Osage Rehab And Health Care Center

F-F584. The deficiency referred to a buildup of a black substance with the appearance of mold on the pipes of the heating elements in resident rooms on the East end of the building. The Maintenance Supervisor at the time indicated the heating and cooling elements in all of the rooms on the East side of the building contained hot water that flowed through the pipes in the winter and each box in the resident's rooms the hot water flowed through the pipes and in the summer the water changed from hot to cold. Related to the setup of the system

the water condensed which caused moisture build up so the pipes contained mold. The facility reported they installed the current system in the 1960's.

According to an email dated 4/9/25 at 10:04 PM the current Maintenance Supervisor agreed with the above description of the heating and cooling system.

An observation on 4/3/25 at 12:30 PM revealed the same buildup of the black substance with the appearance of mold on all of the heating/cooling unit pipes for all 16 rooms on the East side of the building. As well as other specified issues listed below:

a. room [ROOM NUMBER], occupied by Resident #2 contained an active toilet leak. The floor appeared to have standing water around the toilet itself, which ran across the bathroom floor. Resident #2, identified by

the facility as interviewable, indicated his toilet leaked for a long time. Resident #2 confirmed he used the toilet on a regular basis but it didn't bother him, however, it still needed fixed.

During an interview on 4/3/25 at 1:10 PM Resident #5 in room [ROOM NUMBER] A, identified by the facility as interviewable confirmed her toilet leaked off and on. Staff C, Housekeeping, present during the interview confirmed the facility had a long-standing problem of the toilets leaking. Staff C indicated the facility completed various interventions such as toilet ring but the toilets continued to leak on the East (older) end of

the building.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 4 165173 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165173 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Osage Rehab and Health Care Center 830 South Fifth Street Osage, IA 50461

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 During an interview on 4/3/25 at 1:58 PM Staff A, Certified Nursing Assistant (CNA), confirmed she observed mold on heating/cooling elements in resident rooms on the East end of the building that had been there since Level of Harm - Minimal harm or she started work two (2) years ago. potential for actual harm

During an interview on 4/3/25 at 2:29 PM Staff B, CNA, confirmed she observed the toilets leak in the rooms Residents Affected - Some of Resident #2 (room [ROOM NUMBER]) and Resident #4 (room [ROOM NUMBER]) located across the hall from each other on the East end of the building and the last rooms on the South end).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 165173 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165173 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Osage Rehab and Health Care Center 830 South Fifth Street Osage, IA 50461

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 25854

Residents Affected - Few Based on resident interview, staff interview, Alarm Response Report forms, and facility policy review, the facility failed to answer resident call lights in a timely manner and within the regulated 15-minute time frame for 2 residents reviewed (Residents #6 and #1). The facility identified a census of 28 residents.

Findings include:

1. During an interview on 4/3/25 at 3:23 PM Resident #6 confirmed she timed her call light on for over 15 minutes, which pissed her off.

Review of the facility's Alarm Response Report form for a one (1) week period of time from 3/27/25 thru 4/2/25 revealed the facility failed to answer her call light within the allotted 15-minute time frame on the following dates:

a. 3/27/25 at:

i. 11:10 AM for 21:42 minutes

ii. 5:44 PM for 18:49 minutes

iii. 9:53 PM for 19:50 minutes

iv. 9:53 PM for 10:30 minutes

v.10:13 PM for 26:02 minutes.

b. 3/30/25 at 1:23 AM for 17:03 minutes.

2. During an interview on 4/3/25 at 2:50 PM Resident #1, identified by the facility as interviewable, confirmed

she recently timed her call light as on for two (2) hours on an unknown evening shift as she used the clock

on her wall. She reported the call lights as especially bad when the facility had agency staff scheduled. Resident #1 explained after supper the staff assisted all of the other residents to bed and then they answered her call light. When asked how she felt she replied, she's used to it by now but questioned what would happen if she had an emergent situation? By the time they arrived it could have been too late.

Review of the facilities Alarm Response Report for a 1-week period of time from 3/27/25 thru 4/2/25 revealed

the facility failed to answer the resident's call light within the allotted 15-minute time frame on the following dates:

a. 4/1/25 at 2:43 PM 18:40 minutes.

b. 3/28/25 at

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 165173 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165173 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Osage Rehab and Health Care Center 830 South Fifth Street Osage, IA 50461

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 i. 1:40 PM - 22:44 minutes

Level of Harm - Minimal harm or ii. 11:07 AM - 18:28 minutes. potential for actual harm

During an interview on 4/3/25 at 1:58 PM Staff A, Certified Nursing Assistant (CNA), confirmed the staff Residents Affected - Few failed to answer the residents' call lights within 15 minutes due to staffing. Staff A described the situation as worse on the 2 PM until 10 PM shift. She added the agency staff refused to answer the residents' call lights.

During an interview on 4/3/25 at 2:29 PM Staff B, CNA, confirmed the staff failed to answer residents' call lights within 15 minutes due to resident behaviors and staffing issues.

The facility's Answering the Call Light Policy dated 2001 described the Purpose of the procedure as an assurance of timely call light responses to resident's requests and needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 165173