Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heart Of The Ozarks Healthcare Center during CMS and state inspections, most recent first.
Two nurse aides were allowed to work beyond the required four-month period without completing state-approved CNA training and certification. Facility staff delayed enrolling new NAs in classes, citing instructor turnover and a practice of waiting to assess new hires, resulting in NAs providing direct care without proper credentials. Leadership acknowledged the lapse and confusion regarding regulatory timelines.
The facility failed to manage dented canned goods properly, leading to the serving of potentially contaminated food. Dented cans of peaches were found on a storage rack and served to residents, despite policies against using such cans. Staff interviews revealed inconsistencies in checking for dents and handling dented cans, with some staff unaware of proper procedures. The Dietary Manager noted that multitasking contributed to the oversight, and the DON emphasized the expectation not to serve food from dented cans.
A resident with severe cognitive impairment was left with a cup of medications to self-administer without a documented assessment or order for self-administration. The resident reported difficulty swallowing the medications, and staff interviews confirmed that the facility's policy was to observe residents taking their medications, which was not followed in this instance.
A resident's request to change their code status to DNR was not documented in their medical record, leading to a discrepancy in their care plan. Despite the resident's request during a care plan meeting, staff continued to see the resident as a full code. Interviews revealed a lack of communication and follow-through among staff, resulting in the failure to update the resident's code status.
A resident with Alzheimer's and a history of wandering was not properly monitored due to a failure to document checks of their personal electronic monitoring device. Despite being identified as an elopement risk, the care plan lacked specific instructions for the device, and staff did not document checks in the TAR due to an order entry error. This oversight compromised the resident's safety.
The facility failed to address significant weight loss in two residents by not identifying risks timely, updating care plans, or notifying physicians. One resident on a vegan diet experienced a 10.5% weight loss over three months without proper intervention. Another resident with diabetes and anorexia lost 20.8 pounds without timely action. The facility's weight monitoring system was inadequate, leading to deficiencies in care.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate due to incorrect dosages given to two residents. One resident received a higher dose of escitalopram than prescribed due to a failure in updating the medication order during a system transition. Another resident was given a lower dose of acetaminophen than ordered, as the CMT believed it was acceptable. Staff interviews revealed a lack of communication and adherence to procedures for medication orders.
A resident with myasthenia gravis was spoken to in an undignified manner by a CMT, who argued and made inappropriate comments about not assisting due to pregnancy. The incident was observed by an LPN and a CNA, who intervened and reported it to the DON. The facility's investigation confirmed the breach of dignity and respect policies.
Failure to Ensure Timely CNA Training and Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) completed state-approved certified nursing assistant (CNA) training, competency evaluation, and certification testing within four months of hire, as required by federal and state regulations. Two NAs, one of whom was employed for nearly six months and another who remained employed beyond four months, were allowed to work providing direct care to residents without completing the necessary training and certification within the mandated timeframe. Facility records confirmed that one NA never began CNA classes before leaving employment, while the other only started classes after being employed for over 120 days. Interviews with facility staff, including the CNA instructor, LPN, ADON, DON, and Administrator, revealed a lack of understanding and inconsistent practices regarding the required timeline for NA training and certification. Staff reported that NAs were not sent to classes immediately upon hire, with some waiting up to 45 days or more before being enrolled. The facility experienced turnover in CNA instructors, which contributed to delays in training. Staff also indicated that NAs continued to work on the floor during this period, and there was confusion about the maximum allowable time for NAs to work without certification. The facility's own policy stated that NAs must complete training and competency evaluation within four months of hire and should not be employed beyond this period without certification. Despite this, both NAs in question worked beyond the 120-day limit without meeting these requirements. The Administrator, DON, and ADON acknowledged responsibility for ensuring compliance but admitted that the NAs continued to provide care to residents without timely completion of the required training and certification.
Failure to Manage Dented Canned Goods
Penalty
Summary
The facility failed to ensure food safety by not properly managing dented canned goods, leading to potential contamination. During an observation, two dented cans of diced peaches were found on a storage rack with other canned goods. Despite the facility's policy requiring dented cans to be set aside and not used, staff served diced peaches from these dented cans to residents during a lunch meal. The Dietary staff admitted to not noticing the dents initially and assumed it was acceptable to serve the food if the dents occurred during transport. Interviews with dietary staff revealed inconsistencies in checking for dents and handling dented cans. One staff member did not check for dents before serving, while another was unaware of a designated area for dented cans. The Dietary Manager acknowledged the oversight and mentioned that the staff member responsible was multitasking, which contributed to the error. The Director of Nursing expressed an expectation that staff should not serve food from dented cans, highlighting a lapse in adherence to food safety protocols.
Failure to Ensure Appropriate Medication Administration
Penalty
Summary
The facility failed to ensure that residents only self-administered medications if it was clinically appropriate. This deficiency was observed when a Certified Medication Technician (CMT) left a cup of medications in a resident's room for self-administration without a documented assessment or physician's order for self-administration. The resident, who had severe cognitive impairment and a history of stroke, seizures, and aphasia, was left with multiple medications on their side table, which they were instructed to take on their own. The resident reported that staff always left medications on the table and that they sometimes experienced difficulty swallowing them. Interviews with various staff members, including CMTs, a Registered Nurse (RN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the facility's expectation was for staff to observe residents taking their medications and not to leave medications unattended. Despite this expectation, the CMT involved admitted to leaving the medications on the bedside table, contrary to the facility's policy and the care plan, which did not include self-administration of medications for the resident.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's choice of code status was clearly and consistently documented throughout their medical record. The resident, identified as Resident #73, had initially been documented as a full code, meaning all resuscitation procedures would be provided if necessary. However, during a quarterly care plan meeting, the resident expressed a desire to change their code status to Do Not Resuscitate (DNR). Despite this request, the change was not reflected in the resident's medical records, and staff continued to see the resident as a full code in both the computer system and physical chart. Interviews with various staff members, including a Certified Nurse Aide (CNA), Licensed Practical Nurse (LPN), Social Service Director (SSD), and the Minimum Data Set (MDS)/Care Plan Coordinator, revealed a lack of communication and follow-through regarding the resident's request. The MDS/Care Plan Coordinator informed the charge nurse of the resident's request, but did not ensure the code status was updated. The SSD assumed the MDS Coordinator had the resident sign the DNR form, but this was not verified. As a result, the resident's code status remained unchanged in the facility's records. The Director of Nursing (DON) acknowledged that the staff should have updated the resident's code status during the care plan meeting. The failure to update the code status was attributed to a breakdown in communication and procedure, as staff members were not aware of the resident's request or did not take the necessary steps to document the change. This oversight highlights a deficiency in the facility's process for managing and updating residents' code status preferences.
Failure to Monitor Elopement Risk Resident
Penalty
Summary
The staff at the facility failed to ensure an environment as free from hazards as possible by not care planning the use of and documenting the monitoring of a personal electronic monitoring device for a resident with a history of wandering and a prior elopement attempt. The resident, who was admitted with diagnoses including Alzheimer's disease, severe cognitive impairment, and daily wandering behavior, was identified as an elopement risk. Despite this, the care plan did not include specific instructions regarding the use of the personal electronic monitoring device, which was ordered by the physician to be checked for placement and functionality every shift. Observations and interviews revealed that the resident was wearing the personal electronic monitoring device, but staff did not document the required checks in the Treatment Administration Record (TAR) as per the physician's order. Certified Nursing Aide (CNA) A and Registered Nurse (RN) B were aware of the device and its intended checks, but the checks were not being documented because the order was not correctly entered into the TAR. The Director of Nursing (DON) confirmed that the order was entered incorrectly in the new system, leading to the omission of the checks in the TAR. The failure to document the monitoring of the personal electronic monitoring device was attributed to an error in entering the order into the facility's electronic system. This oversight resulted in staff not being alerted to perform the necessary checks, despite the resident's known risk of elopement and wandering behavior. The resident's safety was compromised due to the lack of proper documentation and monitoring, as the staff relied on the TAR to prompt them for these checks.
Failure to Address Resident Weight Loss
Penalty
Summary
The facility failed to ensure that weight loss among residents was unavoidable by not identifying weight loss risks in a timely manner, failing to update care plans with necessary interventions, and not notifying physicians about significant weight changes. Resident #64 experienced a significant weight loss over several months, which was not addressed adequately by the facility staff. The resident was on a vegan diet, and their family provided meals, but the facility did not implement the recommended interventions such as vegan supplement shakes or snacks. The resident's care plan was not updated to reflect dietary changes or weight loss interventions, and the facility failed to document weights consistently, leading to a lack of timely response to the resident's weight loss. Resident #26 also experienced significant weight loss, which was not promptly identified or addressed by the facility. The resident had a history of diabetes, anorexia, and muscle wasting, and upon readmission, showed a poor appetite and significant weight loss. Despite recommendations for weekly weights and protein shakes, the facility did not implement these interventions or notify the physician of the weight loss. The lack of communication and documentation resulted in the resident's weight loss going unaddressed for an extended period. The facility's weight monitoring system was inadequate, as evidenced by the failure to document and track residents' weights accurately. Staff interviews revealed a lack of awareness and communication regarding residents' weight changes, and the facility's weight meetings did not effectively identify or address significant weight losses. The facility's policies and procedures for weight assessment and intervention were not followed, leading to deficiencies in the care provided to residents experiencing weight loss.
Medication Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 7.69% due to two medication errors out of 26 opportunities. The first error involved Resident #44, who was prescribed escitalopram oxalate 5 mg daily for depression. However, the resident was administered a 10 mg dose from July 1 to August 21, 2024, due to a failure in updating the medication order during a transition to a new electronic medical record system. The Assistant Director of Nursing (ADON) confirmed that the order for the 5 mg dose was not faxed to the pharmacy, and the facility did not receive the correct dosage, leading to the continued administration of the incorrect dose. The second error involved Resident #54, who was prescribed acetaminophen 500 mg three times a day for rheumatoid arthritis. On August 21, 2024, Certified Medication Technician (CMT) G administered a 325 mg dose instead of the prescribed 500 mg. CMT G believed it was acceptable to give a lower dose, which was contrary to the physician's order. The Director of Nursing (DON) and other staff members, including CMT H and CMT I, emphasized the importance of adhering to the prescribed dosages and consulting with a nurse if there were any discrepancies. Interviews with staff, including CMTs and the ADON, highlighted a lack of communication and procedural adherence regarding medication orders. The ADON and DON expected staff to follow the correct procedures, such as faxing new orders to the pharmacy and ensuring the correct dosage was administered. However, these expectations were not met, leading to the medication errors observed during the survey.
Resident Dignity Compromised by Staff Interaction
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by an incident involving a Certified Medication Technician (CMT) who spoke to a resident in an undignified manner. The resident, who had been diagnosed with myasthenia gravis, a condition affecting muscle control, was unable to lift their feet while being transported in a wheelchair. The CMT, who was eight months pregnant, argued with the resident, raising their voice and making inappropriate comments about not assisting due to their pregnancy. The incident was observed by a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), who intervened and reported the behavior to the Director of Nursing (DON). The LPN and CNA noted that the CMT's approach was not respectful and that the resident appeared distressed. The facility's policy on dignity emphasizes treating residents with respect and sensitivity, particularly those with cognitive impairments, and prohibits demeaning practices. Interviews with staff and the resident's family confirmed the resident's inability to control their legs due to their medical condition. The facility's investigation verified the incident, as it was witnessed by multiple staff members and acknowledged by the CMT involved. The report highlights a breach in the facility's policy on resident dignity and respect, as the CMT's actions did not align with the expected standards of care.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ava
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Ridge Manor | 15.1 mi | ★★★★★ | 3 | 0 |
| Glenwood Healthcare | 15.9 mi | ★★★★★ | 0 | 0 |
| Hartville Care Center | 23.2 mi | ★★★★★ | 0 | 0 |
| Autumn Oaks Caring Center | 26.7 mi | ★★★★★ | 1 | 0 |
| Gainesville Nursing | 28.7 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.