Federal inspectors found Osage Rehab and Health Care Center's MDS Coordinator had checked boxes indicating that care planning was needed for specific residents but never filled out the sections describing how problems would be addressed, what risks existed, or whether referrals to specialists were necessary.
The incomplete assessments affected residents with serious medical conditions. One woman developed two unstageable pressure ulcers during her stay at the facility. These severe wounds have bases hidden by dead tissue, making their true depth impossible to determine until the dead tissue is removed.
The MDS Coordinator indicated on September 28 that the woman's pressure ulcer areas needed to be implemented in her care plan. But the coordinator left blank the required sections for impact assessment, care planning rationale, risk factors, and potential referrals to other health professionals.
Staff C, a registered nurse interviewed December 22, said the woman's pressure ulcers were "getting better" and confirmed she hadn't developed new ulcers since admission. The nurse noted the MDS Coordinator "worked offsite and not at the facility."
The resident herself, who showed no cognitive impairment on mental status testing, told inspectors December 18 she didn't believe new pressure ulcers had formed since her admission.
A second resident's incomplete assessment involved more dramatic circumstances. The man, who scored 3 on cognitive testing indicating severe impairment, had diagnoses of Parkinson's disease, dehydration, and depression when he weighed 230 pounds.
By December, his weight had dropped to 190.4 pounds.
A December 5 weight summary note documented a meeting between the Assistant Director of Nursing and the facility dietician. The note recorded that he had "lost 9% of his body weight in 1 month, admitted to hospice level of care, ate very poorly, and refused many meals."
Staff recommended having a provider document the 40-pound weight loss as unavoidable.
Despite this dramatic weight change and the resident's multiple medical conditions, his nutrition assessment worksheet from October 3 remained incomplete. The MDS Coordinator had indicated nutritional status should be addressed in the care plan but never filled out sections describing the impact, rationale for care planning, risk factors, or need for specialist referrals.
The man's most recent assessment showed he weighed 190 pounds and was not on a physician-prescribed weight-loss regimen. The assessment confirmed he was receiving hospice-level care.
The facility's parent company discovered the problem through its own review. The Assistant Director of Nursing told inspectors December 22 that the company "started an internal audit for the CAA's on December 19 after learning of the incomplete worksheets."
The timing was notable. The company began its internal audit just three days before federal inspectors arrived at the facility.
Inspectors attempted to reach the MDS Coordinator on December 23 but received no response. As of December 29, no return call had been received.
The violations occurred at a 25-bed facility where comprehensive assessments are required within specific timeframes and must be updated at least every 12 months. The Minimum Data Set assessments and Care Area Assessment worksheets form the foundation for developing individualized care plans.
Care Area Assessment worksheets serve as clinical decision-making tools. When triggered by MDS data, they require staff to analyze specific resident conditions and document how those conditions will be addressed through care planning. The worksheets must include impact assessments, care rationales, risk factor identification, and determinations about specialist referrals.
For pressure ulcers, the assessment process becomes critical because these wounds can worsen rapidly without proper intervention. Unstageable pressure ulcers represent particularly serious conditions where tissue death obscures the wound's true extent.
The nutrition assessment takes on similar importance for residents experiencing significant weight loss. A 9% weight loss in one month, as documented for the second resident, represents a substantial change requiring careful evaluation and intervention planning.
The resident with severe cognitive impairment faced multiple challenges. His Parkinson's disease, dehydration, depression, and poor eating habits created a complex medical picture requiring coordinated care planning. His transition to hospice care indicated his condition had deteriorated significantly.
Federal regulations require facilities to assess residents completely upon admission and then periodically, ensuring care plans address identified problems through systematic evaluation processes. The incomplete worksheets represented failures in this fundamental requirement.
The facility's internal audit, launched after discovering the incomplete assessments, suggested awareness of broader compliance problems. Starting the review just days before the federal inspection indicated the timing may not have been coincidental.
Both residents' cases demonstrated how incomplete assessments can leave vulnerable people without proper care coordination. The woman with pressure ulcers and the man losing weight both needed comprehensive evaluation processes that never occurred despite obvious clinical triggers.
The MDS Coordinator's off-site work arrangement created additional complications. With the coordinator not physically present at the facility, communication gaps and oversight problems became more likely, potentially contributing to the incomplete documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Osage Rehab and Health Care Center from 2025-12-22 including all violations, facility responses, and corrective action plans.