Inspection Reports for
Heart of the Ozarks Healthcare Center

The facility failed to ensure nurse aides completed their training, competencies, and testing within four months of hire. Two nurse aides did not complete the required certified nursing assistant training program and continued to provide direct care to residents.

The facility failed to have a system in place to ensure nurse aides completed their training, competencies, and testing in a timely manner. Two nurse aides worked providing direct care without completing a state-approved certified nursing assistant training program, competency evaluation, and certification test within four months of hire.

The facility failed to ensure combustible decorations met fire safety standards, including the use of real wax candles with intact wicks and lack of fire-rating documentation for decorations. Additionally, the facility did not complete required 24-hour documented visual fire monitoring following a fire in a resident room.

The facility was found deficient in multiple areas including failure to ensure clinically appropriate self-administration of medications, inconsistent documentation of residents' code status, inadequate monitoring and care planning for residents at risk of elopement, failure to timely identify and intervene in resident weight loss, medication administration errors exceeding acceptable rates, and failure to prevent serving food from dented cans.

The facility failed to ensure all residents were treated with dignity and respect by staff, as evidenced by an incident involving a Certified Medication Technician arguing with a resident in an undignified manner. The allegation was substantiated by staff interviews and observations.

The complaint was substantiated based on observations, staff interviews, and the facility's investigation. The incident involved CMT A making inappropriate comments and speaking disrespectfully to Resident #1, who had myasthenia gravis and required assistance with mobility.

The facility failed to ensure all residents were treated with dignity and respect by staff. Specifically, CMT A was observed arguing with Resident #1 in a loud, chastising voice and making inappropriate comments. The allegation was verified by staff interviews and observation.

The facility failed to complete required resident assessments within mandated timeframes, ensure physician orders for catheter care, maintain food safety and sanitation standards, and keep kitchen equipment in safe operating condition. Multiple deficiencies were cited related to resident assessments, catheter care, respiratory care, food procurement and sanitation, and facility maintenance.

The facility failed to complete timely annual and quarterly Minimum Data Set (MDS) assessments for multiple residents, lacked physician orders for catheter care for one resident, failed to administer ordered oxygen therapy to one resident, and had multiple food safety and sanitation deficiencies including a contaminated ice machine, wet stacked cups, unclean kitchen surfaces, missing stove knobs, and unsanitary kitchen floors and light fixtures.

The complaint investigation substantiated that a Certified Nurse Aide slapped a resident who was combative during care. The facility did not report the abuse allegation within the required two-hour timeframe to management and the state licensing agency.

The facility failed to protect a resident from abuse when a Certified Nurse Aide (CNA A) slapped the arm of a combative resident. The facility also failed to report the allegation of abuse immediately to management and the state licensing agency within the required two-hour timeframe.

The visit was complaint-related, triggered by multiple allegations including facility disrepair, abuse reporting failures, bed hold policy noncompliance, inadequate resident care, dialysis order omissions, infection control lapses, and pest infestations. Substantiation status is not explicitly stated.

The facility was found to have multiple deficiencies including failure to maintain the building in good repair with water-stained ceiling tiles and roof leaks, failure to timely report and investigate suspected resident abuse, failure to provide written bed hold policy to residents upon hospital transfer, failure to timely report and treat skin issues, failure to have physician orders for dialysis specifying location and schedule, failure to properly conduct and document tuberculosis testing, failure to properly isolate and treat scabies cases, and failure to maintain an effective pest control program with ongoing roach infestations.

The facility was cited for multiple deficiencies including failure to maintain a safe, clean, and homelike environment, failure to report alleged violations of abuse and neglect timely, failure to investigate and prevent resident-to-resident abuse, failure to provide bed-hold policy to residents, failure to ensure quality care including dialysis and infection control, and failure to maintain an effective pest control program.

The facility failed to maintain the integrity of the building construction by allowing unsealed penetrations between the attic and shared spaces, and failed to maintain electrical wiring in compliance with NFPA 70 by not protecting electrical panels and improperly using extension cords and power taps. These deficiencies had the potential to affect all residents, staff, and visitors.

The facility failed to provide appropriate documentation and monitoring for PRN psychotropic medication orders beyond 14 days for several residents. Additionally, the facility did not maintain a safe, functional, and comfortable environment due to a leaking ceiling causing a fall hazard.

The facility failed to maintain the kitchen exhaust hood with a grease collection drip tray and container, and failed to maintain the automatic fire sprinkler system, specifically the Fire Department Connection (FDC) which was immobile. These deficiencies had the potential to affect residents, staff, and visitors.

The investigation was complaint-related involving allegations of resident-to-resident sexual abuse and failure to investigate grievances. The allegations were substantiated as the facility failed to protect residents and properly investigate and report abuse.

The facility failed to properly investigate a resident grievance regarding missing rings and failed to document findings and follow-up. The facility was also unaware of sexual activity between two cognitively impaired residents and failed to protect them from abuse and neglect. The facility did not report allegations of abuse timely to the State Survey Agency and failed to notify family and involved parties appropriately.