Osage Rehab and Health Care Center

In the surveyor’s words

From the most serious findings on record at Osage Rehab and Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF693Jul 17, 2024

  Based on clinical record review, staff interview, Physician interview, Emergency Medical Service (EMS) interview, and facility policy review, the facility failed to provide adequate care and services to maintain the highest functional status for 1 of 2 residents with gastronomy tube (GT) (Resident #2). Resident #2 had an order to have his head of bed elevated while receiving his feeding. As the nurse gave Resident #2 his feeding, they had the head of bed lowered. When Resident #2 started to vomit, the nurse stopped the feeding, but failed to elevate Resident #2's head of the bed. When the certified nurse aides attempted to assist the nurse, the nurse told them to have him lay flat. Resident #2 suffered from aspiration pneumonia and septic shock. […]

• Immediate jeopardy, isolatedF686Jun 13, 2023

  Based on staff interviews, record review, facility policy and procedure review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing and from deteriorating on a resident with a history of pressure ulcers for one of two residents reviewed (Resident #2). The facility failed to identify the root cause and implement appropriate interventions. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began April 13, 2023 on June 7, 2023 at 4:30 p.m. Facility staff removed the Immediate Jeopardy on June 8th, 2023 through the following actions: a. […]

• Immediate jeopardy, isolatedF684Nov 18, 2022

  Based on observation, clinical record review, staff and resident interview and facility policy review the facility failed to provide the necessary assessments for 1 of 7 residents reviewed with a condition change, (Resident #2). A determination was made the facility's non-compliance placed residents in the facility in immediate jeopardy, beginning on 9/17/22. The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 8/31/22 documented Resident#2 with diagnosis that included psychoactive substance abuse, bipolar, depression, deep vein thrombosis (DVT), hypertension (HTN) and a hip fracture. […]

• Immediate jeopardy, isolatedF741Nov 18, 2022

  Based on observation, clinical record review, staff interview and facility policy review the facility failed to provide sufficient staff with appropriate competencies and skills to provide nursing and related services to assure resident safety for one resident with psychosocial disorders, (Resident #2). A determination was made the facility's non-compliance placed residents in the facility in immediate jeopardy, beginning on 9/17/22. The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 8/31/22 documented Resident#2 with diagnosis that included psychoactive substance abuse, bipolar, depression, deep vein thrombosis (DVT), hypertension (HTN) and a hip fracture. […]

• Actual harm, isolatedF689Feb 28, 2025

  Based on observation, clinical record review, staff interview and resident interview, the facility staff failed to maintain appropriate nursing supervision to prevent a cat bite which resulted in a wound infection for one (1) resident reviewed. (Resident #3) The facility identified a census of 31 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief interview for Mental Status (BIMS) score of 6, indicating severely cognitive impairment. The MDS listed Resident #3 as independent with most activities of daily living (ADLs). […]