Osage Rehab and Health Care Center failed to complete required assessment worksheets for two residents despite identifying serious health conditions that demanded immediate care planning. The violations occurred as one resident lost 40 pounds in a single month and another developed two severe pressure ulcers during their stay.
The facility's MDS Coordinator, who worked remotely rather than at the 25-bed nursing home, checked boxes indicating that care plans needed updates but left entire sections blank. These sections should have detailed the impact on residents, care planning rationale, risk factors, and whether referrals to other health professionals were needed.
Resident #4 developed two unstageable pressure ulcers after admission. These severe wounds hide their true depth and severity beneath dead tissue that must be removed before proper treatment can begin. The facility's September assessment identified the ulcers as acquired during the resident's stay, not present at admission.
But the assessment worksheet remained incomplete. The MDS Coordinator checked that pressure ulcer care needed to be implemented but failed to fill out any supporting documentation about treatment approaches or specialist referrals.
"I didn't have new pressure ulcers form since my admission to the facility," the resident told inspectors on December 18.
Staff C, a registered nurse, described the resident's pressure ulcers as "getting better" and confirmed no new ulcers had formed since admission. She explained that the MDS Coordinator "worked offsite and not at the facility."
The second case involved more dramatic health decline. Resident #24, who has severe cognitive impairment from Parkinson's disease, weighed 230 pounds according to an October assessment. By December, his weight had plummeted to 190 pounds.
A December 5 meeting note between the Assistant Director of Nursing and the facility dietitian documented the alarming weight loss. The resident 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 weight loss as unavoidable.
Yet the required nutrition assessment worksheet remained incomplete. The MDS Coordinator had indicated nutritional status should be addressed in the care plan but left all explanatory sections blank.
The 40-pound weight loss occurred as the resident transitioned to hospice care, indicating his condition had deteriorated significantly. Federal regulations require nursing homes to complete comprehensive assessments that identify care needs and guide treatment decisions, particularly for residents experiencing rapid health changes.
Both residents had completed cognitive assessments that showed vastly different mental capacities. Resident #4 scored 15 on the Brief Interview for Mental Status, indicating no cognitive impairment. Resident #24 scored just 3, reflecting severe cognitive impairment that would affect his ability to communicate needs or participate in care decisions.
The facility discovered the assessment problems during an internal audit that began December 19, just three days before federal inspectors arrived. The Assistant Director of Nursing told inspectors the facility's parent company had started reviewing incomplete worksheets after learning of the violations.
Inspectors attempted to contact the MDS Coordinator on December 23 but received no response. As of December 29, the coordinator had not returned the call.
The violations represent failures in the most basic nursing home requirements. Federal regulations mandate that facilities assess residents completely upon admission and then periodically, at least every 12 months. These assessments must identify health problems and guide care planning to prevent deterioration.
Care Area Assessment worksheets serve as the bridge between identifying problems and creating treatment plans. When left incomplete, they leave residents without proper care coordination and potentially expose them to preventable complications.
For Resident #4, the incomplete assessment meant pressure ulcer care proceeded without documented consideration of risk factors, treatment rationale, or specialist consultation needs. Pressure ulcers can worsen rapidly without proper intervention and have been linked to infections, prolonged healing, and increased mortality in nursing home residents.
For Resident #24, the incomplete nutrition assessment occurred as he experienced dramatic weight loss that staff described as related to poor eating and meal refusal. Rapid weight loss in nursing home residents often signals the need for modified diets, feeding assistance, or medical intervention to address underlying causes.
The remote work arrangement for the MDS Coordinator created additional barriers to proper assessment completion. Assessment coordinators typically need direct access to residents, medical records, and facility staff to complete comprehensive evaluations.
The facility reported a census of 25 residents during the inspection. The violations affected at least two residents, representing 8% of the facility's population at the time of the federal review.
Both assessment failures occurred despite the facility having systems in place to identify the problems. Staff correctly noted pressure ulcers in one case and documented concerning weight loss in the other. The breakdown occurred in translating these observations into complete care planning documentation.
The December complaint investigation found minimal harm or potential for actual harm affecting few residents. However, the violations highlight systemic problems in the facility's assessment processes that could affect care quality for other residents requiring comprehensive evaluations.
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.