Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arrowhead Senior Living Community during CMS and state inspections, most recent first.
Infection control practices were not followed during perineal care for one resident and during wound care for three residents. A CNA and CMT used the same soiled gloves after removing a urine-saturated brief and then touched clean items, and an IP used soiled gloves while cleansing wounds for multiple residents. The facility also had an incomplete water management program that lacked a written water system description, a facility-specific risk assessment, control measures, corrective actions, and complete documentation of annual testing.
Failure to identify, assess, and relieve pressure on residents with wounds: Two residents with diabetes, limited mobility, and heel wounds were observed with their heels and toes pressed against the mattress, pillow, or footboard, and one resident developed a new dark purple indented area on the great toe while wound care was being performed. The IP/Wound Nurse and LPN documented wounds as diabetic or pressure-related at different times, while a resident’s heel wound worsened and another resident’s heel remained unprotected in a recliner with the heel pressed into the footrest. The report also noted wound care hand hygiene/glove changes were not followed consistently during treatment.
Staff failed to obtain and document physician orders for oxygen therapy for three residents who were observed receiving oxygen, despite facility policy requiring such orders. Interviews revealed staff were unaware of the need for individualized orders and relied on a general standing order, resulting in a lack of proper documentation and oversight.
The facility failed to reconcile narcotics at shift changes, as narcotic count sheets often lacked signatures from two licensed staff, violating policy. Interviews confirmed the expectation for dual staff counts, but records showed repeated documentation failures, raising concerns about medication security.
Infection Control and Water Management Deficiencies
Penalty
Summary
Facility staff failed to follow infection control practices during perineal care for one resident and during wound care for three residents. During observation of perineal care for a resident who was transferred to the toilet with a sit-to-stand lift, a CNA and a CMT washed hands and applied gloves, removed a urine-saturated brief, discarded it, and then used the same soiled gloves to place a clean brief on the resident. The CNA also touched the resident’s clean pants, shirt, and the lift with the same gloves. In interview, the CNA stated gloves should have been changed and hands washed after touching the soiled brief and before touching clean items, and an LPN stated staff are expected to wash hands and change gloves from dirty to clean tasks. During wound care, the Infection Preventionist provided care to one resident’s right foot and, after putting on gloves and removing the soiled dressing, cleansed the wound with the same gloves. During wound care for another resident’s left leg, the Infection Preventionist removed drainage-stained tubi-grips and rolled gauze and then used the same soiled gloves to cleanse multiple wounds on the leg. For a third resident with wounds to both heels and a great toe, the Infection Preventionist removed soiled dressings, washed hands, and changed gloves between some tasks, but also cleansed wounds after removing dressings while using the same gloves. The Infection Preventionist stated he or she had been taught to remove the soiled dressing, cleanse the wound, and then change gloves and wash hands, and the DON stated staff should change gloves and wash hands after removing a soiled dressing during wound care. The facility also failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the water systems to inhibit growth of waterborne pathogens and reduce the risk of Legionella. The Water Management Program lacked a written description of the building water system, a facility-specific risk assessment, control measures for identified risk areas, corrective actions when control measures were out of range, and complete documentation of annual water system testing. The Plant Operations Director stated he or she tested water heaters and spas annually, did not test ice machines or resident rooms, did not know whether testing locations should be documented, and did not document weekly checks of UV devices or water flushes. The administrator stated the plan included water heaters, ice machines, stagnant water areas, and low-use resident room fixtures, but also stated the plan should include corrective actions and did not know how many test locations were used.
Failure to identify, assess, and relieve pressure on residents with wounds
Penalty
Summary
Facility staff failed to ensure two residents with wounds received necessary treatment and services in accordance with professional standards when pressure wounds were not identified, assessed appropriately, and were not consistently protected from pressure. One resident had multiple pressure injuries and diagnoses including diabetes, dementia, and kidney insufficiency, with assessments showing reduced mobility and dependence on staff for dressing and bed mobility. The resident’s records included orders for wound care to both heels and skin prep to the right great toe, along with a care plan for pressure relief boots, heel floating, and a low air loss mattress. Despite these interventions being documented, observations showed the resident’s heels and toe repeatedly pressed against the mattress or footboard, and the resident’s feet were not consistently floated or protected from pressure. During observations, the resident was seen in bed with both heels resting directly on a pillow, later with both heels dug into the air mattress, and later with the right great toe and left foot pressed directly into the wooden footboard. A CNA repositioned the resident but did not float the feet on a pillow, leaving the feet pressed against the footboard and the heels dug into the mattress. When the IP/Wound Nurse and an LPN provided wound care, the resident’s right great toe remained pressed against the footboard while treatment was being performed. The IP/Wound Nurse identified a new dark purple indented area on the right great toe and described it as a new Stage 1 pressure injury. The same resident’s left heel wound was documented as worsening, with granulation tissue, eschar, slough, and a red peri-wound area, while the right heel wound was documented as a diabetic ulcer even though staff observed pressure-related positioning and the physician stated the heel wounds were from pressure over bony prominences. A second resident had a right heel wound documented as a diabetic ulcer or stasis ulcer and was assessed as at risk for pressure sores, with maximal assistance needed for bed mobility and application of dressings to the feet. The care plan included bilateral heel boots as tolerated. However, observation showed the resident in a recliner with the right heel pressed into the footrest, and the resident did not have a heel protector on that heel. When the resident attempted to lift the leg, the resident could not do so, and an LPN placed a pillow under the leg and removed the dressing, revealing a dime-sized wound with pink/red granulation tissue. The LPN stated the wound appeared to be from pressure and that the top layers of skin were not present. The DON also stated staff should change gloves and wash hands after removing soiled dressings during wound care, and the report documented that the IP/Wound Nurse removed soiled dressings and cleansed wounds using the same gloves before changing gloves and washing hands.
Failure to Obtain Physician Orders for Oxygen Administration
Penalty
Summary
Facility staff failed to obtain physician orders for oxygen use for three residents who were observed receiving oxygen therapy. Review of the facility's Oxygen Safety and Management policy indicated that oxygen should only be provided based on physician orders specifying the rate, route, and frequency of administration. However, for all three residents sampled, there was no documentation of physician orders for oxygen in their care plans or physician order sheets, despite observations confirming that each resident was receiving oxygen via nasal cannula at varying flow rates. The facility had a standing order for oxygen, but it was not individualized or documented in the residents' records as required. Interviews with staff, including the DON, CMT, RN, and administrator, revealed a lack of awareness and clarity regarding the process for obtaining and documenting oxygen orders. Staff relied on verbal handoffs and a general standing order, rather than ensuring each resident had a specific physician order for oxygen therapy. The nurse practitioner clarified that while emergency oxygen could be administered, ongoing use required communication with the physician for proper orders, which had not occurred for the residents in question.
Failure to Reconcile Narcotics at Shift Changes
Penalty
Summary
The facility failed to properly reconcile narcotics at the change of shift, as evidenced by numerous instances where narcotic count sheets lacked the required two licensed staff signatures. This deficiency was observed across multiple halls and dates, indicating a systemic issue with the facility's adherence to its own policy on controlled medication storage. The policy mandates that two licensed staff members conduct and document a physical inventory of all controlled medications at each change of shift, but this was not consistently followed. Interviews with various staff members, including LPNs, RNs, the MDS Coordinator, the DON, and the Administrator, confirmed that the expectation was for two licensed staff to count narcotics at each shift change. Despite this, the documentation did not reflect compliance with this procedure. Staff members acknowledged the importance of this practice to ensure accurate narcotic counts and prevent discrepancies, yet the records showed repeated failures to document the counts properly. The facility's Director of Nursing and other staff members admitted that they could not verify that narcotic counts had been completed on the dates where the narcotic logs were not signed by two licensed staff members. This lack of documentation raises concerns about the facility's ability to ensure the security and proper handling of controlled medications, as required by their policy and regulatory standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Osage Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Regional Health Systems | 1.3 mi | ★★★★★ | 0 | 0 |
| Ozark Rehabilitation & Health Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Osage Beach Rehabilitation And Health Care Center | 2.2 mi | ★★★★★ | 1 | 0 |
| Stonebridge Lake Ozark | 4.2 mi | ★★★★★ | 3 | 0 |
| Laurie Care Center | 9.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.