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 Osage Beach Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident who was totally dependent for transfers and required a mechanical lift with two-person assistance was transferred by a CNA alone, contrary to facility policy and manufacturer guidelines. During the transfer, the lift struck a wall-mounted TV, causing it to fall and injure the resident's head and arm. The resident, who is paraplegic and obese, reported the incident and expressed concern about single-staff transfers.
Staff did not notify a physician after a resident, who was cognitively intact and had Guillain-Barre syndrome with paraplegia, was struck on the arm and head by a falling television. Although the incident was reported internally, there was no documentation of physician notification as required by facility policy. Interviews confirmed that the RN did not realize the extent of the incident and failed to contact the physician, contrary to expectations set by the DON and administrator.
Facility staff failed to use barriers for glucometer supplies and did not wear gloves during insulin administration for several residents with diabetes, risking contamination. Interviews revealed a lack of awareness of infection control protocols. Additionally, the facility's water management program was incomplete, lacking specific control measures and corrective actions, with staff unfamiliar with the program's requirements.
Facility staff failed to document code status orders for a resident and had conflicting orders for another, leading to confusion about their medical intervention preferences. Additionally, three residents had medications prescribed without documented clinical conditions or symptoms, highlighting lapses in the facility's documentation process. The DON and Infection Preventionist acknowledged these issues, noting challenges with a new external company handling admission orders.
A facility failed to obtain informed consents and complete side rail assessments for five residents, leading to a deficiency in compliance with their policy on the proper use of side rails. Residents with varying cognitive and physical impairments were observed with bed rails in use without the necessary documentation. Interviews with staff revealed confusion and lack of clarity regarding responsibility for completing assessments and obtaining consents.
Facility staff failed to protect resident information by leaving computer screens open and unattended, exposing medication details for multiple residents. Despite awareness of HIPAA regulations, RNs repeatedly left screens visible in public areas, violating privacy policies.
Facility staff failed to accurately document MDS assessments for three residents, leading to deficiencies. A resident's PASRR Level II determination was not reflected in the MDS, and another resident's vision was inaccurately assessed. The MDS Coordinator, responsible for completing assessments, admitted to oversights and lack of awareness. The facility lacked a specific MDS policy, relying on CMS guidelines and the RAI manual.
The facility failed to prominently post the DHSS elder abuse and neglect hotline number, as required by policy. Observations showed the number was placed at the end of an unoccupied hall, not visible to residents or staff. Interviews revealed that neither the SSD nor the DON were aware of its improper placement, and residents were unaware of its location.
Facility staff failed to provide adequate hygiene care for three residents, who required substantial assistance with personal hygiene and bathing. Despite scheduled showers twice a week, observations noted greasy hair and unkempt appearances, with residents expressing dissatisfaction. Staff interviews revealed inconsistencies in documenting and communicating refusals, contributing to the deficiency.
A medication error occurred when an LPN, unfamiliar with residents, administered a roommate's medication to a resident, leading to hospitalization. The resident, with moderate cognitive impairment and various diagnoses, received medications not prescribed for them, resulting in low blood sugar and blood pressure. The error was discovered when the LPN noticed the resident did not have a catheter, prompting immediate medical intervention.
The facility did not conduct and document an annual facility-wide assessment to determine necessary resources for resident care during daily operations and emergencies. The assessment lacked required staffing information. The administrator acknowledged the incomplete assessment and stated staffing was based on census data. The facility had 73 residents.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
Facility staff failed to provide a proper mechanical lift transfer for a resident, resulting in an accident where a television was struck by the lift and fell, causing injury to the resident's head and arm. The facility's policy and the lift manufacturer's manual both require two staff members to assist with mechanical lift transfers, especially for residents with conditions such as obesity, contractures, or combativeness. The resident in question was assessed as cognitively intact, totally dependent for transfers, paraplegic, obese, and required a mechanical lift with two-person assistance for all transfers. Despite these requirements, a Certified Nursing Assistant (CNA) performed the transfer alone. During the transfer, the CNA raised the mechanical lift, which hit the television mounted on the wall, causing it to fall and strike the resident. The CNA acknowledged operating the lift alone and reported the incident to a Registered Nurse (RN), initially stating the television did not hit the resident, but later confirming it struck the resident's arm and head. The resident reported feeling a knot on the head and expressed concern that staff often use only one person for mechanical lift transfers, despite being paralyzed. Interviews and documentation confirmed that the facility's policy was not followed, leading to the accident and injury.
Failure to Notify Physician After Resident Injury
Penalty
Summary
Facility staff failed to notify a physician in a timely manner after a television fell from the wall and struck a resident in the arm and head. The resident was assessed as cognitively intact and had a history of Guillain-Barre syndrome and paraplegia. According to the facility's policies, staff are required to notify the physician and document the content of the discussion following any change in patient status or accident. However, nurse notes indicated that although the incident was reported by a CNA, there was no documentation that the physician was notified of the change in condition. Interviews with staff revealed that the RN on duty did not realize the resident had been struck by the television and therefore did not contact the physician. Both the DON and the administrator stated that their expectation is for staff to notify the physician of any accidents, particularly those involving the head, and to document the notification. Despite these expectations and policies, the required physician notification did not occur in this incident.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility staff failed to adhere to infection prevention protocols by not using barriers for glucometer supplies and not wearing gloves during insulin administration. This was observed in seven residents who were sampled, all of whom had a diagnosis of diabetes. Registered Nurses were seen placing glucometers directly on dining room tables without barriers, which could lead to contamination. Additionally, some nurses did not wear gloves while administering insulin, increasing the risk of exposure to blood and bodily fluids. Interviews with the staff revealed a lack of awareness and understanding of the infection control protocols. One RN acknowledged the risk of contamination but could not explain why gloves were not worn. Another RN did not see an issue with placing the glucometer on the table, despite acknowledging the potential for contamination. The Director of Nursing and the facility administrator also recognized the risks but were unsure about the necessity of wearing gloves during insulin administration. The facility also failed to develop and implement comprehensive policies for the inspection, testing, and maintenance of its water systems to prevent the growth of waterborne pathogens like Legionella. The facility's water management program lacked specific control measures, acceptable ranges, and corrective actions. The maintenance director was unfamiliar with the program's control measures and did not document water quality test results or take corrective actions. The administrator admitted to a lack of knowledge about the water management program and could not locate specific control measures or corrective actions in the plan.
Documentation Failures in Code Status and Medication Indications
Penalty
Summary
The facility staff failed to meet professional standards of care by not documenting code status orders for residents, which is crucial for determining the level of medical intervention a resident wishes to receive. Specifically, Resident #9 did not have a documented order for code status, despite being moderately cognitively impaired and expressing a preference for full code status. The Director of Nursing (DON) and Clinical Coordinator acknowledged the oversight, noting that the admitting nurse is responsible for verifying and entering the code status order, while the Health Information staff audits these orders. However, the Health Information staff admitted to not checking code status orders for residents who have been at the facility for a while, leading to the oversight. Resident #37 had conflicting orders for code status, with both DNR and full code status documented on different dates. The DON confirmed that a resident should not have two different orders for code status and attributed the error to the admitting nurse's responsibility to verify and enter the correct order. The Health Information staff is supposed to audit these orders, but the discrepancy was not caught, leading to confusion about the resident's code status. Additionally, the facility failed to document clinical conditions or symptoms for the use of medications for Residents #75, #79, and #80. Resident #75 was on an antibiotic without a documented indication for use, Resident #79 was prescribed an antipsychotic medication without a documented clinical condition, and Resident #80 was on a blood pressure medication without documentation of the condition it was treating. The Infection Preventionist/Clinical Coordinator and the DON acknowledged the lapses, noting that the facility had recently started using an external company for entering admission orders, which had not been going smoothly. The pharmacist also had not reviewed the medications for new admissions in a timely manner, contributing to the lack of documentation for medication indications.
Failure to Obtain Consents and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consents and complete side rail assessments for five residents, leading to a deficiency in compliance with their own policy on the proper use of side rails. The policy requires an assessment to determine the resident's symptoms, risk of entrapment, and reason for using side rails, as well as obtaining consent from the resident or their legal representative. However, the facility did not have signed consents or completed assessments for the use of bed rails for the residents in question. Resident #18, who has severe cognitive impairment and requires substantial assistance for mobility, was observed multiple times with bed rails in the upright position without a signed consent or assessment in their electronic medical record. Similarly, Resident #43, who is cognitively intact, was also observed with a bed rail in the upright position without the necessary documentation. Residents #64, #76, and #77, all with varying degrees of cognitive and physical impairments, were also found to have bed rails in use without the required consents and assessments. Interviews with facility staff, including the MDS/Care Plan Coordinator, RN, and DON, revealed a lack of clarity and responsibility regarding who should complete the initial and ongoing side rail assessments and obtain informed consents. The MDS Coordinator admitted to missing some residents during audits, and there was confusion among staff about the process and oversight for ensuring compliance with the facility's policy. The administrator also expressed uncertainty about the procedures for bed rail assessments and consents, indicating a systemic issue in the facility's management of side rail use.
Failure to Protect Resident Information
Penalty
Summary
Facility staff failed to protect residents' personal information by leaving computer screens open and unattended in public areas, exposing medication information for six residents. Observations revealed that Registered Nurse (RN) A left screens open with visible medication information for three residents in Hallway A, while RN B did the same for two residents on the insulin cart. RN C also left screens open with resident information visible in the dining room. These actions occurred despite the facility's policy to comply with the HIPAA Privacy Rule and maintain the confidentiality of Protected Health Information (PHI). Interviews with the involved RNs and the Director of Nursing (DON) confirmed awareness of the risk of exposing resident information and the importance of minimizing screens when unattended. The administrator also acknowledged the need to close screens to protect privacy. Despite this awareness, the repeated failure to secure computer screens resulted in the exposure of sensitive resident information, violating the facility's privacy policy and HIPAA regulations.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility staff failed to document accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the federally mandated assessment process. For Resident #9, the MDS inaccurately reflected the resident's PASRR Level II determination, which indicated a serious mental illness related to Bipolar I Disorder. The MDS Coordinator admitted to an oversight and lack of awareness of the resident's PASRR Level II determination. Similarly, Resident #41's MDS did not accurately reflect the resident's PASRR Level II status, despite having diagnoses of Major Depression Disorder and PTSD. The MDS Coordinator was unaware of the resident's Level II status, resulting in an inaccurate assessment. Additionally, Resident #43's MDS inaccurately assessed the resident's vision as adequate, despite the resident's self-reported blindness and inability to watch TV. The Director of Nursing (DON) acknowledged the inaccuracies in the MDS assessments and noted that the MDS Coordinator, who had been in the role for about seven months, was responsible for completing the assessments without any double-checking for accuracy. The facility lacked a specific MDS policy and relied on CMS guidelines and the RAI manual for guidance, which contributed to the inaccuracies in the assessments.
Failure to Prominently Post DHSS Hotline Number
Penalty
Summary
The facility failed to post the Department of Health and Senior Services (DHSS) elder abuse and neglect hotline number in a location that was accessible and visible to residents, their representatives, visitors, and staff. The facility's policy, revised on 02/01/2023, required that the names, addresses, and telephone numbers of pertinent state client advocate groups be prominently posted. However, observations on multiple occasions revealed that the hotline number was posted at the end of an unoccupied hall, rather than in a prominent location. Interviews with the Social Service Designee (SSD) and the Director of Nursing (DON) confirmed that they were unaware the number was not posted in the front area of the facility, as required. Interviews with residents indicated that they were not aware of the hotline number's location, and some had never heard it discussed. The Administrator stated that the SSD was responsible for ensuring the information was posted, but acknowledged that it was currently located near the DON's office rather than in a more visible area. This oversight resulted in residents and staff being unaware of the hotline number's location, which is a critical resource for reporting abuse and neglect.
Inadequate Hygiene Care for Residents
Penalty
Summary
The facility staff failed to provide adequate hygiene care for three residents, as observed and documented in the report. Resident #5 was assessed to require substantial assistance with personal hygiene and bathing, with a scheduled shower twice a week. However, records showed inconsistent documentation of showers, and observations noted the resident with greasy hair, indicating a lack of proper hygiene care. The Clinical Coordinator confirmed that the resident did not refuse showers, yet the scheduled care was not consistently provided. Resident #24 also required substantial assistance with personal hygiene and was scheduled for showers twice a week. Despite this, the resident was observed with long nails and greasy hair, and expressed dissatisfaction with the infrequency of showers. The Clinical Coordinator mentioned occasional refusals but was unsure of any pattern, and the documentation did not reflect consistent care or refusals. Resident #80, admitted with severe cognitive impairment, required supervision for personal hygiene and was scheduled for showers twice a week. The resident was observed with unkempt hair and expressed concerns about not receiving a shower since admission. The Clinical Coordinator was unaware of any refusals, and the documentation showed only one shower and one refusal. Interviews with staff revealed inconsistencies in documenting and communicating refusals, contributing to the deficiency in providing adequate hygiene care.
Medication Error Leads to Hospitalization
Penalty
Summary
Facility staff failed to ensure residents remained free from significant medication errors when a Licensed Practical Nurse (LPN) administered the wrong medication to a resident. The error occurred when the LPN, unfamiliar with the residents, addressed a resident by the name of their roommate, and the resident responded, leading the LPN to administer medications intended for the roommate. The medications included Lantus insulin, hydralazine, metformin, and gabapentin, which were not prescribed for the resident. The error was discovered when the LPN noticed the resident did not have a catheter, which was expected for the roommate. The resident, who was moderately cognitively impaired and had diagnoses including anemia, gastric reflux disease, benign prostatic hyperplasia, and anxiety, experienced an adverse reaction. The resident's blood sugar dropped to 70, and their blood pressure trended downwards, necessitating hospitalization. The incident was reported to the physician, and the resident was monitored with blood sugar checks and given snacks to counteract the insulin effects. The error was attributed to the LPN's unfamiliarity with the residents and a mix-up in the medication administration record (MAR) that flipped the bed assignments.
Failure to Conduct Annual Facility-Wide Assessment
Penalty
Summary
The facility staff failed to conduct and document an annual facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, covering the period from September 2022 through August 2023, lacked required information on staffing for these operations. During an interview, the administrator acknowledged the absence of a complete facility assessment and admitted awareness of the annual requirement, stating that staffing decisions were made based on census data. The facility had a census of 73 residents at the time of the report.
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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) |
|---|---|---|---|---|
| Arrowhead Senior Living Community | 2.2 mi | ★★★★★ | 0 | 0 |
| Stonebridge Lake Ozark | 2.4 mi | ★★★★★ | 1 | 0 |
| Lake Regional Health Systems | 3.1 mi | ★★★★★ | 3 | 0 |
| Ozark Rehabilitation & Health Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Laurie Care Center | 11.2 mi | ★★★★★ | 0 | 0 |
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