Ozark Nursing And Rehab

Based on observation, interview, and record review, the facility failed to ensure clean linens and clothing were handled and transported in a manner to prevent contamination by failing to maintain covers on laundry carts during delivery to resident care areas. This deficient practice occurred during three separate observations and had the potential to affect all residents residing in facility.Based on observation, interview, and facility policy review, the facility failed to ensure clean linens and clothing were handled and transported in covered carts during delivery to resident care areas to prevent contamination or spread of infection during three of three observations, which had the potential to affect all residents residing in the facility. The findings include: On 02/19/2026 at 8:15 AM, this Surveyor observed Laundry Tech (LT) #1 pushing a laundry cart down the 400 Hall without a cover over the clean clothing. On 02/19/2026 at 8:22 AM, this Surveyor observed LT #1 pushing a laundry cart down the 100 Hall without a cover over the clean clothing. On 02/19/2026 at 8:34 AM, this…

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 observations, interviews, and facility policy review, it was determined the facility failed to ensure kitchen equipment used during meal preparation and service was kept clean and uncontaminated to prevent the spread of illness with the potential to effect 76 residents served from the 1 of 1 kitchen reviewed for food preparation and service. Findings include: A review of the facility's undated policy titled Handwashing and glove usage in food service, indicated Food handlers must wash hands after touching dirty equipment and work surfaces. During an observation on 08/11/2024 at 12:30 PM, [NAME] #2 touched the green pea ladle scoop to the ladle handles of the cauliflower and pureed green peas resting in the two right adjacent containers of the stem table while plating resident food. The green pea ladle was then placed back in the container of green peas and continued to be used for plating of resident food without being washed and sanitized. During an interview on 08/11/2024 at 1:00 PM, Registered Dietician (RD) #1 agreed the ladle for the green peas was considered dirty…

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 kitchen food items stored in the dry storage area, were covered, and sealed; the dish washing machine room ' s air vents were cleaned to provide a sanitary environment for clean dishes, and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 79 residents who received meals from the kitchen (total census: 80), as documented on a list provided by the Dietary Supervisor on 06/22/23 at 1:37 PM. The findings are: 1. On 06/19/23 at 11:15 AM, on a rack in the Storage Room there were two cans of pasta sauce that had dents at their rims. The Surveyor asked the Intern Dietary Supervisor what the outcome of a dent to the rim of a can could be. She stated, Botulism. 2. On 06/19/23 at 11:26 AM, the following opened containers of spices were on a shelf in the Storage Room. a. A container of oregano. b. A container of onion powder. c. A container of white pepper. d.…

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 ensure a resident's urinary catheter drainage bag was kept in a privacy bag from view of other residents/visitors to promote dignity for 1 (Resident #39) of 1 sampled resident who had an indwelling catheter. This failed practice had the potential to affect 5 residents who had catheters according to a list provided by the Director of Nursing (DON) on 06/21/23 at 8:33 AM. The findings are: 1. Resident #39 had diagnoses of obstructive uropathy. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/23 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had an indwelling catheter. a. On 06/19/23 at 11:14 AM, Resident #39 was sitting up in a recliner in his room. There was a urinary catheter drainage bag sitting in a plastic wash basin on the floor next to the resident's recliner. There was no privacy bag covering the drainage bag. b. On 06/20/23 at 8:55 AM, Resident #39 was sitting up in a recliner with his…

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 follow a Physicians Order for placement of compression stockings for 1 (Resident #61) of 10 (Residents #15, #19, #20, #26, #27, #43, #46, #61, #62 and #63) sampled residents who had Physician Orders for compressions stockings. The findings are: 1. Resident #61 had diagnoses of Essential (Primary) Hypertension, Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems and Chronic Kidney Disease, Unspecified. a. A Physicians Order dated 06/01/23 documented, Compression Stockings in place to BLE [bilateral lower extremities] during daytime; remove at HS [hour of sleep] . b. The June 2023 Medication Administration Record (MAR) documented, Compression stockings in place to BLE during daytime; remove at HS . and documented they had been applied at 6:00 AM and removed at 8:00 PM on 06/20/23 and applied at 6:00 AM on 06/21/23. c. On 06/20/23 at 12:07 PM, Resident #61 was sitting up in a chair in her room. Resident #61's ankles and feet were swollen to an extent that made it difficult to…

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 suprapubic/indwelling catheters were free of sediment to prevent possible infection for 1 (Resident #39) of 1 sampled resident. This failed practice had the potential to affect 5 residents according to a list provided by the Director of Nursing (DON) on 06/21/23 at 8:33 AM. The findings are: 1. Resident #39 had diagnoses of Urinary Tract Infection, Site not Specified and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/23 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had an indwelling catheter. a. A Care Plan with an initiated date of 04/04/23 documented, [Resident #39] has a foley catheter r/t [related to] obstructive uropathy . Position catheter bag and tubing below the level of bladder, secure catheter tubing to leg with applicable device . b. On 06/19/23 at 11:14 AM, Resident #39 was sitting up in a recliner in his…

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 ensure fortified food was prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 14 residents who received fortified foods from 1 of 1 kitchen according to a list provided by the Interim Dietary Supervisor on 06/22/23 at 1:37 PM. The findings are: 1. On 06/22/23 at 1:37 PM, the menu for breakfast documented the residents who received a Super Calorie diet were to receive 1 cup of Super Cereal. 2. On 06/22/23 at 7:50 AM, a pan of Super Cereal was on the steam table with a 4-ounce spoon inside the pan. At 7:55 AM, the Surveyor asked Dietary Employee (DE) #1, How did you prepare the super calorie cereal? She stated, I used oatmeal, ½ cup of heavy cream and ½ cup of brown sugar. The Surveyor asked what size of spoon she used to serve and how many servings were given to each resident. She stated, I used a 4- ounce spoon and I gave one serving each. The Surveyor asked if she looked at 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 observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 8 residents who received pureed diets as documented on a list provided by the Interim Dietary Supervisor on 06/22/23 at 1:37 PM. The findings are: 1. On 06/21/23 at 9:26 AM, Dietary Employee (DE) #1 placed 8 servings of polish sausage into a blender, added broth and pureed. She poured the pureed polish sausage into a pan, covered the pan with foil, and placed it in the oven. The consistency of the pureed polish sausage was gritty and not smooth. 2. On 06/21/23 at 9:59 AM, DE #1 had gloves on her hands. She picked up a pan of corn bread and placed it on the counter. She used her contaminated gloved hands, removed 14 slices of corn bread from the pan, and placed the corn bread into a blender to be pureed and serve to the residents on pureed diets. The consistency of the pureed cornbread…

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 maintain accurate documentation in the health records regarding placement of compression stockings for 1 (Resident #61) of 10 (Residents #15, #19, #20, #26, #27, #43, #46, #61, #62 and #63) sampled residents who had a Physicians Order for compression stockings and replacement of foley catheter collection bags for 1 (Resident #39) of 1 sampled resident who had an indwelling catheter. The findings are: 1. Resident #61 had diagnoses of Essential (Primary) Hypertension, Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems and Chronic Kidney Disease, Unspecified. a. A Physicians Order dated 06/01/23 documented, Compression Stockings in place to BLE [bilateral lower extremities] during daytime; remove at HS [hour of sleep] . b. The June 2023 Medication Administration Record (MAR) documented, Compression stockings in place to BLE during daytime; remove at HS . The MAR revealed staff documented they had been applied the compression stockings at 6:00 AM and removed at 8:00 PM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure an indwelling urinary catheter bag was maintained in a manner to prevent contamination for 1 (Resident #39) of 1 resident sampled for catheters. The findings are: 1. On 06/19/23 at 11:14 AM, Resident #39 was sitting in a recliner in his room. There was a urinary catheter drainage bag in a plastic wash basin on the floor next to the resident's recliner. The top of the drainage bag was folded down and over the drainage tube, restricting the flow of urine into the drainage bag. There was a dried substance on the bottom and one side of the basin which was in contact with the catheter bag. 2. On 06/20/23 at 8:55 AM, Resident #39 was sitting in a recliner with his eyes closed. The urinary catheter drainage bag was folded over itself and sitting directly on the floor to the left side of the recliner. The tubing was stretched over the end of the elevated footrest on the recliner and stretched back to the base of the chair. A plastic wash…

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 provide nail care for 1 (Resident #35) of 1 sampled resident who was dependent on staff for assistance with Activities of Daily Living (ADL). The findings are: 1. Resident #35 had diagnoses of Weakness and Need for Assistance with Personal Care. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/23 documented the resident required extensive physical assistance of one person with personal hygiene and physical help with bathing. a. A Care Plan with an initiated date of 05/17/23 documented [Resident #35] has an ADL self-care performance deficit r/t [related to] debility . Personal Hygiene: [Resident #35] requires extensive assistance x [times] 1 staff with personal hygiene . b. On 06/19/23 at 11:10 AM, Resident #35 was sitting up in a wheelchair. Her fingernails were approximately 1/4 inch past her fingertips on both hands. The Surveyor asked Resident #35 if she liked them that way. Resident # 35 replied, No, but I can't cut them myself. c. On 06/21/23 at 9:31 AM, Resident…

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 adequately maintain the cleanliness of an oxygen concentrator for 1 (Resident #45) of 5 (Residents #34, #45, #51, #55 and #58) sampled residents who received supplemental oxygen in the facility per a list provided by the Minimum Data Set (MDS) Coordinator on 06/23/23 at 11:41 AM. The findings are: Resident #45 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation. a. A Physicians Order dated 03/18/23 documented, .Oxygen at 2-4 LPM [liters per minute] via nasal cannula, may remove for ADLS [activities of daily living] . b. On 06/21/23 at 9:40 AM, Resident #45 was lying in bed with oxygen in place via nasal cannula. The Surveyor observed an abundance of particles and debris gathered on the concentrator, primarily on the concave edge under the flow rate meter. c. On 06/21/23 at 3:34 PM, Resident #45 was lying in bed with oxygen in place via nasal cannula. The Surveyor observed that the particles below the flow rate meter were 1/4 inch deep and was a mixture of hair, smokeless…

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 rooms were free of damage for 2 (rooms [ROOM NUMBERS]) rooms on the 200 Hall. The findings are: 1. On 06/19/23 at 2:10 PM, in Resident room [ROOM NUMBER], the Surveyor observed the paint was scraped off the wall on the right side of the window beside the recliner. There were scratches in the veneer wall guard pieces attached below where the paint was scraped off the wall. The Resident ' s family member was in the room and expressed she was unhappy with the condition of the resident's room. She asked the Surveyor, Can you stay long enough to get these walls painted? 2. On 06/21/23 at 11:14 AM, in Resident room [ROOM NUMBER] the paint on the wall and veneer wall guard remained damaged. The area measured 11 inches by 10 inches. 3. On 06/21/23 at 11:31 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #3 to room [ROOM NUMBER]. The Surveyor asked if maintenance was aware of the peeling paint and scratches on 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.