Ozark Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at Ozark Care & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from physical abuse when one staff member (Licensed Practical Nurse (LPN) D) yelled at, and physically forced, the resident into his/her chair. The resident resisted causing a skin tear and bruises on his/her forearm. The facility census was 79.The Administrator was notified on 07/15/26, at 5:12 P.M., of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 07/06/26. On 07/06/26, the Administrator suspended the accused Licensed Practical Nurse (LPN D). The Director of Nursing (DON) completed pain and skin evaluations on Resident #1 and evaluated the resident for signs/symptoms of adverse psychosocial effects. […]

• Immediate jeopardy, isolatedF600Jul 30, 2024

  Based on record review and interview, the facility failed to protect each resident's right to be free from neglect when staff failed to check on one resident (Resident #1), who resided in the locked special care unit (SCU), for over 11 hours. Staff found the resident under his/her bed, unresponsive, with dried blood and emesis present. The resident was sent to the hospital and later passed away. The facility did not have a system in place to ensure on-site nursing staff monitored care provided by the aides and to ensure nurse aides performed walking rounds per facility policy. The facility census was 71. The Administrator and the Director of Nursing (DON) were notified on 07/26/24, at 6:15 P.M., of an Immediate Jeopardy (IJ) which began on 07/23/24. […]

• Immediate jeopardy, isolatedF760Mar 6, 2024

  Based on interview and record review, the facility failed to ensure all residents were free from significant medication errors when staff continued to administer a medication for 12 days, instead of 5 days as ordered, which resulted in a gastrointestinal bleed and contributed to the death of one resident (Resident #1). A sample of eight residents were reviewed. The facility census was 65. The Administrator and Director of Nursing (DON) were notified on 03/06/24 at 12:10 P.M., of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 02/07/24. On 02/07/24, the DON and Assistant DON (ADON) reviewed the resident's chart and began an investigation, educated the employee involved and nursing staff, and in-serviced all facility staff on 02/20/24. […]

• Actual harm, isolatedF689Mar 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure the residents remained free of accident hazards and received adequate assistance with assistive devices to prevent further accidents when the facility failed to ensure staff were trained on and operated mechanical lifts (Hoyer - a mobile, mechanical device designed to safety lift and transfer patients with limited mobility between beds, wheelchairs, toilets, or baths ) in a safe manner by standards of practice resulting one resident (Resident # 2) falling from the lift and suffering lacerations and continued numbness in chine. […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2024

  Based on observations, interviews, and record review, the facility failed to ensure all food stored in the main kitchen was free from possible contamination when staff failed ensure food was appropriately labeled and dated, and not expired or past used by date. The failure had the potential to increase the prevalence and spread of food borne illnesses and infection for all 68 facility residents. Review of the facility's policy titled, Cold Food Storage Chart, undated, indicated that opened foods must be dated with the open date and leftovers must be labeled with the date it was made and what it is. 1. […]