Inspection Reports for
The Ozarks Methodist Manor
205 SOUTH COLLEGE, MARIONVILLE, MO, 65705-9340
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
105% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
79% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Apr 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's money, specifically $40 missing from Resident #1's wallet after returning from the hospital.
Complaint Details
The complaint investigation was triggered by an allegation from the resident's guardian that a Certified Nursing Assistant (CNA A) may have taken $40 from the resident. The resident thought a family member took the money. The allegation was reported to the Ombudsman and local police. Multiple staff, including CNAs and Licensed Practical Nurse (LPN D), were interviewed. The resident's family member and guardian provided statements. The facility conducted two follow-up investigations but was unable to determine what happened to the money.
Findings
The facility failed to ensure residents were free from misappropriation when $40 was taken from Resident #1's wallet without the resident's knowledge or consent. Despite multiple staff interviews and investigations, the facility was unable to determine what happened to the missing money. The investigation remains open with no individual identified as responsible.
Deficiencies (1)
Failure to protect resident from wrongful use of belongings or money, specifically $40 missing from Resident #1's wallet.
Report Facts
Amount of money missing: 40
Resident census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in allegation of possible theft of $40 from resident |
| LPN D | Licensed Practical Nurse | Charge nurse during incident, interviewed regarding missing money |
| CNA C | Certified Nursing Assistant | Assisted resident during incident, interviewed |
| CNA B | Certified Nursing Assistant | Witnessed resident interactions during incident, interviewed |
| Social Services Director | Social Services Director | Reviewed investigation statements and spoke with guardian |
| DON | Director of Nursing | Reviewed investigation, interviewed about ongoing investigation |
| Administrator | Administrator | Interviewed about ongoing investigation and resident funds |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Jan 9, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including dignity in meal service, cleanliness of bathroom vents, timely completion and transmission of resident assessments, comprehensive care planning, pressure ulcer care, nutritional monitoring and intervention, staffing requirements, nurse staffing postings, dietary manager qualifications, completeness of medical records, infection prevention program review, and antibiotic stewardship.
Deficiencies (13)
Failed to ensure residents were treated with dignity during meal service, resulting in a resident being left without a meal while others ate.
Failed to maintain clean bathroom exhaust vents for seven residents.
Failed to complete a significant change assessment within 14 days for a resident admitted to hospice.
Failed to transmit completed Minimum Data Set (MDS) assessments to CMS within required time frames for four residents.
Failed to develop comprehensive care plans with measurable goals and interventions for six residents, including failure to address diagnoses and treatments.
Failed to provide appropriate pressure ulcer care and update care plans for a resident with a pressure ulcer.
Failed to identify and intervene for significant weight loss and poor intake for two residents.
Failed to ensure registered nurse coverage for at least eight consecutive hours a day, seven days a week on multiple dates.
Failed to post daily nurse staffing information accurately, missing resident census, nurse license type, and actual hours worked.
Dietary Manager lacked required certification and had not completed Serv-Safe courses.
Failed to maintain complete and accurate medical records, specifically missing physician progress notes for a resident.
Failed to conduct an annual review and update of the Infection Prevention and Control Program (IPCP).
Failed to conduct ongoing antibiotic stewardship review for a resident receiving multiple antibiotics over several months.
Report Facts
Weight loss percentage: 9.6
Weight loss percentage: 19.38
RN coverage missing days: 8
Antibiotic courses: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Named in relation to lack of certification and failure to complete Serv-Safe courses. |
| Registered Dietitian | Registered Dietitian | Provided information about dietary services and certification status of Dietary Manager. |
| Director of Nursing | Director of Nursing | Named in relation to oversight of nursing coverage, antibiotic stewardship, and care plan expectations. |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in relation to care plan development and weight loss monitoring. |
| Social Services Director | Social Services Director | Named in relation to care plan and medical record documentation. |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding wound care and resident care. |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Interviewed regarding weight monitoring and resident care. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed regarding meal intake recording and resident care. |
| Restorative Nursing Aide 1 | Restorative Nursing Aide | Interviewed regarding weights and resident care. |
| Administrator | Administrator | Named in relation to staffing issues, medical record documentation, and infection control program oversight. |
| Infection Preventionist | Infection Preventionist | Named in relation to infection prevention and control program review. |
| Human Resources Director | Human Resources Director | Named in relation to staffing and nurse coverage. |
| Central Supply | Central Supply | Named in relation to staffing and nurse coverage. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: Jul 12, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report an allegation of abuse involving a staff member threatening and cursing at a resident.
Complaint Details
The complaint involved a staff member (Certified Nurse Aide B) threatening and cursing at a resident (Resident #1), which was overheard by another staff member (Housekeeper A). The facility failed to report this allegation within the required two-hour timeframe to management and the state licensing agency.
Findings
The facility failed to report an allegation of abuse immediately to facility management and the state licensing agency within the required two-hour timeframe. This deficiency was uncorrected from a previous citation.
Deficiencies (1)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Census: 61
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper | Staff member who overheard the abuse | |
| Certified Nurse Aide | Staff member who threatened and cursed at the resident |
Inspection Report
Census: 59
Deficiencies: 10
Date: May 18, 2023
Visit Reason
The inspection was conducted to investigate allegations of abuse, review compliance with care and safety regulations, and assess facility operations including dietary services, infection control, resident care, and environmental conditions.
Findings
The facility failed to timely report and investigate an allegation of abuse, ensure proper documentation and follow-up of residents' code status and behavioral health needs, maintain adequate fall prevention care plans, provide timely treatment for urinary tract infections, employ a qualified dietary manager, maintain food safety and sanitation standards, properly dispose of refuse, maintain accessible call light systems, and implement an effective pest control program.
Deficiencies (10)
Failed to timely report an allegation of abuse to the state licensing agency and failed to complete an investigation of the allegation.
Failed to ensure residents' code status forms were properly signed and documented.
Failed to identify and implement new fall prevention interventions after resident's functional decline and multiple falls.
Failed to provide timely treatment and care for a resident with symptoms of urinary tract infection.
Failed to provide necessary behavioral health care and services including care planning and social services follow-up for a resident with depression.
Failed to employ a qualified dietary manager with required certification or education.
Failed to store and prepare food in accordance with professional standards including improper cold food temperatures, storage of dented and expired food, inadequate cleaning and sanitation, improper hairnet use, and improper glove use.
Failed to properly dispose of empty cardboard boxes in kitchen areas to prevent pest harboring.
Failed to ensure call light pull cords in residents' bathrooms were accessible and of adequate length.
Failed to maintain an effective pest control program as evidenced by presence of live and dead cockroaches and beetles in kitchen areas.
Report Facts
Facility census: 59
Date of inspection: May 18, 2023
Number of dented cans observed: 9
Cold food temperatures: 51.6
Cold food temperatures: 43.3
Cold food temperatures: 42.6
Cold food temperatures: 41.5
Leukocyte esterase: 3
White blood cells: 2
Bacteria: 1
E. coli colony count: 100000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| D | Certified Nursing Assistant (CNA)/Certified Medication Technician (CMT) | Interviewed regarding abuse allegation and resident care |
| E | Certified Nursing Assistant (CNA) | Interviewed regarding abuse allegation and fall interventions |
| F | Certified Medication Technician (CMT) | Interviewed regarding abuse allegation and fall interventions |
| I | Licensed Practical Nurse (LPN) | Interviewed regarding abuse allegation, UTI care, depression signs, and care plan updates |
| Administrator | Administrator | Interviewed regarding abuse reporting, dietary management, cleaning, pest control, and call light accessibility |
| DON | Director of Nursing | Interviewed regarding abuse investigation, care plans, depression care, and pest control |
| MDS/Care Plan Coordinator | MDS/Care Plan Coordinator | Interviewed regarding care plan updates and resident declines |
| P | Licensed Practical Nurse (LPN) | Interviewed regarding UTI care and lab result monitoring |
| Q | Certified Medication Technician (CMT) | Interviewed regarding fall interventions and depression signs |
| DA N | Dietary Aide | Observed and interviewed regarding food temperature and glove use |
| DA M | Dietary Aide | Observed and interviewed regarding food temperature and glove use |
| DA J | Dietary Aide | Interviewed regarding food temperature, expired food, cleaning, and pest control |
| K | Dietary Aide | Interviewed regarding food temperature, expired food, cleaning, hairnet use, and pest control |
| L | Assistant Dietary Manager | Interviewed regarding food temperature, expired food, cleaning, hairnet use, and pest control |
| DM | Dietary Manager | Interviewed regarding qualifications, food safety, cleaning, hairnet use, glove use, expired food, dented cans, and pest control |
| ES/PD | Environmental Services/Plant Director | Interviewed regarding pest control and call light maintenance |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 9
Date: Jan 23, 2020
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with federal regulations and ensure resident safety and quality of care.
Findings
The facility was found deficient in multiple areas including failure to post prior survey results in an accessible location, incomplete and late Minimum Data Set (MDS) assessments and transmissions, inadequate policies and procedures for abuse reporting, failure to document antibiotic monitoring for a resident with a urinary tract infection, lack of physician orders and cleaning protocols for a resident's CPAP machine, incomplete documentation of a resident's decline before death, and non-functioning bathroom exhaust ventilation in multiple resident rooms.
Deficiencies (9)
Failed to ensure prior survey results were posted in a readily accessible public location for residents and visitors.
Failed to develop and implement policies and procedures for timely reporting of abuse to the Department of Health and Senior Services within two hours.
Failed to complete Minimum Data Set (MDS) assessments within required timeframes for three residents.
Failed to electronically transmit encoded MDS data within 14 days for one resident.
Failed to ensure a registered nurse certified the MDS completion date within 14 days after the assessment reference date for three residents.
Failed to document monitoring of antibiotic use every shift for one resident with a urinary tract infection.
Failed to have a physician order for use and cleaning of a CPAP machine for one resident; CPAP machine was unclean and dusty.
Failed to document a resident's decline in condition for seven days before death.
Failed to maintain functioning bathroom exhaust ventilation systems in 23 resident bathrooms.
Report Facts
Residents affected: 60
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Assisted MDS coordinator with completing late MDS assessments and training |
| RN C | Registered Nurse | Interviewed regarding antibiotic documentation and CPAP machine care |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding survey result posting, abuse reporting, MDS assessments, antibiotic monitoring, CPAP machine care, and documentation |
| Administrator | Facility Administrator | Interviewed regarding survey result posting, MDS assessments, antibiotic monitoring, CPAP machine care, and documentation |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding abuse reporting procedures |
| Certified Nurse Aide A | Certified Nurse Aide | Interviewed regarding location of survey results |
| Certified Nurse Aide F | Certified Nurse Aide | Interviewed regarding resident condition changes and care |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding bathroom exhaust ventilation system |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment completion and transmission |
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