Federal inspectors found the facility's MDS coordinator, who works offsite, left critical sections blank on assessment worksheets for two residents during a December complaint investigation. The incomplete paperwork violated requirements for comprehensive resident evaluations.
Resident 24 weighed 230 pounds when assessed in October. By December 2, his weight had dropped to 190.4 pounds — a 9% loss in just one month. The facility's weight summary noted he "ate very poorly" and "refused many meals" before being admitted to hospice care.
Despite the dramatic weight loss, staff had failed to complete the nutrition assessment worksheet required when his October evaluation flagged nutritional concerns. The MDS coordinator checked a box indicating nutrition "should be addressed on the Care Plan" but left blank the sections describing impact, rationale for care planning, risk factors, and whether referrals to other health professionals were needed.
A December 5 meeting between the assistant director of nursing and dietician recommended having the provider document the weight loss as "unavoidable." The resident had diagnoses of Parkinson's disease, dehydration, and depression, with a cognitive assessment score of 3 indicating severe impairment.
The facility made similar assessment failures for Resident 4, who developed two unstageable pressure ulcers during her stay. These severe wounds have bases hidden by dead tissue, making their depth and severity impossible to determine without removing the dead tissue first.
Her October assessment documented the pressure ulcers as acquired at the facility, not present at admission. The MDS coordinator again checked boxes indicating pressure ulcer care needed to be implemented but failed to complete required sections about impact, rationale, risk factors, and potential referrals.
Both the resident and her nurse told inspectors the pressure ulcers were improving and no new ones had formed since admission. Resident 4 had no cognitive impairment, with a mental status score of 15.
The registered nurse interviewed December 22 confirmed the MDS coordinator "worked offsite and not at the facility." This arrangement left the coordinator disconnected from daily resident care while responsible for critical assessments that guide treatment planning.
Care Area Assessments serve as roadmaps for developing individualized care plans. When coordinators skip required sections, they leave gaps in identifying how conditions impact residents, what interventions might help, and when specialist referrals are needed.
The assistant director of nursing revealed the facility's parent company launched an internal audit of all CAA worksheets on December 19 — three days before the federal inspection concluded. The audit began only "after learning of the incomplete worksheets," suggesting the problems extended beyond the two residents inspectors reviewed.
Inspectors attempted to contact the MDS coordinator December 23 but received no response. As of December 29, the coordinator had not returned their call.
The facility reported a census of 25 residents during the inspection. With incomplete assessments affecting two of the residents reviewed, the scope of assessment failures across the entire facility remained unclear.
Federal regulations require facilities to assess residents completely upon admission and then periodically, at least every 12 months. These assessments must identify care needs and trigger appropriate interventions before conditions worsen.
For Resident 24, the nutrition assessment gap coincided with his transition to hospice care as his condition deteriorated. The 40-pound weight loss represented nearly 20% of his original body weight — a significant decline that proper assessment protocols are designed to catch early.
Pressure ulcer assessments carry similar urgency. Unstageable ulcers like those affecting Resident 4 can hide extensive tissue damage beneath dead skin. Without complete assessments identifying risk factors and care strategies, these wounds can progress to life-threatening infections.
The offsite coordinator arrangement raises questions about oversight of resident care. Assessment coordinators working remotely may lack the daily resident contact needed to complete thorough evaluations and recognize subtle changes in condition.
Staff interviews revealed awareness that assessments were incomplete, yet the problems continued until federal inspectors arrived. The December 19 internal audit suggests management knew about widespread assessment failures but had not corrected them.
Both residents affected by the assessment failures had serious underlying conditions — severe cognitive impairment and Parkinson's disease for one, pressure ulcers for the other. These vulnerable residents particularly needed complete assessments to guide appropriate care.
The facility's 25-resident census makes the assessment failures more concerning. In smaller facilities, staff typically have more opportunities to know residents individually and catch problems early. Yet basic assessment requirements still went unfulfilled.
Resident 24's dramatic weight loss while under hospice care illustrates how incomplete assessments can mask whether decline is truly unavoidable or results from inadequate intervention. Proper nutrition assessments might have identified strategies to slow the weight loss or improve his quality of life.
The MDS coordinator's failure to return inspector calls suggests ongoing problems with accountability. Federal regulations require facilities to cooperate with inspections and provide access to staff responsible for resident care.
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.