Dove Healthcare - Osseo
DOVE HEALTHCARE - OSSEO in OSSEO, WI — inspection on February 25, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
lower impairment and ambulates with a walker. R23 requires substantial assistance to roll left to right
identifies 2 restorative interventions.
The resident requires restorative intervention r/t Impaired
current level of mobility through review date.Date Initiated: 05/13/2025 Revision on: 05/13/2025 Target Date: 03/03/2026#1 RESTORATIVE: ACTIVE ROM Program #1 Hand Bike Level 4 x 10 minutes 3x-5x per week MTWTHF Date Initiated: 05/13/2025On 2/25/26 at 11:00 AM, Surveyor reviewed R23's restorative documentation.11/30/25- 12/6/25: Hand Bike - Missed 4 days 12/7/25-12/13/25: Hand Bike - Missed 1 day 12/14/25- 12/20/25: Hand Bike - Missed 3 days, Group exercises - Missed 2 days12/21/25-12/27/25: Group exercises - Missed 1 day12/28/25-1/3/26: Hand Bike - Missed every day 1/4/26- 1/10/26: Hand Bike - Missed every day, Group exercises - Missed 1 day1/11/26- 1/17/26: Hand Bike - Missed every day 1/18/26-1/24/26: Hand Bike - Missed 2 days 1/25/26-1/31/26: Hand Bike - Missed 1 day 2/1/26-2/7/26: Hand Bike - Missed 3 days, Group exercises - Missed 1 day2/8/26-2/14/26: Hand Bike - Missed 2 days, Group exercises - Missed 1 day2/15/26- 2/21/26: Hand Bike - Missed every day, Group exercises - Missed 2 daysOver the last 13 weeks, R23's arm bike intervention was documented 5 times not applicable and 1 time resident not available.Over the last 13 weeks, R23's group exercise intervention was documented 17 times not applicable.If not applicable is being used as not available, no evidence or documentation that timing or restorative offerings have been evaluated to accommodate resident choices.On 2/24/25 at 11:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA) K who stated CNA K's primary role is to do restorative care. CNA K stated today she worked with both R3 and R4 on a dressing program. CNA K stated as long as they stretch while dressing, they are doing their restorative. CNA K stated those are the two CNA K gets up every time CNA K works. CNA K stated that R3 has a walking program and R3 does the NUSTEP. CNA K stated R3 did that already today for 15 minutes. CNA K stated R4 did 50 minutes on the arm bike today in 2 sections. CNA K stated R4 chooses to do that the 5 days a week when CNA K is here.
Surveyor asked if it is R4's choice to only do her restorative when CNA K is here.
CNA K stated no I am the only one technically trained to do restorative. No one else can.
Surveyor asked CNA K what if you go on vacation or something. CNA K stated we just had that last week.
They had someone lined up but that fell through, and R3 only went down to the bike 2 days when Director of Nursing (DON) B took her.On 2/24/26 at 4:10 PM, Surveyor interviewed DON B who stated that according to MDS, restorative should be 5 days a week. DON B stated that CNA K was gone but DON B took R3 down twice. DON B stated she does not think R4 received any therapy.
Surveyor clarified that residents did not get 5 days of restorative. DON B stated, yes, no one got restorative.On 2/24/26 at 4:18 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated CNA K took over the restorative program about one month ago when existing restorative CNA had some health issues.
NHA A stated as CNA K stepped into the role, we had a working plan of someone backing her up. We planned for CNA M to back her up when CNA K went on vacation. NHA A stated NHA A was in the process of coordinating the training of CNA M before CNA K went on vacation, but therapy wasn't available initially when NHA A tried to coordinate the training and then NHA A got sick. NHA A stated CNA M was not trained before CNA K went on vacation; we did not have a backup when CNA K went on vacation. On 02/25/26 at 9:02 AM, Surveyor interviewed NHA A to clarify how some residents have it documented they received their restorative 7 days a week if there is only one restorative CNA. NHA A and DON B stated it is because of how charting is set up.
All staff have access to do the residents' ROM, as staff are getting them dressed and it can be charted by any CNA. DON B stated that restorative of passive ROM and active ROM can be done by all CNAs and does not have to be restorative CNA.
525709 02/25/2026
Dove Healthcare - Osseo 51019 Ridge View Road Osseo, WI 54758
prevent accidents.
observation, interview and record review, the facility did not ensure that each resident received
of 4 residents (R8) reviewed for accident prevention in a sample of 31.The facility did not utilize gait belt during a toileting transfer to enhance R8's function or safety and placed R8 at risk of injury.Findings include:The facility policy, titled Safe Resident Handling/Transfers, last revised 01/2025, states in part: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure and comfortable experience for the resident.R8 was admitted to the facility on [DATE] and has diagnoses of wedge compression fracture of fifth lumbar vertebra (fracture of spine lower back), age related osteoporosis (weak and fragile bones), cerebral infarction (stroke), macular degeneration (vision loss).R8's Minimum Data Set (MDS) assessment, dated 02/10/2026, indicated that R8 has a Brief Interview for Mental Status (BIMS) score of 8/15 which means moderate cognitive impairment. R8's care plan, last revised 08/01/2025, with a target date of 05/24/2026, states: I have chronic comorbidities which may affect my ability to perform activities of daily living (ADLs). I require assistance with ADLs and transfers.
Interventions include Transfer: one assist non-mechanical sit to stand with gait belt.encourage to stand tall, allow her time.On 02/24/2026 at 7:23 AM, Surveyor observed R8 being assisted with toileting by certified nursing assistant (CNA) D. CNA D placed gait belt around R8's waist while R8 was sitting in recliner chair. R8 was able to grasp the bars of the Sara Steady (non-mechanical mobile lift device to assist with safe standing and short transfers) and lift self without assist to standing position on the Sara Steady foot platform. R8 was transported to toilet with Sara Steady device and placed onto toilet by CNA D. To be noted: toilet was low level without a high-rise seat in place and R8 had to bend low to be seated onto toilet.
When toileting was completed, R8 was unable to reach forward far enough because of low level toilet to grasp bar of Sara Steady to stand self again. CNA D assisted R8 to stand position by steadily lifting while pulling upward on R8's shoulder/arm until R8 was able to stand on Sara Steady foot platform to be transported to a wheelchair. CNA D did not use the gait belt already in place around R8's waist when assisting R8 to standing position.
Gait belt was loose around R8's waist and not effectively tightened for R8's transfer. On 02/24/2026 at 7:23 AM, during observation of R8 being transferred from toilet to wheelchair by CNA D, Surveyor asked CNA D what the proper transferring technique would be for residents who required assistance for standing. CNA D stated in R8's situation, there should have been a high-rise toilet seat in place on toilet so R8 could have reached the Sara Steady grab bars and assist self when standing. CNA D did not indicate need for use of gait belt for transfers. On 02/25/2026 at 8:43 AM, Surveyor interviewed director of nursing (DON) B what staff expectations are for proper transferring and lifting techniques of residents. DON B stated a gait belt was to be always used for manual or non-mechanical transfers of residents. DON B stated that no body part of a resident should be pulled on when lifting or transferring a resident at any time.
Record review of facility staff education indicated CNA D completed 100% online training on 12/22/2025 for performing safe transfers.
the resident's discharge, the resident's death or passage of its expiration date. On [DATE] at1:36PM,
Surveyor interviewed ADON C who stated yes, the medication is expired.
Two nurses need to get rid
pharmacy to do audits and manage inventory.
Example 3The facility policy, titled Medication Storage, dated 2/2026 states:Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 2.
Narcotics and Controlled Substances:a.
Schedule II drugs and back up stock of Schedule III, IV, and V medications are stored under double-lock and key.The following medication were in an unlocked refrigerator and not in a lock box.
Lorazepam solution 2mg/ml, 2 unopened for R 13 (not in a lock box).
Lorazepam is a Scheduled IV narcotic medication.On [DATE] at 10:42 AM, Surveyor observed rehab unit medication room as part of the Medication and Storage task with RN G. RN G opened the refrigerator and pulled medication from the fridge.
Refrigerator was not locked. On [DATE] at 10:48 AM, Surveyor interviewed RN G who stated yes, the rehab med room refrigerator should be locked. RN G and Surveyor completed the medication storage task. At the end, RN G attempted to lock the refrigerator. RN G stated I am not sure how this works, I need a key. RN G has been working for the facility since [DATE] per staff roster supplied by Nursing Home Administrator (NHA) A. On [DATE] at 1:12 PM, Surveyor observed long-term care unit medication room with RN K.
Refrigerator was unlocked. RN K was busy, and Surveyor left medication room with plans to come back with management. RN K did not lock the medication refrigerator prior to exiting the room.On [DATE] at 1:36 PM, Surveyor observed the long-term care medication room refrigerator with ADON C. ADON C obtained the key to the medication room from the unit nurse and Surveyor and ADON C entered the medication room. ADON C opened refrigerator up, it was unlocked, to start to pull medication from refrigerator.
Surveyor and ADON C collectively created the refrigerator inventory. On [DATE] at 1:38 PM, Surveyor interviewed ADON C who stated yes, the refrigerator is unlocked. It should be locked. On [DATE] at 2:01 PM, Surveyor observed the short-term rehab unit refrigerator with ADON C. ADON C obtained the key from the unit nurse and together Surveyor and ADON C entered the medication room.
The medication refrigerator was unlocked and ADON C just opened the refrigerator and started an inventory list with Surveyor. On [DATE] at 2:01 PM, Surveyor interviewed ADON C who stated the refrigerator should also be locked, I don't know why it isn't.
Prior to leaving the room, ADON C tried to see if she could lock the refrigerator without the key. ADON C stated I will have to get the key.
525709 02/25/2026
Dove Healthcare - Osseo 51019 Ridge View Road Osseo, WI 54758
reusable, non-critical equipment.each user is responsible for routine cleaning and disinfection of
Steady (non-mechanical device used for transferring residents) into R8's room to assist transferring R8 onto a toilet. CNA D did not disinfect Sara Steady prior to using it with R8.
Disinfection wipes were observed to be in a basket hanging on Sara Steady for staff use.
Upon completion of R8's toileting in which R8 had a bowel movement and CNA D was observed touching Sara Steady with contaminated gloves, CNA D did not clean Sara Steady with disinfectant. CNA D left Sara Steady in R8's room and proceeded to another resident room.
On 02/25/2026 at 7:00 AM, Surveyor observed CNA E bring a Sara Steady into R8's room to assist R8 to toilet. CNA E did not disinfect Sara Steady prior to using it with R8.
Disinfection wipes were observed to be in a basket hanging on Sara Steady for staff use. CNA E did not disinfect Sara Steady after R8 completed toileting and removed Sara Steady from R8's room to store in hallway.
At 7:15 AM, Surveyor observed CNA D retrieve Sara Steady from hallway where CNA E left it and brought it to R31's room, left it in doorway of room and left without cleaning device. At 7:40 AM, CNA D and CNA F returned to assist in R31's room and assist R31 to toilet using Sara Steady. CNA D and CNA F did not disinfect Sara Steady prior to using it with R31.
Upon completion of R31's toileting, CNA F left room to transport R31 to a meal. CNA F informed Surveyor she would return to clean Sara Steady, which was observed by Surveyor to be done.
Surveyor interviewed director of nursing (DON) B about what staff expectations were for disinfecting multi-resident use equipment. DON B stated all equipment is to be disinfected both prior to and after resident use. DON B stated it cannot be assumed cleaning of equipment was done prior to using it.
525709 02/25/2026
Dove Healthcare - Osseo 51019 Ridge View Road Osseo, WI 54758