Ozarks Methodist Manor, the

Inspectors wroteBased on interviews and record review, the facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed possible abuse involving one resident (Resident #1) and failed to report the allegation in a timely fashion. The facility census was 59. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents were free from misappropriation when one resident (Resident #1) had $40 taken from his/her wallet in his/her room at the facility without the resident's knowledge or consent. The facility had a census of 60. Review of the facility policy titled, Abuse Prevention Policy/Elder Justice Act, revised 01/16/19, showed misappropriation of resident property included the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of the resident's belongings, or money without the resident's consent. 1. Review of Resident #1's face sheet (basic information sheet) showed the following: -admission date of 09/18/18; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify weight loss and poor intake and failed to implement interventions to aid in the prevention of weight loss for one resident (Resident #14) who had severe weight loss of 9.60% in one month and for one resident (Resident #228) who had weight loss of 19.38% in five months. Three residents were reviewed for weight loss in a facility with a census of 58. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, revised 09/17, showed staff should report significant weight loss, abrupt change in appetite and food intake to the physician. [...]

Inspectors wroteBased on interviews and record review, the facility failed to consistently use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week between 07/04/24 and 12/30/24. This deficient practice had the potential to affect all 58 residents residing in the facility. 1. Review of the facility's Staffing Sheets, provided by the Human Resources Director (HR Director), dated 07/04/24 through 12/30/24, showed there was no RN coverage on the following dates: -On 07/04/24; -On 07/06/24; -On 07/07/24; -On 07/31/24; -On 08/01/24; -On 09/02/24; -On 12/23/24; -On 12/30/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manger met the required training, certification, and/or experience This deficient practice had the potential to affect all 58 residents who received meals in the facility. Review of the facility's Director of Food and Beverage Services, updated 07/14, showed the position required certification as required by state regulations. 1. During an interview on 01/06/24, at 2:37 P.M., the Dietary Manager (DM) said she had been employed at the facility for two years. She was not certified and did not have any Serv-Safe courses. She had been enrolled in classes since 2023, but had not been able to complete the courses. During an interview on 01/09/24, at 11:31 A.M., the Registered Dietitian (RD) said she was aware the DM was not certified. [...]

Inspectors wroteBased on record review and interview, the facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP) and update their program, as necessary, including revision of the IPCP as national standards changed. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use for all 58 facility residents. Review of the facility policy titled Infectious Disease Threat Communications Plan, revised April 2019, showed The Infectious Disease Threat Communications Plan was reviewed and updated at least annually. 1. Review of a binder provided by the facility titled Infection Prevention showed the following: -The binder appeared disorganized and had policy pages out of order or missing pages. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a clean homelike environment for all residents when the bathroom exhaust fan vents of seven residents (Resident #281, #280, #76, #5, #279, #22, and #11) were kept clean. Review of the facility policy titled, Job Duties, Housekeeper (South Hall), dated 10/22/24, showed weekly duties included to dust all vents in rooms and bathrooms. 1. Observation on 01/06/25, at 3:10 P.M., showed the exhaust vent in the shared bathroom of Resident #281, Resident #280, and Resident #76 was covered in a layer of fuzzy, gray dust, dirt, and debris. Observation on 01/06/25, at 3:28 P.M., showed the exhaust vent in the shared bathroom of Resident #5, Resident #279, and Resident #22 was covered in a layer of fuzzy, gray dust, dirt, and debris. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure completed Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) assessments were sent to the Centers for Medicare and Medicaid Services (CMS) system with required time frames days after completion for four residents (Resident #11, #19, #15, and #1) out 21 sampled residents reviewed for MDS transmission. Review of the facility's policy titled Nursing Services Policy and Procedure Manual for Long-Term Care - Assessments and Care Planning, dated July 2017, showed it did not address transmission of MDS data to the CMS system. Review of the CMS 2024 Resident Assessment Instrument (RAI) Manual, accessed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf on 01/09/24, showed the following: -Encoding Data: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a comprehensive care plan directing measurable goals and interventions for three residents (Resident #231, #11, and #10) of a total sample of 21 residents. 1. Review of the facility's Behavioral Assessment, Intervention and Monitoring policy, revised March 2019, showed the care plan will incorporate findings from the comprehensive assessment and Pre-admission Screening and Resident Review (PASARR) Level II determinations (as appropriate), and be consistent with current standards of practice. Review of Resident #231's admission Record, located in the Profile tab of the EMR, showed the following: -admission date of 10/28/19; -Diagnoses included paranoid schizophrenia (a type of schizophrenia accompanied by paranoia. [...]

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to develop a comprehensive care plan directing measurable goals and interventions for six residents (Resident (R) 19, R228, R231, R11, R10, and R14) of a total sample of 21 residents. This failure placed residents at risk for unmet care needs and the inability to meet their maximum practicable level of functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity/respect at all times when staff failed to serve residents sitting at the same table consecutively during meal service resulting in one resident (Resident #233) sitting without a meal while tablemates ate. Review of the facility's policy titled Dining Room Dignity Service Policy, undated, showed meals would be provided to all residents sitting at the table at the same time. 1. Observation of a meal on 01/06/24, at 5:25 P.M., showed four residents sat at the same table. Three of the residents were served their meal at 5:25 P.M The fourth resident, Resident #233, was not served his/her meal. Staff served the surrounding tables their meals without noticing the resident did not have a meal. The resident was observed raising his/her hand to get staff's attention. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change assessment within 14 days of the significant change when facility staff did not complete the assessment for one resident (Resident #228) after being admitted to hospice services. A sample of 21 residents were reviewed. Review of the facility's Resident Assessment Instrument policy, revised September 2010, showed the assessment coordinator is responsible for ensuring that the interdisciplinary assessment team conduct timely resident assessments and reviews when there has been a significant change in the resident's condition. 1. Review of Resident #228's admission Record, located in the Profile tab of the Electronic Medical Record (EMR) showed the following: -admission date of 07/29/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure ulcer care per standards of practice when staff failed to document full and accurate assessments of a pressure ulcer and failed to care plan the pressure ulcer and interventions in place to prevent and/or treat pressure ulcers for one resident (Resident # 19), for three residents reviewed for pressure ulcers, in a total sample of 21 residents reviewed. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, revised April 2018, showed the following: -During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or poorly-healing wounds. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' medical records were complete and accurately documented when the facility failed to ensure physician progress notes were documented and available for review in the electronic medical record (EMR) for one resident (Resident #133), reviewed out of a total sample of 21 residents. 1. Review of Resident #133's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 06/19/23; [...]

Inspectors wroteBased on record review and interviews, the facility failed to conduct ongoing review for antibiotic stewardship for one resident (Resident #15), of three residents reviewed for antibiotic stewardship, who received multiple antibiotics over multiple months. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed the following: -All clinical infections treated with antibiotics will undergo review by the infection preventionist (IP), or designee; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 58 current residents. 1. Observations throughout the facility, on 01/06/25 through 01/09/25, showed the Daily Nursing Roster was posted in the facility at the North Hall Nurse Station on 01/06/25, at 2:00 P.M.; on 01/07/25, at 9:50 A.M.; on 01/08/25, at 5:00 P.M.; and on 01/09/25, at 11:25 A.M., without ensuring all information was documented. The daily postings failed to document the daily resident census, whether or not the nurse was a Licensed Practical Nurse (LPN) or Registered Nurse (RN), or the actual hours worked by the staff. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services when the dietitian was not employed full-time by the facility. The facility census was 59. Review of the facility's policy titled Director of Food and Beverage Services, revised 07/2014, showed the following: -The Director of Food and Beverage Services is responsible for the overall effective dietary services; selecting, training and supervision all dietary services personnel; procuring supplies and equipment; assisting with budget preparation and operating within budgetary guidelines. (The policy did not address the requirements of being a Certified Dietary Manager, Certified in Food Services Manager, or education/training related to service management or hospitality.) 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to ensure foods were held at an appropriate temperature to inhibit the growth of pathogens that can cause foodborne illness; staff failed to discard dented cans when staff stored dented cans on the shelves along with cans of food staff used to prepare resident food; staff failed to discard expired food stored on the shelves along with food used to prepare resident food; staff failed to clean the floor in the dry storage rooms, dishwashing and food preparation area, refrigerators and freezers that stored food used to prepare resident food; staff failed to wear hairnets appropriately while preparing resident's food; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to dispose of empty card board boxes in the kitchen area on the north hall to prevent the harboring of pests. The facility census was 59. Review showed the facility did not provide a policy related to cleaning or refuse disposal. 1. Observation on 05/15/23, at 8:52 A.M., showed in the kitchen area on the north hall, an empty box of oatmeal cream pies laid on the floor on the right side of the washing sink and behind the trash can. Observation on 05/16/23, at 7:50 A.M., showed the following: -One empty box with used gloves, cellophane, and pieces of cardboard laid on the floor in front of the hand washing sink; -Two empty oatmeal cream pie boxes laid on the floor on the right side of the hand washing sink behind the trash can. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program when dead and live roaches and brown beetles were observed on the floors in the main kitchen, kitchen on the north hall, and in a freezer in the kitchen on the north hall. The facility census was 59. Review of the facility's Pest Control Policy, undated, showed the following: -The pest control company agrees to furnish regularly scheduled monthly services. Each service can normally be performed during normal working hours on a set date. Each service trip our technician will check with the responsible person and leave an invoice indicating the day they were there, materials used, and any activity noted; -Emergency Maintenance, can call back at no additional cost, will be available for covered pest and services if service is provided monthly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's (Resident #1) code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was signed by a person capable of making an informed decision for the resident, failed to ensure a code status form was signed by the resident for one resident (Resident #17), and failed to ensure one resident's (Resident #212) had a code status present in the medical record A sample of four residents was selected for review out of a facility census of 59. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the state licensing agency (Department of Health and Senior Services- DHSS) within the required time frame when one resident (Resident #48) alleged staff were assaulting him/her. A sample of two residents was selected in a facility with a census of 59. Review of the facility's policy titled Abuse, Neglect Exploitation and Misappropriation Prevention Program, revised 04/2021, showed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an investigation of an allegation of abuse when one resident (Resident #48) alleged staff assaulted him/her A sample of two residents was selected in a facility with a census of 59. Review of the facility's policy titled Abuse, Neglect Exploitation and Misappropriation Prevention Program, revised 04/2021, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 09/2022, showed the following: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to identify, develop, implement, and care plan new interventions in attempt to prevent falls for one resident (Resident #23) who had a decline in his/her function resulting in multiple falls. A sample of three residents were reviewed in a facility with a census of 59. Record review of the facility's Fall - Clinical Protocol Policy, revised March 2018, showed the following information: -Staff will evaluate and document falls that occur while the individual is in the facility including when and where they happen and any observations of the events;. -Falls should be categorized as: those that occur while trying to rise from a sitting or lying to an upright position; those that occur while upright and attempting to ambulate; and other circumstances such as sliding out of a chair or rolling from a low bed to floor; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #10) who had a history of chronic (recurring) urinary tract infections (UTI-an infection in any part of the urinary system) received timely treatment and care after the resident voiced symptoms of a urinary tract in a sample of three residents. The facility census was 59 residents. Record review of the facility's Lab and Diagnostic Test Results-Clinical Protocol, revised November 2018, showed the following information: -The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs; -The staff will process test requisitions and arrange for tests; -The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's received behavioral health services to maintain the highest practical psychosocial well-being when the facility failed to care plan and implement resident specific interventions for and failed to have social services follow-up with one resident (Resident #32) who had a history of depression and had expressed signs of possible depression. A sample of three residents were reviewed in a facility with a census of 59. 1. Review of Resident #32's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included major depressive disorder and anxiety disorder. Review of the resident's social services initial note, dated [DATE], showed the resident was widowed and lived alone prior to entering the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to adequately equipped with a full call light system when call light pull cords in two residents' (Resident #23 and Resident #10) rooms were too short where residents not always easily access the pull cord for staff assistance. The facility census was 59. Review of the facility's policy titled Resident Call System, dated September 2022, showed the following: -Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station; -Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor; -The resident call system is routinely maintained and tested by the maintenance department. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the prior survey results were posted in a readily accessible public location for residents, family members, and residents' legal representatives. The facility census was 60. 1. Observation on 1/21/20 at 2:00 P.M., showed several binders, including the binder containing the 4/7/18 annual survey results, placed on a shelf located above a small table, near the South nurses' station. The binder, containing the survey results, would not be easily accessible to residents, or anyone else, in a wheelchair or who had difficulty walking, without asking for assistance. During an interview on 1/21/20 at 2:10 P.M., Certified Nurse Aide (CNA) A said the survey results should be at the nurses' desk but he/she did not know the exact location of the survey results book. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessments were completed within the required timeframe for three residents (Resident #7, Resident #11, and Resident #15) out of a sample of 18 residents. The facility census was 60. Record review of the facility policy, titled Electronic Transmission of the MDS from the Nursing Services Policy and Procedure Manual for Long-Term Care, dated 2001 and revised September 2010, showed the following information: [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit encoded data Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, assessments from the facility to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days on one resident (Resident #3) out of a sample of 18 residents selected for review. The facility had a census of 60 residents. Record review of the facility policy, titled Electronic Transmission of the MDS from the Nursing Services Policy and Procedure Manual for Long-Term Care, dated 2001 and revised September 2010, showed the following information: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse certified the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, completion date (Z0500B) no later than 14 days after the assessment reference date (ARD - A2300) for three residents (Resident #3, Resident #5, and Resident #12). The facility census was 60. Record review of the Resident Assessment Instrument (RAI) manual, dated 10/1/17, showed the following: -Z0500B description: MDS Completion Date - date of the RN assessment coordinator's signature, indicating that the MDS is complete; -In accordance with the requirements at 42 CFR 483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation system in proper working condition when 23 residents' bathrooms did not have functioning exhaust vents. The facility had a census of 60. 1. Observation on 01/23/2020, beginning at 8:30 A.M., showed the exhaust ventilation system in the following rooms did not work when tested: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to document monitoring of antibiotic use for one resident (Resident #39) with a urinary tract infection. A sample of 18 residents were selected for review in a facility with a census of 60. Record review of the facility's policy titled Infections-Clinical Protocol, revised March 2018, showed the following: -The nursing staff and physician or provider will monitor the progress of a resident with an infection until it is resolved. 1. Record review of Resident #39's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 11/8/19, showed the following: -admitted to the facility on [DATE]; -Moderately impaired cognition; -Required supervision/assistance of one staff with toileting; -Had an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #19) with a CPAP (continuous positive airway pressure) ventilation machine had a physician order for the use and care of the machine. A sample of 18 residents were selected for review in a facility with a census of 60. Record review of the facility's policy titled, Continuous Pressure Airway Pressure (CPAP) Administration, undated, showed: -Purpose to administer CPAP to maintain open airway to the resident with obstructed sleep apnea or respiratory problems breathing when sleeping; -Check physician's order for pressure setting and method of administration; -CPAP machine should be placed on table near bed; -Fill humidifier with distilled water to appropriate level (optional may use tap water); -Assist resident as needed to applying and adjusting CPAP mask and head strap; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the record was accurate and complete when staff did not document one resident's (Resident #52) decline in condition for seven days before the resident's death. A sample of 18 residents was selected for review in a facility with a census of 60. Record review of the facility's policy, undated, titled Charting and Documentation showed the following: -The purpose of these guidelines is to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, as well as the resident's progress; -Guidance to the physician in prescribing appropriate medications and treatments; -The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident; -Nursing services personnel with a record of the physical and mental status of each resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop written policies and procedures for reporting abuse, mistreatment, neglect, and misappropriation of resident property in accordance with federal requirements when the facility's policy did not direct staff to report all allegations of abuse to the Department of Health and Senior Services (DHSS) within two hours. The facility's was 60. 1. Record review of the facility's Abuse Prevention Policy/Elder Justice Act, revised on 1/16/19, showed the following information: -It is the policy of the facility to establish a resident-sensitive and secure environment to assure proper and respectful treatment of all residents. The facility is obligated to ensure that residents have the right to be free from verbal, mental, physical and sexual abuse, involuntary seclusion and neglect. [...]