Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ossian Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including hypertension and a recent fracture, experienced critically low blood pressure and lethargy. Despite care plan requirements and staff knowledge that physician notification was needed for blood pressures below 90/50 mmHg, the LPN did not notify the physician or supervisory staff after obtaining abnormal readings, resulting in delayed intervention.
The facility failed to ensure proper dishware sanitation due to a malfunctioning dishwasher and inadequate documentation. The dishwasher did not meet sanitizing guidelines, and test strips failed to show proper disinfection levels. Staff interviews revealed inconsistent testing and documentation practices, and a maintenance issue with the dishwasher went unnoticed until identified by a surveyor.
The facility failed to follow CDC COVID-19 guidelines and proper PPE protocols, leading to potential exposure risks. Staff were observed entering and exiting COVID-positive rooms without appropriate PPE, such as N95 masks and eye protection, and failed to change masks after leaving isolation rooms. Interviews revealed inconsistencies in PPE use and a lack of signage for isolation precautions, despite the facility's ongoing outbreak.
A resident's Advance Directive form was not signed by their physician in a timely manner upon admission, despite the resident's request for a DNR order. The form lacked the necessary physician's signature until over a month later, and the facility's policy did not include a procedure for obtaining this signature.
The facility failed to complete comprehensive MDS assessments, leading to inadequate Care Plans for two residents. One resident with PTSD did not have relevant goals and interventions in her Care Plan, while another resident on antipsychotic medications lacked documentation and instructions for staff on medication side effects. Interviews with staff revealed a lack of processes to ensure diagnoses were reviewed and implemented into Care Plans.
A facility failed to ensure a resident's PASRR included all current mental health diagnoses, such as Adjustment Disorder and PTSD, as documented in the MDS. The social worker admitted there was no process to routinely update PASRRs, although plans for quarterly reviews were mentioned. The Administrator and DON expected PASRRs to reflect current diagnoses.
A facility failed to ensure appropriate use of antipsychotic medication for a resident with cognitive impairment, lacking specific interventions and informed consent. The care plan did not include instructions for monitoring side effects, and staff interviews revealed a lack of processes for addressing psychotropic medication use.
A resident with moderate cognitive impairment and a history of falls was left without required fall interventions, including a clip alarm and motion sensor, leading to a fall with major injury. The incident occurred when CNAs left the resident unattended, and staff were unsure of the Care Plan requirements.
Failure to Notify Physician and Intervene for Critically Low Blood Pressure
Penalty
Summary
The facility failed to provide timely interventions and notify the resident's physician after a resident presented with significantly low blood pressure, lethargy, and drowsiness. The resident, who had a history of hypertension, heart failure, anemia, and a recent thoracic spine fracture, was dependent on staff for transfers and required assistance with bed mobility. On the night in question, the resident's blood pressure readings were as low as 63/36 mmHg and 61/50 mmHg, and he was described as very drowsy, sleeping through assessments, but responsive when given scheduled pain medication. Despite these abnormal findings, there was no immediate notification to the physician as required by the care plan, which specified that the provider should be updated if the systolic blood pressure was less than 90 or diastolic less than 60. Interviews with staff and the physician confirmed that blood pressures below 90/50 mmHg should prompt physician notification. The LPN on duty attempted to verify the blood pressure readings with different cuffs, suspecting an error, but did not notify the physician or supervisory nursing staff as expected. The resident was later assessed by the ADON, who also noted abnormal presentation and low blood pressure, and confirmed that the expectation was for the nurse to reassess with a manual cuff and notify appropriate personnel. The DON and Administrator echoed these expectations. The failure to follow established protocols for assessment and notification led to a delay in appropriate medical intervention for the resident.
Dishwasher Sanitation Failure Due to Malfunction and Poor Documentation
Penalty
Summary
The facility failed to ensure proper sanitation of dishware due to a malfunctioning dishwasher and inadequate documentation practices. Upon observation, the dishwasher was found to be operating with a wash temperature of 150 degrees and a rinse temperature of 151 degrees, which did not meet the manufacturer's guidelines for either hot water or chemical sanitizing. The chemical sanitizing system was not functioning correctly, as evidenced by test strips that failed to indicate the required disinfection level. Staff interviews revealed that the dishwasher had a crack in one of the dispensing lines and another line had blown off, which was only discovered after a surveyor's inspection. The facility's documentation practices were insufficient to verify proper sanitation. The Certified Dietary Manager (CDM) reported that sanitation strips were used three times a week, but there was no documentation to support this prior to a certain date. The November Dish Machine Temperature Chart lacked evidence of proper sanitization, and the CDM could not locate documentation for the previous month. Staff interviews indicated a lack of consistent testing and documentation, with some staff members not recalling performing test strip checks or documenting results. The maintenance director and dietary staff were unaware of the dishwasher's malfunction until it was identified by a surveyor. The maintenance director noted that a line had blown off the dishwasher, and there was no warning system to alert staff of the issue. Staff reported cloudy glasses, which could have indicated a problem, but this was not recognized as a sign of malfunction. The facility lacked a reliable system to ensure dishware sanitation, as evidenced by the absence of consistent documentation and monitoring of the dishwasher's performance.
Failure to Follow CDC COVID-19 Guidelines and PPE Protocols
Penalty
Summary
The facility failed to adhere to CDC COVID-19 guidelines and proper use of personal protective equipment (PPE) to prevent the spread of COVID-19 among residents in the CCDI unit. Upon entrance, it was reported that nine residents were on isolation for COVID-19, with several residents testing positive. Observations revealed that isolation bins were placed outside the rooms of COVID-positive residents, but there was a lack of signage indicating isolation precautions or required PPE. Staff members were observed entering and exiting COVID-positive rooms without wearing appropriate PPE, such as N95 masks and eye protection, and failed to change masks after leaving isolation rooms. Staff interactions with residents further demonstrated non-compliance with infection control protocols. For instance, a Licensed Practical Nurse (LPN) was seen responding to a resident's fall alarm without wearing an N95 mask or eye protection, and later approached a COVID-negative resident without changing the medical mask used in a COVID isolation room. Similarly, a Certified Nursing Assistant (CNA) assisted a COVID-positive resident through common areas without ensuring the resident wore a mask, and the Hospice Aide followed without proper PPE. These actions increased the risk of potential exposure to other residents and staff. Interviews with staff and the Director of Nursing (DON) revealed inconsistencies in understanding and implementing PPE protocols. Staff reported receiving minimal direction on PPE use, and there was a lack of signage to communicate isolation precautions to visitors and vendors. The DON acknowledged the absence of sanitizing wipes for goggles and the need for proper PPE during COVID testing. Despite the facility's outbreak starting weeks prior, there was a clear gap in adherence to infection prevention and control measures, as outlined by CDC guidelines.
Failure to Timely Obtain Physician Signature on Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive form was signed by both the resident and their physician in a timely manner upon admission. Specifically, Resident #9, who was admitted on 10/17/24 and had no cognitive impairment as indicated by a BIMS score of 15, requested a Do Not Resuscitate (DNR) order on the same day. However, the Advance Directive form lacked the physician's signature to confirm the order. Although the Medication Review Report dated 10/18/24 included a DNR order signed by the doctor, it did not document the resident's request. The physician's signature on the Advance Directive form was not obtained until 11/19/24. Interviews with the facility's Administrator and Director of Nursing revealed an expectation for Advance Directives to be signed promptly upon admission, but the facility's policy lacked a procedure for obtaining the physician's signature.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments, which resulted in the lack of a comprehensive Care Plan for two residents. Resident #3, who had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment, was diagnosed with Major Depressive Disorder, Adjustment Disorder, and Post Traumatic Stress Disorder (PTSD). However, the Care Plan did not include goals and interventions relevant to her PTSD. The facility's Social Worker admitted there was no process to ensure all diagnoses were routinely reviewed and implemented into the Care Plan. Resident #36, with a BIMS score of 9 indicating moderate cognitive impairment, was diagnosed with dementia and anxiety and was taking antipsychotic medications. The Care Area Assessment (CAA) of the MDS lacked staff review and documentation of his antipsychotic medications and what would be implemented into the Care Plan. The current Care Plan did not instruct staff on the antipsychotic medications and side effects to monitor for. Interviews with the facility's MDS Coordinator, Administrator, and Director of Nursing revealed an expectation that Care Plans should address mental health diagnoses and the usage of psychotropic medications, including side effects to monitor for and resident-specific interventions.
Inaccurate PASRR Documentation for Resident's Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) for a resident accurately reflected all current mental health diagnoses. Specifically, the PASRR for a resident did not include diagnoses of Adjustment Disorder and Post Traumatic Stress Disorder (PTSD), despite these being documented in the resident's Minimum Data Set (MDS). The facility's social worker acknowledged the omission and admitted there was no existing process to routinely review and update diagnoses on the PASRR, although she plans to implement quarterly reviews in the future. The facility's Administrator and Director of Nursing also expressed that they would expect all resident PASRRs to reflect current mental health diagnoses.
Deficiency in Antipsychotic Medication Management and Informed Consent
Penalty
Summary
The facility failed to ensure that antipsychotic medication was used appropriately for a resident with moderate cognitive impairment, dementia, and anxiety. The resident was prescribed Quetiapine for behaviors and agitation without appropriate diagnoses or resident-specific interventions documented in the care plan. The care plan also lacked instructions for staff on monitoring side effects of the antipsychotic medication. Additionally, the facility did not have a process in place to obtain informed consent for the use of psychotropic medications, and there was no formal documentation provided to families regarding the side effects and risks associated with these medications. Interviews with facility staff, including the MDS Coordinator, Social Worker, Administrator, and Director of Nursing, revealed a lack of processes and expectations for addressing the use of psychotropic medications in resident care plans. The MDS Coordinator admitted that the facility educates families but lacks a formal document outlining the side effects and risks of psychotropic medications. The Social Worker and the facility's leadership expressed that they would expect care plans to include resident-specific interventions and monitoring for side effects, which were absent in this case.
Failure to Implement Fall Interventions for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident with a history of falls and major injury. The resident, who had moderate cognitive impairment and was diagnosed with dementia and anxiety, was dependent on staff for walking and required assistance with transfers. On the day of the incident, the resident was in the dementia unit lobby, sleeping in a recliner with the footrest up. The resident was supposed to have a clip alarm attached to his clothing and a motion sensor in use, but neither was in place at the time of the fall. The fall occurred when both CNAs on the unit left the resident unattended to provide care for another resident. One of the CNAs, Staff B, reported being unsure if the resident was supposed to have an alarm on while in the lobby and did not know where to find the Care Plan to verify this information. The facility's Root Cause Analysis identified the lack of alarm usage, recent medication changes, and staff knowledge of the Care Plan as contributing factors to the fall. The fall resulted in a major injury, as determined by the resident's provider.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ossian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellington Place | 10.6 mi | — | 0 | 0 |
| The Highlands | 12.3 mi | — | 2 | 0 |
| Good Samaritan - West Union | 12.3 mi | — | 9 | 0 |
| Good Samaritan - Waukon | 17 mi | — | 1 | 1 |
| Northgate Care Center | 17.1 mi | — | 18 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.