Inspection Report Summary
The most recent inspection on December 3, 2025, found the facility in substantial compliance following a plan of correction related to a prior complaint investigation. Earlier inspections showed a pattern of deficiencies primarily involving quality of care issues such as timely physician notification and medication management, as well as documentation and infection control concerns. A substantiated complaint in October 2025 cited failure to provide timely interventions and communication regarding a resident’s low blood pressure and altered mental status. Prior complaint investigations were mostly unsubstantiated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be addressing deficiencies through plans of correction, with the most recent report indicating compliance after corrective measures.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
40 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 3, 2025
Visit Reason
The document is a plan of correction acceptance following a survey ending October 20, 2025, certifying the facility in compliance effective December 2, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted for the prior survey.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Oct 20, 2025
Visit Reason
The inspection was conducted as a result of a facility reported incident #2620217-I that occurred between October 15, 2025 and October 20, 2025, involving concerns about quality of care related to a resident's low blood pressure and medication management.
Findings
The facility failed to provide timely interventions and notification to the resident's physician after a resident presented with low blood pressure and altered mental status. Multiple staff interviews and record reviews revealed issues with monitoring vital signs, medication administration, and communication. The facility implemented a plan of correction including staff education, revised care plans, and periodic audits to ensure compliance.
Complaint Details
The visit was complaint-related due to a facility reported incident #2620217-I. The complaint involved concerns about quality of care, specifically failure to monitor and respond appropriately to a resident's low blood pressure and altered mental status. The complaint was substantiated as evidenced by the deficiency cited.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely interventions and notification to the resident's physician after a resident presented with low blood pressure and altered mental status. | Level D |
Report Facts
Resident census: 40
MDS assessment date: Sep 11, 2025
Medication administration dates: Sep 17, 2025
Plan of correction completion date: Dec 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Marshall | Administrator | Signed the plan of correction document |
| Staff D | Educated on blood pressure parameters and involved in resident care and reassessment | |
| Assistant Director of Nursing | ADON | Involved in assessment and communication regarding resident's blood pressure |
| Director of Nursing | DON | Involved in reassessment and education related to resident's blood pressure |
| Staff E | Certified Nursing Assistant | Observed resident and reported on condition |
| Licensed Practical Nurse | LPN | Explained medication changes and blood pressure concerns |
| Pharmacist | Interviewed regarding concerns about low blood pressure |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 4, 2025
Visit Reason
A complaint investigation for facility reported incident #1788009-I was conducted from September 2, 2025 to September 4, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation related to incident #1788009-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 30, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective December 21, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 7
Nov 21, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a facility reported incident.
Findings
The facility was found deficient in multiple areas including failure to ensure timely physician and resident signatures on advance directives, incomplete comprehensive assessments and care plans for residents with mental health diagnoses, failure to ensure fall interventions were in place, improper use and documentation of psychotropic medications, inadequate dishwasher sanitation, and failure to follow COVID-19 infection prevention and control protocols including improper PPE use.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 16 residents' Advance Directive forms was signed by the resident and their doctor in a reasonable amount of time upon admission (Resident #9). | — |
| Failure to complete comprehensive Minimum Data Set assessments resulting in failure to implement a comprehensive Care Plan for 2 of 4 residents reviewed (Resident #3 and #36). | SS=D |
| Failure to ensure PASRR reflected all current mental health diagnoses for Resident #3. | — |
| Failure to ensure fall interventions were in place at the time of a fall when a clip alarm was not attached to Resident #36's clothing. | SS=D |
| Failure to ensure antipsychotic medication had appropriate diagnoses, resident specific interventions, side effect monitoring, and informed consent for Resident #36. | SS=D |
| Failure to ensure proper sanitation of all dishware due to dishwasher malfunction and inadequate monitoring/documentation. | SS=D |
| Failure to follow CDC COVID-19 guidance and utilize appropriate PPE to prevent spread of COVID-19 affecting 7 of 10 residents on the dementia unit. | SS=E |
Report Facts
Residents on COVID isolation: 9
Residents reviewed for advance directives: 16
Residents reviewed for comprehensive assessments: 4
Residents reviewed for fall interventions: 1
Residents reviewed for psychotropic medication use: 1
Dishwasher temperature: 150
Dishwasher temperature: 151
Dishwasher sanitizer level: 10
Dishwasher sanitizer level: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse | Named in findings related to improper PPE use and COVID-19 infection control breaches |
| Staff I | Registered Nurse | Named in findings related to COVID-19 testing and improper PPE use |
| Staff G | Certified Nursing Assistant | Named in findings related to COVID-19 infection control breaches |
| Staff J | Certified Nursing Assistant | Named in findings related to COVID-19 infection control breaches |
| Staff H | Certified Nursing Assistant | Named in findings related to COVID-19 infection control breaches |
| Staff K | Dietary Staff | Named in findings related to dishwasher sanitation testing |
| Staff L | Dietary Staff | Named in findings related to dishwasher sanitation testing |
| Staff M | Dietary Staff | Named in findings related to dishwasher sanitation testing |
| Director of Nursing | Director of Nursing | Named in findings related to multiple deficiencies including COVID-19 infection control and care planning |
| MDS Coordinator | MDS Coordinator | Named in findings related to care plan deficiencies and infection control assistance |
| Social Worker | Social Worker | Named in findings related to PASRR and care plan deficiencies |
| Certified Dietary Manager | Certified Dietary Manager | Named in findings related to dishwasher sanitation |
| Maintenance Director | Maintenance Director | Named in findings related to dishwasher repair and sanitation |
| Administrator | Administrator | Named in findings related to multiple deficiencies including advance directives and infection control |
| Infection Preventionist | Infection Preventionist | Named in findings related to COVID-19 infection control |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 16, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective November 12, 2023, based on the Plan of Correction submitted.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 3
Oct 12, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of facility reported incidents #112481-1 and #115334-1.
Findings
The facility failed to report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals, and Licensing. The investigation was incomplete and lacked thorough documentation, including missing physical assessments and failure to properly label and date opened food items in the dietary department.
Complaint Details
Facility reported incidents #112481-1 and #115334-1 were investigated and found not substantiated. The complaint investigation revealed failure to report abuse allegations timely and incomplete investigations.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals, and Licensing. | SS=D |
| Failure to complete a thorough investigation after an allegation of abuse. | SS=D |
| Failure to properly label and date opened food items in the dietary department. | SS=F |
Report Facts
Resident census: 38
Deficiency count: 3
Correction date: Nov 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Documented red marks on resident's neck and informed staff of findings. |
| Staff E | Certified Medication Aid (CMA) | Reported red marks on resident's neck. |
| Staff F | Licensed Practical Nurse (LPN) | Documented communication of red marks and informed the Administrator. |
| Staff B | Dietary Aide | Reported that all opened food should be labeled and dated. |
| Staff C | Cook | Reported all opened food is to be labeled and dated prior to storage. |
| Staff A | Dietary Manager | Reported expectations for labeling and dating food items. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 26, 2023
Visit Reason
Investigation of facility reported incidents #106689-I and #110589-I.
Findings
No deficiencies were found and the facility was determined to be in substantial compliance.
Complaint Details
Investigation of facility reported incidents #106689-I and #110589-I resulted in no deficiencies. The facility was found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 29, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Ossian Senior Hospice, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective July 29, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 5
Jun 29, 2022
Visit Reason
The inspection was the facility's annual recertification survey conducted from June 26, 2022 to June 29, 2022.
Findings
The facility failed to serve beneficiary notices correctly for 3 residents, failed to implement the use of a roho cushion for 1 resident, failed to follow physician ordered parameters for daily weights and use of a roho cushion for 2 residents, and failed to provide proper nutritional servings and food safety measures. Multiple deficiencies were cited related to Medicaid/Medicare coverage notices, comprehensive care plans, professional standards, menus and nutritional adequacy, and food procurement and sanitation.
Deficiencies (5)
| Description |
|---|
| Failed to serve beneficiary notices correctly for 3 of 3 residents sampled. |
| Failed to implement the use of a roho cushion per the care plan for 1 of 13 residents reviewed. |
| Failed to follow physician ordered parameters on daily weights and utilize a roho cushion as ordered for 2 of 13 residents sampled. |
| Failed to provide the servings size called for with residents on pureed diets with regular serving sizes. |
| Failed to ensure the automatic dishwasher sanitized dishes/utensils as required. |
Report Facts
Deficiencies cited: 5
Resident census: 31
Residents sampled: 13
Residents sampled: 3
Residents sampled: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nursing Assistant (CNA) | Observed moving resident and noted cushion placement. |
| Staff D | Certified Nursing Assistant (CNA) | Reported on resident cushion preference and care plan. |
| Staff D | Registered Nurse (RN) | Reported on care plan and cushion orders. |
| Director of Nursing | Interviewed regarding cushion use and care plan compliance. | |
| Staff B | Cook | Observed meal preparation and serving sizes. |
| Staff A | Cook | Interviewed about dishwasher temperatures and maintenance. |
| Dietary Manager | Interviewed about dishwasher issues and food service. |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 6
Jul 29, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey in accordance with Medicare Requirements for Long Term Care Facilities to assess compliance.
Findings
The facility was found to be NOT IN COMPLIANCE with multiple deficiencies identified including failure to ensure residents' wishes regarding advance directives were documented, quality of care issues leading to hospitalization, incomplete nurse staffing data posting, medication preparation errors, food safety violations, and infection control deficiencies.
Deficiencies (6)
| Description |
|---|
| Failure to ensure the resident's wishes per the Iowa Physician Orders for Scope of Treatment (IPOST) were documented and consistent with physician orders. |
| Quality of care deficiency including failure to prevent hospitalization for a resident and inadequate assessment and response to resident's condition. |
| Failure to post accurate nurse staffing data for 20 out of 27 days in July 2021. |
| Failure to properly prepare a prefilled medication device before administration. |
| Failure to serve food at safe and appetizing temperatures, including mashed potatoes served below safe temperature. |
| Failure to maintain an effective infection prevention and control program including inadequate hand hygiene and glove use during resident care. |
Report Facts
Total residents: 38
Survey dates: 2021-07-26 to 2021-07-29
Days nurse staffing data missing: 20
Residents receiving mashed potatoes: 27
Residents observed for hand hygiene: 2
Residents with blood sugar check observed: 1
Residents with wound dressing observed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in medication preparation and blood sugar check findings |
| Staff B | Licensed Practical Nurse (LPN) | Named in resident unresponsiveness and Narcan administration findings |
| Staff C | Licensed Practical Nurse (LPN) | Named in resident unresponsiveness and Narcan administration findings |
| Staff D | Director of Nursing (DON) | Named in multiple interviews regarding resident care and infection control |
| Staff E | Named in food temperature observation | |
| Staff F | Named in infection control observation | |
| Administrator | Named in interviews regarding staffing and infection control |
Inspection Report
Routine
Census: 36
Deficiencies: 0
Dec 9, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on December 9 - 10, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Report Facts
Total Census: 36
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Oct 22, 2020
Visit Reason
The inspection was conducted as a Focused Infection Control Survey and Complaint investigations #88204 and #93010 between October 13 and 22, 2020.
Findings
The facility was found to have deficiencies related to infection control, including failure to follow CMS COVID-19 screening recommendations for sampled residents, failure to notify residents and families timely about COVID-19 exposures, and issues with staffing and documentation regarding the Director of Nursing position and COVID-19 policies.
Complaint Details
Complaint #88204-C was substantiated. Complaint #93010-C was not substantiated.
Deficiencies (3)
| Description |
|---|
| Failure to meet the requirement for a full-time Director of Nursing with specific duties and responsibilities. |
| Failure to follow CMS COVID-19 screening recommendations for 5 of 5 sampled residents. |
| Failure to notify residents, representatives, and families timely about COVID-19 exposures and positive test results. |
Report Facts
Census: 38
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse, Acting Director of Nursing | Named as Acting Director of Nursing and involved in COVID-19 screening and notification deficiencies. |
| Staff G | Registered Nurse, Acting Director of Nursing | Named as Acting Director of Nursing and involved in Director of Nursing duties coverage. |
| Ana Scott | RN | Mentioned as acting Director of Nursing until permanent hire. |
| Brittany Bodensteiner | LPN | Mentioned as acting Director of Nursing until permanent hire. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/15/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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