Ozarks Methodist Manor, The

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.

• 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.

Observation on 01/06/25, at 4:38 P.M., the exhaust vent in the private bathroom of Resident #11 was covered in a layer of stringy cobweb-like fibers and fuzzy gray dirt, dust, and debris.

During concurrent observations and interviews on 01/09/25, beginning at 1:43 PM, the Environmental Services/Plant Director (ESD) and Environmental Services/Plant Assistant (ESA) both confirmed the bathroom vents for Resident #281, Resident #280, Resident #76, Resident #5, Resident #279, Resident #22, and Resident #11 were covered in a layer of cobwebs, dust, dirt, and debris and stated the vents needed to be vacuumed.

The ESD stated the vents were last cleaned about two months ago.

The ESA stated the vents were to be vacuumed on a quarterly basis, though the vents were inspected for proper functioning weekly.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

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.

• 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; -Diagnoses included hypertensive (high blood pressure) heart disease, diabetes, and myocardial infarction (heart attack).

Review of the resident's Census tab showed there resident began on hospice care on 11/20/24.

Review of the resident's Social Services Note, dated 11/20/24, and located in the Prog Notes tab of the EMR, showed the resident was admitted to hospice services.

Review of the resident's MDS tab showed a quarterly MDS assessment, with an ARD date of 11/12/24, was completed.

Staff did not complete any further MDS assessment was done after 11/12/24.

During an interview on 01/09/25, at 2:32 P.M., the MDS Coordinator (MDSC) reported she did not recall the resident changing to hospice care. A significant change MDS was to be completed when the resident started hospice care.

During an interview on 01/09/25, at 4:55 P.M., the Director of Nursing (DON) said she expected completion of a significant change MDS within 14 days of a resident changing to hospice care.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

transmit initial, annual, or significant change assessments.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

Review of resident's care plan showed the following: -Staff did not care plan regarding the resident's skin lesion or the need to apply moisture barrier to the area; -Staff did not care plan interventions related to the resident's catheter.

During an interview on 01/09/25, at 2:32 P.M., the ADON/MDSC said she was aware most residents' Care Plans were lacking information and was trying to work on updating the Care Plans in the building this week.

The MDSC acknowledged information about the resident's skin lesion was missing from his Care Plan and she would expect the issue to be included on the Care Plan with pertinent approaches to monitor the area and notify the physician of any changes.

• Review of Resident #10's admission Record, located under the Profile tab of the EMR, showed the

following: -admission date of 04/25/23; -Diagnoses that included heart failure and acute kidney failure.

Review of the resident's physician orders, dated 12/18/24, showed physician order for admission to hospice.

Review of the resident's significant change in status MDS, with an ARD of 12/23/24, and located under the MDS tab of the EMR, showed the following: -The resident was cognitively intact; -The resident was receiving hospice care.

Review of the resident's Care Plan, dated 10/06/24, and located under the Care Plan tab of the EMR, showed staff did not care plan related to receipt of hospice services.

During an interview on 01/09/25, at 2:32 P.M., the Assistant Director of Nursing (ADON) said there had been a lack of consistency in getting care plans in place and that there had been a lot of missing areas on care plans.

The ADON stated that she would expect hospice services to be included in the care plan with the facilities responsibilities and interventions.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

Review of R10's Care Plan, dated 10/06/24 and located under the Care Plan tab of the EMR, revealed there was no care plan for Hospice Care developed.

In an interview on 01/09/25 at 2:32 PM the Assistant Director of Nursing (ADON) stated that there had been a lack of consistency in getting care plans in place and that there had been a lot of missing areas on care plans.

The ADON stated that she would expect Hospice to be included in the care plan with the facilities responsibilities and interventions.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

During an interview on 01/09/25, at 11:59 A.M., Licensed Practical Nurse (LPN) 2 said the resident had orders to float her heels in bed.

The resident had completed weight-bearing transfers with the assistance of two staff, but then changed to a hoyer lift after developing the pressure ulcer to his/her heel.

During an interview on 01/09/25, at 2:05 P.M., LPN 1 said she rounded with the wound care provider for certain residents, which included the resident.

The resident used the Broda chair because of comfort and safety, not due to the pressure ulcer.

The resident would not bend her right leg.

During an interview on 01/09/25, at 2:32 P.M., the Assistant Director of Nursing/MDS Coordinator (ADON/MDSC) said there had been a lack of consistency with getting Care Plans in place.

The MDSC was trying to get them caught up. As soon as the pressure ulcer was identified, it should have been added to the Care Plan.

During an interview on 01/09/25, at 4:55 P.M., the Director of Nursing (DON) said when a resident developed a pressure ulcer, she expected intervention to be put in place and documented in the EMR.

The DON reported that when the resident's foot pedal was an issue, a pressure relieving boot was placed that the wound care provider had suggested.

Per the DON, after a couple of weeks, the boot was making it worse, so the resident started using the Broda chair.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

During an interview on 01/09/25, at 11:05 A.M., the RD said she was in the facility twice a month.

The RD did a nutritional assessment on admission and then after a period of time, which the RD tried to keep to within a year.

She reviewed weights by running a report from the EMR and checked in with the nurses regarding any concerns.

The RD expected to be notified of weight loss when she was in the facility and stated she was available by phone, which was probably better than waiting two weeks for her next time in the facility.

She had not been aware of the resident's weight loss, which started in August 2024 until December 2024.

The RD only had weights of 133 lbs in August 2024 and then 129 lbs in November 2024.

The RD was unaware of any dietary interventions prior to December

During an interview on 01/09/25, at 11:59 A.M., LPN 2 said he/she seldom had anything relayed to him/her regarding weights. RNA 1 weighed residents, and the DON entered the weights into the EMR.

When the provider saw the weights, the provider may give orders.

Occasionally, the RD asked questions or made recommendations.

During an interview on 01/09/25, at 2:32 PM, the ADON/MDS Coordinator (MDSC) reported a lack of consistency with getting care plans in place.

There have been a lot of missing items on care plans.

Staff discuss weight loss at care conferences, and dietary can update them as well then.

The MDSC stated a care plan was to reflect significant weight loss shortly after it occurred.

During an interview on 01/09/25, at 4:55 P.M., the DON said she entered weights into the EMR.

The DON ran a report to see the residents with weight loss and gain.

Those residents were added to the risk meeting.

The DON checked current orders and asked for supplement orders or medication review.

The DON expected the dietician to be aware of weight loss. A weight report was provided during the RD's visits and EMR access was available.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

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.

During an interview on 01/09/25, at 11:30 A.M., Central Supply (CS) and the HR Director confirmed that the facility had more licensed practical nurses than registered nurses and that there were days that the facility had not been able to schedule a registered nurse to work at the facility for at least eight hours a day.

During an interview on 01/09/25, at 5:22 P.M., the Director of Nursing confirmed that there had been RN coverage issues, and that the facility was struggling to get full eight-hour RN coverage daily.

During an interview on 01/09/25, at 11:47 A.M., the Administrator confirmed that there were days that the facility had not been able to have a registered nurse work for at least eight consecutive hours a day, seven days a week.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

During an interview on 01/09/25, at 11:30 AM, Central Supply (CS) and the Human Resources (HR)Director confirmed that they were not aware that the daily nurse postings required the resident census and/or the need to identify the licensing of the nurse.

They said the Director of Nursing (DON) was the one responsible for posting them daily.

During an interview on 01/09/25, at 5:22 P.M., the DON said she was not aware that the daily nurse posting forms did not have all the documentation required.

During an interview on 01/09/25, at 11:47 A.M., the Administrator said he was not familiar with the requirements of the daily nurse postings.

Review of the facility's Director of Food and Beverage Services, updated 07/14, showed the position required certification as required by state regulations.

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.

She is in the facility two days a month for approximately 16 hours and spends most of her time precepting the DM in her courses, but she has had a hard time finishing them.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

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; -Diagnoses included atherosclerotic heart disease (thickening or hardening of the arteries), chronic obstructive pulmonary disease (COPD - a condition caused by damage to the airways or other parts of the lung), low-tension glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), and osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes).

Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 12/25/24, showed the resident had a was severely cognitive impaired.

Review of the resident's Progress Notes tab of the EMR showed no documentation of the physician progress notes.

Review of the resident's Miscellaneous tab of the EMR showed no documentation of the physician progress notes.

Review of the resident's EMR showed there was no documentation of the physician progress notes accessible during the survey review dates without the physician submitting photos of his laptop, as noted in the Administrator interview below.

During an interview on 01/08/25, at 11:25 A.M., Social Service Director (SSD) said the physician progress notes should be documented under the Miscellaneous tab in the EMR for the facility residents.

She could not recall how long physician progress notes had not been consistently placed into resident records.

She confirmed the physician progress notes could not be found in the EMR for the resident.

During an interview on 01/09/25, at 5:22 P.M., the Director of Nursing confirmed that the facility had been having a hard time getting the physician progress notes from the physician's dictating company.

She confirmed the resident records were not complete without the physician progress notes.

During an interview on 01/09/25, at 9:28 A.M., the Administrator confirmed that the facility had been having a problem with getting the dictated physician progress notes and having them placed into the resident records.

The Administrator was not aware of how long this had been a concern.

The Administrator provided physician progress notes for the resident, which were photo images of the physician's laptop screen, and not documentation that had been available in the EMR.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

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.

• 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.

The content of one page did not match the content of the following page. -The binder included a policy titled COVID-19 Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes Centers for Disease Control and Prevention (CDC) guidelines dated [DATE]. -Another policy titled Coronavirus Disease (COVID-19) Prevention and Control was dated March 2020. -The binder included a copy of a document titled F-Tag Help F-F880 that was not dated and did not specify how often the IPCP was to be reviewed.

During an interview on 01/09/25, at 4:36 P.M., the Infection Preventionist stated the IPCP policies had not been reviewed since June when the Infection Preventionist was hired.

During an interview on 01/09/25, at 6:10 P.M., the Administrator was unsure when the IPCP was last reviewed and did not have written documentation.

The Administrator said the policies were reviewed during a QAPI (quality assurance) meeting, but was not sure.

The Administrator was unable to provide documentation as to when the IPCP was last reviewed.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

Review of the resident's Laboratory Report, located in the Misc tab of the EMR, showed a culture and sensitivity lab result, dated 12/13/24, that showed the organism causing the infection was resistant to ciprofloxacin and susceptible to amoxicillin & pot clavulanate.

Review of the facility's Infection Control Line Listing, located in the Infection Control binder. showed the resident was not listed on the log for antibiotic stewardship review dated August 2024, September 2024, November 2024, and December 2024.

The Infection Control Line Listing log sheets were incomplete with missing information for resident room numbers, dates of labs/pathogen, date/Symptoms, and predisposing factors.

During an interview on 01/09/25, at 4:36 P.M., the Director of Nursing (DON), who also served as the IP, said antibiotic stewardship was done by her and logged in the Infection Control binder.

When asked about what protocols were followed, the DON said the residents were watched for signs and symptoms, labs ordered, and discussed with the provider.

The DON said staff follow what the doctor gives us.

The DON said the McGeer criteria (tool designed to support facility healthcare-associated infection surveillance) was followed for signs and symptoms.

For documentation, a progress note was written on each resident.

The DON said there was no policy that she was aware of for following the McGeer criteria or protocols to follow for reviewing antibiotic stewardship.

Every resident that was prescribed an antibiotic should be on the log.

The resident should have been on the log.

During an interview on 01/09/25, at 6:10 P.M., the Administrator said the DON was responsible for the antibiotic stewardship program.

The Administrator said that guidelines were to be followed for appropriate ordering of antibiotics.

265594 01/09/2025

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705

During an interview on 01/09/25, at 4:36 P.M., the Infection Preventionist stated the IPCP policies had not been reviewed since June when the Infection Preventionist was hired.

During an interview on 01/09/25, at 6:10 P.M., the Administrator was unsure when the IPCP was last reviewed and did not have written documentation.

The Administrator said the policies were reviewed during a QAPI (quality assurance) meeting, but was not sure.

The Administrator was unable to provide documentation as to when the IPCP was last reviewed.

265594

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 265594 B.

Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ozarks Methodist Manor, The 205 South College, Marionville, MO 65705