Ozark Riverview Manor

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective pain management program was in place for all residents when staff failed to document complete assessments of pain and failed to document administration of pain medication after complaints of pain for one resident (Resident #1) who suffered a broken hip. The facility census was 74. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Resident #61, #74, and #6) . The facility census was 77. Review showed the facility did not provide a shower policy. 1. During interviews on 09/22/25, at 9:58 A.M., during the resident council group meeting, the residents said there were issues with receiving showers. Some residents receive two showers per week, but most only receive one. 2. Review of Resident #61's face sheet (a general information sheet) showed the following:-admission date of 11/16/23;-Diagnoses included congestive heart failure, morbid obesity, and depression. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not correctly reconciling each month. The facility managed funds for 25 residents. The census was 77. Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not correctly reconciling each month. The facility managed funds for 25 residents. The census was 77. Review showed the facility did not provide a policy related to the resident funds. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper assessment and documentation was completed before side rail use, failed to document risk versus benefit review, failed to obtain informed consent, and failed to care plan use of side rails for two residents (Residents #8 and #75), and failed to complete gap measurements to reduce risk of entrapment for three residents (Resident #8, #12, and #75). The facility census was 77. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to nurse aides were not employed and used for resident care longer than four months without proper certification when four nurse aides (Nurse Aide (NA R, NA S, NA T, and NA U), of fifteen sampled NAs, failed to complete a certified nurse aide (CNA) training program within four months of employment in the facility as a nurse aide. The facility census was 84. Review showed the facility did not provide a policy regarding nurse aide certification or training. 1. Review of NA R's personnel information showed the following:-Date of hire of 01/24/25 (eight months and two days since date of hire);-Staff did not have documentation NA R had completed the nurse aide training program. Review of the state agency CNA registry, on 09/26/25, showed the NA R did not have an active CNA certification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain or improve residents' functional status as directed by therapy for three residents (Residents #55, #72, and #75). The facility census was 77. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) per nursing standards of infection control during wound care for one resident (Resident #5), during urinary catheter (thin tube that remains in the bladder for continuous urine drainage, often held in place by a small balloon and connected to a collection bag) care for one resident (Resident #67), and during medication administration via peg tube for one resident (Resident #12). The facility census was 77. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each residents' representatives were notified timely of changes in condition when staff failed to notify one resident's (Residents #72) representatives regarding a change in condition and new orders. A sample of 26 residents was reviewed for notification of changes; the facility census was 77. Review showed the facility did not provide a policy regarding notification of resident representatives. 1. Review of Resident #72's Face Sheet (resident information) showed the following:-admission date of 11/08/24;-Diagnoses included complete amputation at knee level, anorexia, depression, anxiety, and heart failure;-Contact Emergency Contact (EC) #1 if any new orders are received or if a change in condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate oral care for one resident (Resident #12) who was dependent on staff for all activities of daily living. The facility census was 77. Review showed the facility did not provide a policy specific to assisting residents with oral care. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities when staff failed to provide preferred activities to one resident (Resident #72) who voice importance of attending activities. The facility census was 77. Review showed the facility did not provide a policy related to activities. 1. Review of Resident #72's face sheet (resident information) showed the following:-admission date of 11/08/24;-Diagnoses included complete amputation at knee level, anorexia, depression, anxiety, and heart failure. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure access to survey results to family, visitors, and residents when the prior survey results were not kept in a readily accessible, public location. The facility census was 77. Review showed the facility did not provide a policy regarding survey results accessibility. 1. Observation on 09/24/25, at 2:00 P.M. showed the following:-A white binder located behind the front desk, lying flat in a wire bin;-Two sets of public bathroom keys lying on top of the binder;-The height of the desk counter was approximately four feet tall;-The binder was not visible behind desk if seated in a wheelchair;-No signage was present notifying of the location of the survey results. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective system of records and disposition of controlled medications when staff could not locate two cards of a controlled medications and failed to destroy the discontinued controlled medication in a timely fashion for one resident (Resident #1). The facility census was 56. On 04/02/24, the Assistant Director of Nursing (ADON) was notified of the Past Non-Compliance that occurred on 04/01/24. The ADON notified the physician, the Director of Nursing (DON), and the Administrator. The Administrator notified the Ozark Police Department. The DON and ADON completed an narcotic count audit. Administration interviewed staff and residents and reviewed the camera surveillance. The Administrator suspended the employee pending completion of the investigation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed ensure medication error rates below 5% when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.) the insulin pens before administering insulin to three residents (Residents #6, #3, and #20). The facility had three medication errors out of 34 opportunities for error resulting in a facility medication error rate of 8.82%. The facility census was 56. Review of the facility policy regarding insulin administration, revised September 2014, showed the following: -Purpose to provide guidelines for the safe administration of insulin to residents with diabetes; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed ensure all residents were free from significant medication errors when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.) the insulin pens before administering insulin to three residents (Residents #6, #3, and #20). The facility census was 56. Review of the facility policy regarding insulin administration, revised September 2014, showed the following: -Purpose to provide guidelines for the safe administration of insulin to residents with diabetes; -The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an effective infection control program when when staff failed to sanitize the glucometer (used to check blood sugar levels) after performing accuchecks and failed to have a clean, sanitary barrier to place the glucometer on while performing the accuchecks for four of four residents (Residents #6, #3, #20 and #5) during the medication pass and when staff failed to wash and/or sanitize hands properly during and after a dressing change for one resident (Resident #1). The facility census was 56. 1. Review of the facility policy Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, showed the following: -Non-critical items are those that come in contact with intact skin, but not mucous membranes. Most non-critical reusable items can be decontaminated where they are used; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers when staff failed to document physician notification of wound development/changes, failed to obtain orders for all treatments provided, failed to document complete and routine assessments of wounds, failed to consistently implements identified interventions, and failed to update the care plan timely regarding actual skin breakdown and intervention changes for one resident (Resident #24) of seven sampled residents. The facility census was 56. Review of the facility's policy Prevention of Pressure Injuries, revised April 2020, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure any resident weight loss was unavoidable when staff failed to identify weight loss, failed to notify the physician and register dietician of weight loss, failed to care plan weight loss, and failed to implement new interventions to prevent future weight loss for one resident (Resident # 22). The facility census was 56. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated September 2017, showed the following: -The nursing staff will monitor and document the weight and dietary intake of residents; -The staff and physician will define residents with weight loss and significant risk for impaired nutrition; -The staff will report to the physician any significant weight loss; -The staff and physician will identify pertinent interventions based on identified causes; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for all residents on oxygen per professional standards of practice when staff failed to ensure oxygen equipment was cared for in a manner to prevent possible contamination or bacteria growth, when staff failed to administer oxygen per physician orders, and when staff failed to care plan regarding oxygen use and the care of oxygen equipment for one resident (Resident #42). The facility census was 56. Review of the facility's policy titled Oxygen Administration, revised October 2010, showed the following: -Verify that there is a physician's order for this procedure; -Review the physician's orders or facility protocol for oxygen administration; -Review the resident's care plan to assess for any special needs of the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a valid physician's order indicating where and when the resident was to go for dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) treatment and failed to provide thorough assessments and on-going monitoring for one resident (Resident # 19) The facility had a census of 52. Record review of the Nursing Guidelines Manual, dated March 2015, regarding dialysis showed the following: -Care of the shunt/fistula/graft/port (an entry into the body used for dialysis): keep the area clean and dry; feel for the thrill sensation (a vibrating sensation that can be felt) daily; inspect the access site for redness, swelling or warmth; avoid excessive pressure to the puncture site; watch for bleeding after dialysis; and monitor for signs of infection. [...]