Ozark Health Nursing And Rehab Center

Based on observation, record review, and interview, it was determined that the facility failed to report to the Office of Long-Term Care (OLTC), an allegation of sexual abuse of one (Resident #46) by another (Resident #34) resident within two hours of the allegation being made. The findings are: 1. A review of an admission Record indicated Resident #34 was admitted to the facility with diagnoses that included: congestive heart failure, cognitive communication deficit, and dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/15/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment for daily decision making. Section E - Behaviors, indicated: Resident #34 did not have verbal, physical, or other behaviors symptoms directed toward others. Review of Resident #34's Care Plan initiated 08/25/2022, and revised on 01/16/2024, revealed the resident had a behavior problem related to being sexual with others. Interventions included: Resident currently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined that the facility failed to ensure evidence of an investigation for an allegation of sexual abuse was maintained after the investigation was conducted and failed to report to the Office of Long Term Care (OLTC) the results of the investigation to enable the state agency to provide the necessary oversight of the facility's efforts to investigate for two (Resident #34 and Resident #46) of two residents reviewed for abuse. The findings are: 1. A review of an admission Record indicated the facility admitted Resident #34 with diagnoses that included congestive heart failure, cognitive communication deficit, and dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident # 34 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment for their daily decision making. In Section E - Behaviors, indicated: Resident #34 did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review, it was determined that the facility failed to perform proper hand hygiene, don proper personal protective equipment (PPE), and follow standard infection control procedures for one (Resident #74) of three residents reviewed for isolation precautions. The findings are: A review of the admission Record noted Resident #74 was admitted to the facility on [DATE], for diagnoses which included aftercare following joint replacement surgery. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/2025 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14 (13-15 suggest cognitively intact). A review of the Physician Order Summary revealed Resident #74 was on enhanced barrier precautions (EBP), due to the peripherally inserted central catheter (PICC) line in their right arm and an order to receive antibiotics intravenously, via PICC line for a diagnosis of osteomyelitis (infection in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, interview, the facility failed to ensure that hands were washed between clean and dirty task to prevent food borne illness. The failed practice had the ability to affect 35 residents who receive their meals from 1 of 1 kitchen. The findings are: A. On 01/08/24 at 12:20 PM, Dietary Aide #1 was observed to be wearing black gloves while serving trays from the steam table in the main dining room. Dietary Aide #1 was observed touching utensils, trays, plates, the counter, and a large clear trash bag of refuse during lunch service. Dietary Aide #1 continued to use contaminated gloves while using a scoop to serve homestyle French Fries. Dietary Aide #1 scooped up the french fries to serve and touched them with their right thumb to hold them into the scoop. Dietary Aide #1 continued to serve trays in the main dining room, did not switch gloves or wash hands between tasks. Dietary Aide #2, while wearing black gloves was observed putting trash in a large clear trash bag on the counter behind the serving line. Dietary Aide #1 reached into a stainless-steel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure 2 Residents (#5 and #35) of 13 sampled residents who required assistance with hand hygiene, were assisted with hand hygiene prior to feeding self during meal to prevent contamination and illness. The findings are: Resident #5 had a diagnosis of Schizophrenia. The Quarterly Minimum Data Set (MDS)with an Assessment Reference Date of 10/11/2023 documented the Resident scored 09 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required partial/moderate assistance with her Activity of Daily Living (ADL's.) The Comprehensive Plan of care included the need for assistance with ADLS with an intervention revision on: 01/23/2017 stating Resident #5 requires partial to moderate assistance of one person for personal hygiene; an intervention dated 4/25/23 indicates the resident wants staff to provide all care at times with staff to encourage and assist as needed to ensure daily needs are being met. On 01/08/24 at 9:03 AM Resident #5 was observed sitting in her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the facility failed to ensure physician orders were followed to maintain a medication error rate of less than 5%, to prevent potential complications for 2 (Resident #13 and #61) of 25 residents that could potentially receive medication observed during the medication pass. This failed practice has the potential to inhibit maximum therapeutic outcomes. The medication error rate was 8.00%, based on observations of 25 medications administered. The findings are: a. On 01/09/24 at 3:22 PM, the Surveyor observed the 4:00 PM medication pass with the Licensed Practical Nurse (LPN) #1. The LPN #1 administered Nystatin 100000 suspension 5 ml being given by mouth four times a day X 7, order written 1/4/2023. The LPN #1 failed to shake the bottle before administration as listed on the bottle, to Shake Well. b. The MAR (Medication Administration Record) documented Resident #13 was to receive Nystatin Suspension 100000 UNIT/ML Give 5 ml by mouth four times a day for 7 Days swish and swallow. c. 01/10/24 03:07 PM, in an interview with LPN #1, in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure accommodation of needs were met by not ensuring the call light was within reach for one (Resident #8) of 16 residents (Resident #2, #3, #5, #8, #15, #16, #22, #24, #33, #35, #40 #42, #45, #49, and #62) sampled residents. The findings are: Resident #8 has a diagnosis of TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY and ACQUIRED ABSENCE OF LEFT LEG ABOVE KNEE. On the Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/29/23, the Resident received a score of 15 on the Brief Interview for Mental Status (BIMS). On the annual MDS with an ARD of 7/05/23 the resident is an extensive assist with bed mobility, personal hygiene, transfer, dressing, and toilet use. A. On 01/08/24 at 11:39 AM, Resident #8 was observed to be lying in bed. The call light was observed to be in the top drawer of nightstand and appeared to be out of reach of the resident. The Surveyor asked Resident if he could reach the call light. Resident #8 responded that he could not reach the call light. B. On 01/08/24 at 11:45 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident's catheter bag was secured and off the floor to prevent cross contamination for 1 of 1 sampled Resident #40 who have has a physician's order for an indwelling catheter according. The findings are: Resident #40 has a diagnosis of OBSTRUCTIVE AND REFLUX UROPATHY. On the Quarterly Minimum Data Set (MDS), dated [DATE] the resident received a score of 15 on the brief interview for mental status. On the discharge/return anticipated MDS the resident was noted to be dependent for Chair-bed transfer, sit to stand, lying to sitting and sit to lying. On 1/8/24 at 11:28 AM, the Resident #40 was observed to be sitting in his recliner. Resident's catheter bag was observed to be lying on the floor in front of the recliner, next to the Resident ' s foot. On 1/08/24 at 3:06 PM, Resident #40 ' s catheter bag was observed to be lying on the floor, just to the left side of the recliner. Resident's feet are elevated by the chair's footrest On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure residents had ready and reasonable access to funds managed by the facility for 1 (Resident #49) of 17 (#1, #5, #8, #11, #12, #17, #23, #25, #27, #31, #36, #39, #44, #47, #49, #98, and #153) sampled residents who had a trust fund managed by the facility as documented on a list provided by the Administrator on 10/18/22 at 8:10 AM. The findings are: Resident #49 had a diagnosis of RHEUMATOID ARTHRITIS. On the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/3/22 the resident received a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 13-15 implies that the resident is cognitively intact. a. On 10/18/22 at 9:13 AM, Resident #49 stated, I am unable to obtain money for a family birthday. I was told that I had to have a receipt. b. On 10/19/22 at 8:05 AM, The Surveyor asked the [NAME] Coordinator, Can Resident #49 access her money? She answered, She is known to ask for large sums of money .maybe $100 or $200, that is a large sum to me. She wants to gift cash to family members. When…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to review and revise the resident care plan to meet the residents' needs for 2 (Resident # 23 and #8) of 16 (Residents #28, 54, 48, 44, 12, 14, 23, 39, 27, 8, 49, 54, 17, 24, 36, 153) sampled residents whose care plans were reviewed. The Findings are: 1. Resident #23 had a diagnosis of Urinary Tract Infection. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/19/22 documented a score of 10 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS). She received oxygen, care of a PICC (Peripheral inserted central catheter) line and antibiotics while a resident. a. On 10/17/22 at 11:38AM Resident #23 was in bed with oxygen in use at 1.5 liter per minute (via nasal cannula) dated 10/17/22. A portable oxygen cylinder was on the back of her wheelchair. The PICC line was in place. An IV (intravenous) pole was at the bedside. b. On 10/18/22 at 08:15 AM, Resident #23 was in bed with Oxygen in use. PICC Line in left arm and IV pole at bedside. c. On 10/18/22 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure oxygen signage was displayed in accordance with professional standards of practice when oxygen is in use for 5 (#14, #23, #36, #44, #49)of 9 (5, #8, #14, #23, #31, #36, #39, #44, #47, #49) sampled residents who had a Physician's Order for Oxygen, as documented on a list provided by the Administrator on10/20/22 at 9:40 AM. The findings are: 1. Resident # 23 had a diagnosis of Shortness of Breath. The Quarterly Minimum DATA SET (MDS) with an Assessment Reference Date of 08/19/22 documented a score of 10 (00 - 07 indicates) on the Brief Interview for Mental Status (BIMS). She received oxygen. A Physician's Order dated 10/17/22 documented, May have O2 (oxygen) @ (at) 1-4 LPM (liters per minute) via (by way of) N/C (nasal cannula) PRN (as needed for) SOB (shortness of breath) . a. On 10/17/22 at 11:38 AM, Resident # 23 was in bed with O2 [oxygen] on via N/C [Nasal Canula] @ [at] 1.5 liter per minute dated 10/17/22. There was no Oxygen in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure resident funds were refunded promptly after discharge/death for 11 (#104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114) sampled residents who had trust funds, as documented on a list provided by the [NAME] Coordinator on [DATE] at 8:19 AM. The findings are: 1. On [DATE] at 8:05 AM, The Surveyor asked the [NAME] Coordinator, Why are there 65 residents listed with trust accounts and only 54 residents in the facility? She answered, Some of the residents have been discharged and had received an interest payment after the account was closed out. One resident who was on the books when I took this position. Some of the residents had a balance of as little as a penny and, the people who write the checks downstairs don't know where to send it. Some of the residents had no family or representatives with whom to leave the money. 2. On [DATE] at 8:19 AM, The [NAME] Coordinator highlighted 11 residents on the list of trust account holders who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the resident and resident's representative were notified in writing of the reason for the transfer/discharge to the hospital in a language they could understand for 2 (Resident #14 and #28) of 6 sample selected Residents who were hospitalized from [DATE] to 10/05/2022. This failed practice had the potential to affect 26 Residents who were transferred/discharged to hospitals since 07/02/2022 according to a list provided by the Administrator on 10/20/2022 at 11:49 am. The findings are: 1. Resident #14 had diagnoses of Chronic Kidney Disease, Dementia, and Diabetes Mellitus Type I. The Minimum Data Set [MDS] with as Assessment Reference Date [ARD] 07/29/22 documented a Brief Interview Mental Status [BIMS] of 12 (Indicated Cognition Intact), required extensive assistance with activities of daily living self-performance skills with one-to-two-person physical assist. A Notice of Unplanned Transfer/Discharge and Bed Hold documented. On this date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.