This failure had the potential to result in residents not receiving the required care based on the employee performance competency, orientation validation, and orientation activities provided for the proper care of the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of one resident's (Resident 49) mouth was rinsed after administration of prescribed inhaler Breo Ellipta [an inhaler used as a maintenance medication for asthma (a condition that causes the respiratory airways to swell up, shrink, and fill with mucus)]. This failure had the potential to result in Resident 49 developing irritation of the mouth, discomfort, and an increased risk of infection of the mouth and throat due to medication remaining in the mouth after inhaler use.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure medication error rate was less than five percent (%). Two errors out of 34 total opportunities contributed to an overall medication error rate of 5.88% for one of five residents (Resident 49) observed during medication administration (med pass). Resident 49's cholecalciferol (Vitamin D) 400 units [(IU - international units) a unit of measurement] tablet and fluticasone propionate suspension 50 mcg/act (micrograms per actuation- a unit of measurement) nasal spray were administered per physician's order. This failure had the potential to result in impaired bone health, increased fracture risk, respiratory complications, worsening allergy symptoms, nasal congestion and decreased comfort.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a resident who had a diagnosis of dementia (a progressive state of decline in mental abilities) and legally blind (severe vision loss) understands the legal documents (documents affecting the legal rights of any person) including Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all of certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not, the decision is final and can be enforced by a court, and can only be appealed on very narrow grounds) she signed during admission to the facility for one of three sampled residents (Resident 39). This deficient practice resulted for Resident 39 signing a facility contractual agreement without her full understanding.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure staff wore Personal Protective Equipment (PPE) when handling one of five resident's (Resident 21) gastrostomy tube (gtube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) who was on enhance barrier precautions (EBP - is an approach of targeted gown and glove use during high contact resident care activities). This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. ensure that one of five residents, Resident 49, was provided COVID-19 and Influenza vaccines. This failure had the potential to place Resident 49 at risk of being infected with COVID-19 and Influenza viruses.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure two of 19 sampled resident rooms (room [ROOM NUMBER] and 18) accommodated no more than four residents per room. This deficient practice had the potential to result in and/or create safety hazards, lack of privacy, and care issues for the residents.

Inspectors wroteBased on interview and record, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's hearing aid (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty of hearing) was encoded and assess her hearing ability properly. This deficient practice had the potential to negatively affect the plan of care and delivery of care services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for one of one sampled resident (Resident 1) by failing to: 1. Develop a comprehensive care plan addressing Resident 1's missing right hearing aid. This deficient practice had the potential to result in a lack of meeting necessary care and addressing medical needs for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure audiology (branch of science and healthcare focused on the study, diagnosis, treatment, and prevention of hearing, balance, and related auditory disorders in patients of all ages) consultation appointment was provided in a timely manner for one of one sampled resident (Resident 1). This deficient practice had the potential for Resident 1's deterioration of hearing that could negatively affect her quality of life.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure an inventory of personal belongings was signed by resident or resident representative and facility staff and copy was provided for one of one sampled resident (Resident 1). This deficient practice had the potential for not having proper accountability of Resident 1's personal belongings.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 4) was transferred from chair to bed using an appropriate technique. This deficient practice resulted in Resident 4 feeling discomfort when being transferred.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of four sampled employees (Certified Nursing Assistant 2) had an annual skills competency completed. This deficient practice had the potential to result in residents receiving a decreased quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a sandwich for one of five sampled resident (Resident 40) was identified with a label and date. This deficient practice placed Resident 40 at risk for foodborne illness (any illness resulting from eating contaminated/spoiled foods).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three sampled residents, (Resident 26) call light was within reach. This deficient practice placed Resident 26 at risk for accidents and had the potential to delay in meeting Resident 26 physical and emotional needs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Inform the physician one of one sampled resident (Resident 38) refused to take trazodone (medication to treat depression). This deficient practice placed Resident 38 at risk for worsening of depression and withdrawal effect that could cause medical complications.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure an accurate Minimum Data Set ([MDS] - a federally mandated resident assessment tool), was completed accurately for one of 13 sampled residents (Resident 9). This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Cervices (CMS) and had the potential for a poor care planning which could affect the health and safety of Resident 9.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents, (Resident 26) had a care plan to: 1. Monitor the frequency of outside food being brought in by family. 2. Monitor Resident 26's ability to tolerate regular textured (consists of normal, everyday foods textures that including hard, chewy, dry, and crunch foods) food brought in by family. These deficient practices resulted in failure to monitor Resident 26's prescribed pureed textured diet (a texture-modified diet that consists of foods that are ground, pressed, or strained until they have a smooth, soft consistency, like pudding) and had the potential to place Resident 26 at risk for choking.

Inspectors wroteBased on record review and interview the facility failed to: 1. Revise one of three sampled residents Resident 26) interventions identified by the multidisciplinary care team ([IDT] group of healthcare professionals from different disciplines) who was at risk of aspirating (inhalation of food or liquid into the lungs). The deficient practice had the potential for repeat occurrence.

Inspectors wroteBased on interview and record review, the facility failed to; 1. Ensure one of one sampled resident (Resident 16) who had a stage 4 pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was turned and reposition every two hours. This deficient practice had the potential to worsen and delay wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure resident with long thick elongated (nail plate grows linger than the nail bed) toenails received podiatry (profession dealing with the specialized care of the feet) care services for one of one sampled resident (Resident 36). This deficient practice had the potential to result in discomfort and decline in physical mobility for Resident 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of three sampled residents (Resident 26) bed was placed in the lowest position to prevent injuries during a fall. This deficient practice had the potential in the resident falling from the bed and sustaining an injury.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 146) was provided with a scheduled toileting plan, per bowel and bladder assessment. This deficient practice had the potential for decline in bladder and bowel function for Resident 146.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of one sampled residents received hemodialysis ([HD] a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed) treatment received care in accordance with standards of practice for one of two sampled residents (Resident 9) by failing to communicate to Resident 9's physician regarding Registered Dietitian ([RD] a health professional in nutrition) recommendation to provide Nova source ( a high calorie, nutritional supplement designed for those on dialysis) supplement. This deficient practice had the potential to result in weight loss and malnutrition that can lead to worsened health complication for Resident 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label with an open date of ketorolac (a medication used to treat swelling and redness after eye surgery) and prednisolone acetate (a medication used to treat infection before and after eye surgery) ) ophthalmic solution (liquid eye drops) for Resident 34. This deficient practice had the potential for harm to Resident 34 due to the potential loss of strength of medication. 2. Label with an open date and remove one pouch of expired ipratropium with albuterol (a combination solution use to treat and prevent shortness of breath) inhalation solution for Resident 40. This deficient practice had the potential to result in prolonged use and loss of strength of the expired inhalation solution and can lead to ineffective treatment of respiratory symptoms for Resident 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 26) nasal cannula (a medical device that provides supplemental oxygen to a patient through their nose) was dated and labeled. This deficient practice placed Resident 26 at risk for a respiratory infection (an infectious disease that affects the respiratory system, which is responsible for breathing).

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure two of 19 sampled resident rooms (rooms [ROOM NUMBERS]) accommodated no more than four residents per room. This deficient practice had the potential to result in and/or create safety hazards, lack of privacy, and care issues for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's clinical records were updated for advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one (1) out of 42 sampled residents (Resident 1) by failing to maintain a current signature and adequate dates that match dates on the copy of the resident's advance directives in the resident's clinical record. Based on interview and record review, the facility failed to ensure one of 42 sampled residents advance directive was updated by failing to maintain a current signature and dates that matched the dates on the copy of the residents advance directives in the resident's clinical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the care plan for one of four Residents (Resident 39). This deficient practice had the potential to result in Resident 39 to receive inappropriate interventions and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage, food preparation practices in the kitchen by failing to: 1. Ensure one bag of breaded potato hash browns were not stored in the reach in freezer with no date and label and one large plastic wrapped bacon was open. 2. Ensure Dishwasher 1 (DW 1) knew how to use the proper sanitizer test strip for the dish machine sanitizer (competency - cross reference F802). 3. Ensure DW 1 did not take clean food trays out of the dishwasher and place them on the floor, then pick up the trays up and place the food trays that was on the floor in the rack with other clean trays. And ensure DAS did not place trays on top of clean dishes. 4. Ensure Employee's food was not stored in the resident food refrigerator without a label, date, and temperature log. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders to discontinue use of splints for one out of four Residents (Resident 39). This deficient practice had the potential to result in Resident 39 to receive the inappropriate medical treatment as ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two of 12 sampled resident rooms (room [ROOM NUMBER] and 18) accommodated no more than four residents per room. This deficient practice had the potential to result in and or create safety hazards, lack of privacy and care issues for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 treat two of five sample residents (Resident 1 and Resident 5) with dignity and respect. These deficient practices violated the resident's right to be treated with respect and dignity and had the potential to affect the self-esteem, cause emotionally distress, and psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services as indicated in the physician orders by failing to: 1. Assess and document color and sediments (consistsof biological elements such as leukocytes, erythrocytes, epithelial cells, casts, bacteria, fungi, parasites) in Resident 2 ' s urine. 2. Notify the physician of color and sediments in Resident 2's urine output. This deficient practice resulted in delayed identification of Urinary Tract Infection [UTI- an infection in any part of the urinary system, the kidneys, bladder, or urethra)] delayed in necessary care and treatment and had the potential to lead to worsening infection.