Osage Nursing & Rehabilitation Center

Inspectors wroteBased on record review, observations, and interviews, the facility failed to implement adequate infection control practices when staff failed to store Resident (R)25's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) in a sanitary manner when not in use. The facility failed to ensure proper infection control standards were followed related to hand hygiene during catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care for R32.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure pressure-reducing measures were implemented for Resident (R)12 when staff failed to float her heels per her orders and plan of care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure Resident (R)12's fall preventions were in place.

Inspectors wroteThe facility reported a census of 39 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria.

Inspectors wroteThe facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the lid of the dumpster was kept close.

Inspectors wroteThe facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 11 dates between 04/01/23 and 06/30/23 and four dates between 07/01/23 and 09/30/23 as required.

Inspectors wroteThe facility reported a census of 39 residents which included 18 residents sampled for review. Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment in the laundry.

Inspectors wroteThe facility reported a census of 39 residents which included 18 residents sampled for review. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents of the facility related to those that used the beauty shop. Findings Included: - On 09/05/24 at 09:32 AM, during tour of the beauty shop with Administrative Staff A the following concerns were identified: 1. The beauty shop lacked an operational negative pressure ventilation fan. 2. The filter on the free-standing dryer filter covered in lint. 3. The workstation cabinet contained unlabeled brush, comb, and a dual hair pick with comb that had hair in the brush bristles and the comb teeth. Administrative Staff A verified the findings above. [...]

Inspectors wroteThe facility reported a census of 39 residents. The sample of 18 residents included four residents reviewed for indwelling catheter and incontinence care/treatment. Based on observation, interview, and record review, the facility failed to provide catheter care/and treatment to prevent infection for four residents with indwelling catheters, Residents (R)27, R 14, R16, and R 2.

Inspectors wroteThe facility reported a census of 39 residents with 18 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)22, when staff failed to assist the resident with changing her clothing when her shirt became soiled with food.

Inspectors wroteThe facility reported a census of 39 residents with 18 residents included in the sample. Based on observation, record review, and interview, the facility failed to complete a comprehensive care plan for one Resident (R)12, regarding risk of elopements.

Inspectors wroteThe facility reported a census of 39 residents. The sample of 18 residents included eight residents sampled for activities of daily living (ADLs). Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good personal hygiene for the one sampled Resident (R)27s, related to bathing and shaving.

Inspectors wroteThe facility reported a census of 39 residents with 18 residents selected for review, which included one resident reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure sanitary pressure ulcer care for Resident (R)1.

Inspectors wroteThe facility reported a census of 39 residents with 18 sampled, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to initiate interventions to ensure a safe and secure environment for one Resident (R)12, with a history of wandering behaviors. Findings Included: - Review of Resident (R)12's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. He had wandering behavior one to three days of the assessment period. He had no limitation in range of motion (ROM) and used a walker with supervision while walking 10 to 150 feet. [...]

Inspectors wroteThe facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) for one Resident (R)1 with chronic wounds to prevent the spread of infection as required.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of RN assessment and oversight of care.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents. Based on observations, record review, and interviews, the facility failed to ensure staff treated Resident (R) 91 with dignity. This deficient practice had the risk for decreased self-esteem and dignity for R91.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents. Based on observations, record review, and interviews, the facility failed to ensure adequate equipment was available and used during wheelchair locomotion for Resident (R) 11 and R35. This deficient practice placed the affected residents at risk for unmet needs.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents. Based on record reviews and interview, the facility failed to provide the correct Medicare Liability Notice, CMS 10123-Notice of Medicare Non-Coverage (NOMNC) for Residents (R) 7, R22, and R142. This deficient practice placed these residents and /or legal representatives of uninformed decisions regarding skilled services.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with two residents reviewed for hospice and end of life. Based on observation, record review, and interviews, the facility failed to develop a baseline care plan that included hospice and the services that would be provide to Resident (R) 141. This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial needs for R141.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with two residents sampled for positioning and limited range of motion (ROM) of extremities. Based on observations, record reviews, and interviews, the facility failed to ensure restorative care (care provided to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life) was performed for Resident (R) 6. This deficient practice had the risk for a decline in functional mobility and worsening of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with four residents sampled for accidents. Based on observations, record review, and interviews, the facility failed to provide adequate supervision for Resident (R) 38, who was independently mobile, at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff), had a history of exit seeking behavior, and had poor safety awareness. R38 was outside in the fenced-in patio area without staff supervision and climbed the fence to the other side while staff observed from inside. This deficient practice had the risk for accidents and/or injuries for R38.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with five residents sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported antihypertensive (high blood pressure medications) medications were given outside of parameters for Resident (R) R38. This deficient practice had the risk for physical complications and unnecessary medication usage.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with five residents sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to ensure antihypertensive (high blood pressure medications) were not given outside of ordered parameters for Resident (R) R38. This deficient practice had the risk for physical complications and unnecessary medication usage.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with five residents sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to ensure a 14-day stop date was added to an as needed (PRN) psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication for R38 and failed to ensure a documented rationale for an extension. This deficient practice had the risk for physical complications and unnecessary medication usage.

Inspectors wroteThe facility identified a census of 44, one medication storage room, two medication carts, and two nurse carts. Based on observations, record review, and interviews, the failed to properly store and date one medicated inhaler (device used for administering a medication that was breathed in to relieve asthma or other lung disorders), one medicated eye drop bottle, and four nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) vials. This deficient practice had the risk for unwarranted physical complications and ineffective treatment for affected residents.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with two residents reviewed for hospice and end of life. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication will be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 141 by hospice. This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial needs for R141.