Ozarks Methodist Manor, The

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 265594 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52126 potential for actual harm Based on record review and interviews, the facility failed to conduct ongoing review for antibiotic stewardship Residents Affected - Few for one resident (Resident #15), of three residents reviewed for antibiotic stewardship, who received multiple antibiotics over multiple months.

Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.

Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed the following:

-All clinical infections treated with antibiotics will undergo review by the infection preventionist (IP), or designee;

-The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics;

-All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include resident name and medical record number; unit and room number; date symptoms appeared; name of antibiotic (see approved surveillance list); start date of antibiotics; pathogen identified (see approved surveillance list); site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events.

Review of the facility's policy titled, Antibiotic Stewardship - Staff and Clinician Training and Roles, revised December 2016, showed the Director of Nursing (DON) and will receive initial orientation and ongoing training on how to use surveillance tools to monitor infections rates, antibiotic usage patterns and outcomes.

1. Review of Resident #15's Admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following:

-admitted [DATE REDACTED];

-Diagnoses included acute vaginitis (a condition that causes vaginal irritation, discharge, odor, swelling, itching, or pain) and urinary tract infection (UTI).

Review of the resident's Order Summary Report, Medication Administration Records (MAR), and Treatment Administration Record (TAR), located in the Orders tab of the EMR, showed the following antibiotics were ordered and administered in August 2024, September 2024, November 2024, and December 2024:

-On 08/16/24, cefuroxime oral tablet was ordered for UTI and administered for seven days as ordered;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 265594 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 -On 09/05/24, ceftriaxone sodium injection was ordered for infection and administered one time as ordered;

Level of Harm - Minimal harm or -On 09/06/24, cefuroxime oral tablet was ordered for sinus infection and administered for 10 days as ordered; potential for actual harm -On 11/24/24, Macrobid oral capsule was ordered for vaginitis and administered one time as ordered; Residents Affected - Few -On 11/24/24, Macrobid oral capsule was ordered for vaginitis and administered for five days as ordered;

-On 12/03/24, Diflucan oral tablet was ordered for vaginal yeast/itching and administered one time as ordered;

-On 12/11/24, ciprofloxacin oral tablet was ordered for UTI and administered for two days then changed to Augmentin on 12/13/24;

-On 12/13/24, Augmentin oral suspension was ordered for UTI and administered for five days as ordered;

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 265594