Ozark Rehabilitation & Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 15, 2023

  Based on observation, interview, and record review, facility staff failed to provide protective oversight for one resident (Resident #1) with cognitive impairment and a history of wandering, when on 12/13/2023 the resident exited the facility without staff knowledge and was found lying in the street, less than one mile away from the facility, in the early morning hours by a passerby, who notified the police and the emergency medical services (EMS). The outside air temperature was 31 degrees Fahrenheit (F). The resident was found in only a shirt and undergarments with his/her body temperature at 90.2 degrees F. The facility census was 48. The Administrator was notified on 12/13/23 at 6:30 P.M., of an Immediate Jeopardy (IJ) which began on 12/13/23. […]

• Actual harm, isolatedF689Nov 6, 2024

  Based on interview and record review, facility staff failed to properly stretch one resident (Resident #1) leg for range of motion, in a safe manner which resulted in an injury to his/her leg that required surgical intervention. The facility census was 40. 1. Review of the Restorative Program - range of motion policy, revised 02/03/22, showed the policy is to provide the resident with limited range of motion appropriate treatment and services to increase or prevent further decrease in range of motion. Staff are instructed to provide resident with repetitions as per residents tolerance and care plan and never continue past the point of resistance or pain. 2. […]

• Actual harm, isolatedF600Jun 27, 2024

  Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Resident #2 touched Resident #1's chest inappropriately. The facility census was 40. 1. Review of the facility's Abuse Prevention Program, undated, showed the facility affirms the right of their residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents. […]

• No harm, potential for more than minimal, widespreadF727Feb 29, 2024

  Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated July 2023, showed the facility did not have an RN in the building the following dates: -Tuesday 07/01/23; -Thursday 07/13/23; -Thursday 07/20/23; -Monday 07/24/23; -Thursday 07/27/23; -Saturday 07/28/23. 3. […]

• No harm, potential for more than minimal, widespreadF728Feb 29, 2024

  Based on interview and record review, the facility staff failed to ensure three Nurse Aide's ((NA) NA L, NA M and NA N) completed the nurse aide training program within four months of his/her employment in the facility. The census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of Certified Nurse Aide (CNA) training report showed NA L's hire date as 11/24/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 2/29/24 at 11:56 A.M., the Director on Nursing (DON) said NA L has not started the nurse aide training program yet. 3. Review of the CNA training report showed NA M's hire date as 1/16/23. […]