Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Ozark Riverview Manor during CMS and state inspections, most recent first.
Failure to Honor Resident Shower Preferences: Multiple residents reported not receiving showers at their preferred frequency, and records showed showers were often limited to once weekly or spaced several days apart. One resident with CHF, morbid obesity, and depression wanted two showers per week but often received one; another resident with COPD, CKD, DM2, and ESRD wanted showers before dialysis but the schedule was driven by dialysis and staffing; a third cognitively intact resident said showers had been lax and that two per week were preferred. Staff interviews confirmed shower aides were sometimes pulled to the floor, and nursing notes did not document additional shower attempts or refusals.
Resident trust funds were not accurately reconciled each month. For one account, outstanding checks were repeatedly carried forward on monthly reconciliations even after bank statements showed the checks had cleared for different amounts, and the facility did not provide a resident funds policy. The FS said the error was made by a predecessor, and the CFO said the FS completed the reconciliation.
Side rail use lacked required assessment, consent, care planning, and gap measurements for multiple residents. One resident with seizures had bilateral side rails and an informed consent form, but no documented safety gap measurements. Two other residents used grab bars for mobility, transfers, and repositioning, but their records lacked orders, risk-versus-benefit consent, and routine monitoring; one care plan did not address the grab bar use.
Uncertified nurse aides worked beyond the 4-month training period. Four nurse aides had no documentation of completing CNA training and no active CNA certification on the state registry after being hired more than 4 months earlier. They were scheduled to work and, in several cases, observed providing direct resident care. The DON said the CNA instructor should monitor students to complete coursework and testing within 120 days, and the Administrator stated nurse aides should be certified within 4 months of hire.
Failure to Provide Restorative Nursing Services: A facility did not consistently provide restorative nursing services for three residents with significant functional limitations, including stroke-related hemiplegia, amputation, and weakness. Therapy had identified ROM, transfer, balance, and exercise needs, but records showed missed or undocumented RT, residents reported not receiving services regularly, and staff stated the restorative aide was sometimes pulled to other duties and RT was not always delivered as expected.
Staff failed to follow EBP during care for a resident with a stage 3 pressure ulcer, a resident with an indwelling urinary catheter, and a resident with a PEG tube. Observations showed staff used gloves but did not wear gowns during wound care, catheter care, and medication administration via the feeding tube, even though EBP signs were posted. Interviews with the ADON, DON, LPNs, and the Administrator confirmed that gown and glove use was expected for these types of resident care.
Failure to notify a resident’s representative of changes in condition and new orders. A cognitively intact resident with multiple diagnoses, including a below-the-knee amputation, heart failure, depression, and anxiety, had repeated new medication orders and several changes in condition such as nausea, vomiting, diarrhea, bloody urine, and feeding tube site issues. Notes showed the resident was informed, but staff did not document notifying the EC/NOK. Interviews confirmed the NOK had requested notification of all medication changes and condition changes, and staff said these contacts should be documented in the chart.
A resident who was dependent on staff for all ADLs and had severe cognitive and physical impairments, a feeding tube, and difficulty swallowing did not receive oral care as directed in the care plan. The resident's family reported oral care was missed or inconsistent, the resident was observed with malodorous breath, and the resident indicated staff had not cleaned the mouth and teeth that morning. Staff interviews showed oral care was often left to the shower aide or family rather than being provided consistently by CNAs or nursing staff.
Failure to Offer Preferred Activities and Document Invitations: A resident with multiple diagnoses, including depression, anxiety, and heart failure, had documented preferences for music, animals, favorite activities, fresh air, and religious services, but staff did not consistently offer or document invitations to preferred activities such as Bible study, church, music programs, or bingo. The resident stated staff never notified him/her of activities and had not offered bingo, while the AD and other staff were unsure whether the resident had been specifically invited or whether refusals were documented.
Survey results were not kept in a readily accessible public location and there was no signage identifying where they were stored. A binder with the results was placed behind the front desk in a wire bin, partially hidden by bathroom keys and not visible to someone seated in a wheelchair. Residents said they did not know the results were available, and multiple CNAs and LPNs were unsure where to find them; the DON confirmed the binder’s location behind the desk.
A facility failed to manage controlled medications effectively, resulting in missing narcotic records and unaccounted oxycodone for a resident with arthritis and dementia. The resident's medication was not destroyed as required, and an investigation revealed discrepancies in narcotic counts and forged signatures, implicating an LPN in the diversion of medication.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring reasonable shower preferences for multiple residents. The report states the facility did not provide a shower policy. During a resident council meeting, residents reported problems receiving showers, with some saying they received two showers per week but most only received one. Resident #61 had diagnoses including CHF, morbid obesity, and depression, and was cognitively intact with partial/moderate assistance needed for showering and staff supervision for personal hygiene. The care plan noted a preference to shower on Wednesdays if agreeable. Shower records showed showers were sometimes spaced seven to eight days apart, with refusals documented on some scheduled days and no documentation of additional shower attempts or additional refusals in nursing notes. During observation, the resident’s hair appeared oily, and the resident stated a desire for two showers per week but reported receiving only one shower per week. The ADON said the resident sometimes refused showers depending on what he/she was doing when asked, and the DON said the resident used to like Wednesdays and lately had taken more showers. Resident #74 had diagnoses including COPD, CKD, morbid obesity, type 2 diabetes, and ESRD, and required substantial/maximum assistance for bathing. The resident stated a preference for showers the night before dialysis and said it was important to be clean before going to dialysis. Shower records showed showers generally occurred weekly, with one refusal documented and no additional shower attempts or refusals noted in nursing notes. The ADON said he/she was not aware of refusals, while the DON and CMT/SA described the shower schedule as dependent on dialysis days and staffing, with the resident’s requested timing not consistently accommodated. Resident #6 had diagnoses including COPD, chronic respiratory failure with hypoxia, type 2 diabetes, chronic pain syndrome, and overactive bladder, and was cognitively intact and required partial to moderate assistance with showering and personal hygiene. The care plan did not address shower preferences. Shower forms showed showers on some days but only one shower during one week and no shower by the end of the later week reviewed. The resident told staff that showers had been lax, that two showers per week were preferred, and that it felt good to have a shower. The resident later stated not having a shower for over a week and said he/she did not feel good when showers were missed. Staff interviews reflected that shower aides were sometimes pulled to the floor to work as aides, that residents should receive two showers per week, and that staffing issues affected shower completion.
Resident Trust Fund Reconciliation Errors
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not correctly reconciling the account each month. The facility managed funds for 25 residents, and no policy related to resident funds was provided during review. Review of the corporate maintained bank statements and reconciliation forms for account ending in #7994 showed that outstanding checks #2482 and #2483 were carried forward on monthly reconciliations for multiple months without being updated to match the bank activity. The September 2024 reconciliation listed check #2482 for $97.30 and check #2483 for $155.05 as outstanding, but the October 2024 bank statement showed check #2482 cleared for $97.20 and check #2483 cleared for $395.00. Despite this, the October 2024 reconciliation still listed the older outstanding amounts and also listed check #2483 for $395 deducted from the account. The same outstanding check amounts continued to appear on reconciliations from November 2024 through August 2025. During interviews, the FS stated the data entry error was made by a predecessor and that the CFO reviewed the reconciliation, while the CFO stated the FS conducted the resident trust reconciliation and the employee who made the data entry error was no longer with the company.
Side rail use lacked assessment, consent, care planning, and gap measurements
Penalty
Summary
The facility failed to ensure proper assessment and documentation before side rail use, failed to document a risk-versus-benefit review, failed to obtain informed consent, failed to care plan side rail use for two residents, and failed to complete gap measurements to reduce entrapment risk for three residents. The facility policy required assessment of symptoms, entrapment risk, and the reason for side rail use, along with care planning, consent, and measurement of the space between the mattress and side rails. The census was 77. Resident #12 had diagnoses including right-sided weakness and paralysis following a stroke, TIA, inability to speak, gastrostomy, muscle wasting, epilepsy/convulsions/seizures, low blood pressure, major depressive disorder, anxiety, osteoporosis, contracture, difficulty sleeping, and chronic pain. The quarterly MDS showed severely impaired cognition and impaired range of motion to the upper and lower extremities on one side. The POS ordered side rails x 2 while in bed due to convulsions, epilepsy, and seizure disorder, and the care plan stated the resident had full side rails x 2 per family request for safety and a sense of security. Observations showed bilateral side rails raised while the resident was in bed, and a family member said the rails were requested for safety due to a long history of seizures. The record contained an informed consent form dated 01/04/24, but maintenance logs showed no documentation of safety or gap measurements for the bilateral side rails. Resident #8 had diagnoses including dementia, PTSD, generalized anxiety disorder, history of falling, and weakness. The quarterly MDS showed the resident was cognitively intact, used a wheelchair, and needed supervision or touching assistance with transfers and varying levels of assistance with personal care. During observation, the resident was in bed with a grab bar on the left side and said it was used for mobility and transfer assistance. The care plan did not address the grab bar, the POS did not document an order for grab bars or side rails, and the electronic record showed a bed rail assessment dated 08/20/24 but no risk-and-benefit consent, no side rail measurements, and no routine monitoring. Resident #75 had diagnoses including COPD, fibromyalgia, and chronic pain syndrome. The resident had grab bars on both sides of the bed and said they were used to move around in bed and help roll for staff during personal care. The care plan stated the resident used grab bars x 2 to maximize independence with transferring and repositioning, but the POS did not document orders related to grab bar usage, and the record contained no bed rail assessment, no risk-and-benefit consent, and no side rail measurements or routine monitoring.
Uncertified nurse aides worked beyond the 4-month training period
Penalty
Summary
The facility failed to ensure that nurse aides who had worked more than 4 months were trained and competent, and that nurse aides who had worked less than 4 months were enrolled in appropriate training. Four of 15 sampled nurse aides—NA R, NA S, NA T, and NA U—did not complete a CNA training program within 4 months of hire and did not have active CNA certification on the state registry. The facility also did not have a policy regarding nurse aide certification or training. Record review showed NA R was hired on 01/24/25 and, eight months later, still had no documentation of completing nurse aide training and no active CNA certification; the schedule showed NA R worked multiple shifts and observations showed NA R providing direct resident care. NA S was hired on 04/15/25 and, more than 5 months later, had no training documentation and no active CNA certification, yet was scheduled to work. NA T was hired on 04/29/25 and, more than 4 months later, had no training documentation and no active CNA certification; NA T was observed providing direct care. NA U was hired on 05/13/25 and, more than 4 months later, had no training documentation and no active CNA certification; NA U was also scheduled and observed providing direct care. The DON stated the CNA instructor should monitor students to ensure they complete coursework and testing within 120 days and said she was not aware NA R and NA U were over 120 days. The Administrator stated nurse aides should be certified within four months of hire.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to maintain or improve residents’ functional status as directed by therapy for three residents. The deficiency was identified through observation, interview, and record review, and the facility policy stated that restorative nursing care may be started during the course of a stay or when discharged from rehabilitative care, with individualized goals outlined in the care plan. For one resident with hemiplegia and hemiparesis following a stroke and chronic pain, therapy had previously addressed ROM, strength, balance, transfers, and ADLs, with goals for ROM, strengthening, and transfers. The restorative therapy log showed multiple weeks with no restorative therapy provided, and the resident stated he/she should receive restorative therapy but did not receive it regularly. The resident also said that when restorative therapy was missed, he/she tightened up and it could be painful. The RA said the resident sometimes refused, while the DON said he/she did not believe the resident had refused RT. The resident’s care plan listed ADL dependence, fall risk, and therapy orders, but the POS did not document restorative therapy orders. For another resident with a complete knee-level amputation, the care plan stated the resident required assistance with ADLs, transfers, and mobility using a Hoyer lift and wheelchair, and that the resident would improve current function through the next review date. The resident and NOK both stated restorative therapy had been requested in care plan meetings, but the resident was not on the list and was told he/she would be placed on it. The resident said the ankle was declining and becoming contracted. The RA said the resident did not receive RT, while the ADON, MDS Coordinator, and DON were unsure whether RT had been requested or addressed, and the POS did not include restorative therapy orders. For a third resident with chronic pain syndrome, weakness, wheelchair use, and dependence for multiple ADLs, therapy discharge information showed active ROM and transfer training/balance with specific upper and lower extremity exercises. The baseline care plan stated the resident required two-person physical assist for transfers and that the PT goal was to improve functional status through restorative nursing. The restorative aide notebook contained only limited entries and several date ranges with no documentation of completed or not completed services. The resident said he/she wanted to exercise and had previously done so with staff, but could not make the leg work. Multiple staff members stated RT should occur three times per week, that the RA was sometimes pulled to the floor to work as an aide, that residents did not always receive RT three times per week, and that RT should be documented in the care plan.
Failure to Use EBP During Wound, Catheter, and PEG Tube Care
Penalty
Summary
The facility failed to establish and maintain a complete infection control program when staff did not follow Enhanced Barrier Precautions (EBP) during care for residents with wounds, an indwelling urinary catheter, and a PEG tube. The facility policy stated that EBP requires gown and glove use during high-contact resident care activities, including wound care and device care such as urinary catheters and feeding tubes, and that signs should be posted outside the room indicating the required PPE. The report identified that the facility census was 77. For one resident with a stage 3 sacral pressure ulcer, the resident’s record showed an order for sacral wound care and the care plan identified the wound, but did not address EBP. During observation, the ADON and a CNA entered the room and provided incontinent care and wound care while wearing gloves but not gowns, even though an EBP sign was posted on the door directing staff to wear PPE, including gown and gloves. Interviews with nursing staff and leadership confirmed that residents with wounds should be on EBP and that a gown should have been worn during the wound care. For a second resident with an indwelling urinary catheter, the record showed orders for catheter changes and catheter care every shift, and the care plan identified the catheter but did not address EBP. During observation, two CNAs entered the room, washed hands, applied gloves, transferred the resident, emptied the catheter bag, and provided catheter care without wearing gowns, despite an EBP sign on the door. Staff interviews showed conflicting understanding, with one aide stating catheter care did not require a gown, while other nursing staff and the DON stated that residents with catheters should be on EBP and that gown and glove use was required. For a third resident with a gastrostomy tube, the record showed feeding tube care and medication administration through the tube, and the care plan specifically identified EBP due to the PEG tube. During observation, an LPN used sanitizer and gloves but did not don a gown while administering medication through the tube and handling the feeding tube site. The LPN later stated that both gown and gloves should have been worn and that the gown had been forgotten. Additional staff interviews and the Administrator confirmed that gown and glove use was expected for care involving wounds, catheters, and PEG tubes.
Failure to Notify Resident Representative of Changes in Condition and New Orders
Penalty
Summary
The facility failed to ensure the resident’s representative was notified in a timely manner of changes in condition and new orders. The resident had a history of complete amputation at knee level, anorexia, depression, anxiety, and heart failure, and was cognitively intact. The face sheet directed staff to contact Emergency Contact #1 if any new orders were received or if there was a change in condition, but the facility did not provide a policy regarding notification of resident representatives. Record review showed multiple new orders and changes in condition for the resident, including orders for Midodrine, ondansetron, Ocuvite, potassium, apixaban, Miralax, ciprofloxacin, and Imodium, as well as physician notification for nausea, vomiting, diarrhea, pink urine, bloody urine, a stool sample request for C-Diff, a urine screen collected via catheter, and changes involving the feeding tube site with bloody discharge, gas escaping from the stoma, leakage of brownish contents, redness, and soreness. The progress notes repeatedly documented that the resident was informed or aware, but did not document notification of the emergency contact or next of kin. During interview, the resident and next of kin stated the facility did not regularly contact the next of kin about medication changes or changes in condition, and that concerns had been voiced to staff. Staff interviews reflected that nurses, the RN supervisor, or the nurse entering the order were expected to notify the family of new orders or changes in condition and document the contact in the progress notes. The DON acknowledged the next of kin had voiced concerns about not being notified and stated correspondence was often by email but should be documented in the resident’s record.
Failure to Provide Consistent Oral Care
Penalty
Summary
The facility failed to provide appropriate oral care for a resident who was dependent on staff for all ADLs. The resident had right-sided weakness and paralysis following a stroke, a history of TIA, inability to speak, a gastrostomy tube, muscle wasting, epilepsy, low blood pressure, major depressive disorder, anxiety, difficulty swallowing, osteoporosis, a history of UTI, contracture, a history of COVID-19, difficulty sleeping, and chronic pain. The quarterly MDS showed severely impaired cognition, impaired range of motion to the upper and lower extremities on one side, dependence on others for oral hygiene, and a feeding tube. The care plan directed staff to provide total assistance with ADLs and to perform oral care every shift, after meals, and as needed, including moisture and hygiene throughout the day and night between brushings. Observation and interviews showed the resident's mouth care was not being done as planned. The resident's family member reported staff did not provide daily oral care every shift and sometimes not even daily, and said the resident often had horrible breath when visited. The resident had personal oral care supplies, including an electric toothbrush and toothpaste. During observations, the resident's breath was malodorous, and when asked whether staff had cleaned the mouth and teeth that morning, the resident signed no on two separate occasions and later signed yes when asked if he/she wanted it done. Staff interviews indicated oral care was inconsistent: one LPN said aides should do more oral care every day, a CMT said floor aides usually did not do it and it was done by the shower aide on Monday, Wednesday, and Friday, and a CNA said the shower aide or family often provided it. The DON and Administrator stated oral care should be provided at least every shift or every morning and evening, but the resident's care was not being provided in that manner.
Failure to Offer Preferred Activities and Document Invitations
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment and care plan when staff did not consistently offer preferred activities to one resident. The resident had diagnoses including complete amputation at knee level, anorexia, depression, anxiety, and heart failure, and was cognitively intact but dependent on staff for bathing, personal hygiene, and mobility. The resident’s activity assessment and MDS identified preferences such as listening to music, being around animals, participating in favorite activities, going outside for fresh air, and participating in religious services or practices, while the care plan noted little or no activity involvement and that the resident came to activities by choice. The record showed the facility posted activity calendars and had scheduled bingo, Bible study/church, zoo, gospel music, and music programs, but activity notes did not document that the resident was offered the opportunity to attend Bible study, the zoo program, church, or music programs. The resident’s activity notes mainly reflected delivery of the Daily Chronicle, weekly room visits by the AD, and nail care. The quarterly/annual participation review stated the resident preferred to stay in bed but agreed to try to come to more activities, maybe bingo or music, and also noted it was unknown if assistance should be provided to get the resident to activities. During interviews, the resident stated staff never asked or notified him/her of activities and that staff had not offered to take him/her to bingo. Several CNAs and nurses said residents were reminded of activities and calendars were posted, but they were unsure whether this resident was specifically invited or whether refusals were documented. The AD stated the resident enjoyed TV, reading, and pet therapy, believed the resident may have been invited to a music program and refused, but was unsure whether staff had asked the resident to attend bingo. The DON and Administrator stated activity preferences should be discussed, residents encouraged to attend, and refusals documented, but the record for this resident did not show consistent documentation that preferred activities were offered.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that residents, family members, and visitors could easily view the nursing home's survey results and communicate with advocate agencies because the prior survey results were not kept in a readily accessible public location. Observation showed a white binder containing the survey results placed behind the front desk in a wire bin, lying flat and partially obscured by two sets of public bathroom keys. The desk counter was approximately four feet tall, and the binder was not visible to someone seated in a wheelchair. No signage was present to identify the location of the survey results, and the facility did not provide a policy regarding survey results accessibility. During interviews, residents in the resident council said they were unaware that the previous year's survey results were available for review and none knew where they were located in the facility. The Administrator stated there was no receptionist at the front desk, and multiple CNAs and LPNs said they did not know where the survey results were kept and would have to ask nursing leadership or the Administrator. The DON said the survey results were kept in a binder behind the front desk, but there was no signage indicating the location. The Administrator also stated the binder had previously been placed on top of the front counter but would disappear, and that no residents had asked to view the survey results.
Controlled Medication Management Failure
Penalty
Summary
The facility failed to maintain an effective system for managing controlled medications, leading to a discrepancy involving two cards of controlled medications that could not be located and the failure to destroy discontinued controlled medication in a timely manner for a resident. The resident, who had been admitted with diagnoses including arthritis of the left knee and dementia, had an order for oxycodone, a controlled medication, which was discontinued but not destroyed as per the facility's policy. The resident's medication was not administered during the period it was prescribed, and there was no narcotic control sheet provided for the oxycodone. The investigation revealed that on the day following the resident's discharge, a discrepancy in the narcotic count was reported. An audit showed that narcotics for the discharged resident had been removed from the cart, and the resident's narcotics had not been destroyed by nurse leadership. The facility's investigation concluded that there was sufficient evidence to support that an LPN had diverted medication from the facility. Interviews with staff indicated that discrepancies were noted in the narcotic records, including forged signatures and missing narcotic logs. The facility's policy required controlled substances to be counted upon delivery and at the end of each shift, with any discrepancies reported to the DON or designee. However, the resident's oxycodone was not destroyed in a timely manner, and the narcotic log for the medication was missing. The ADON and DON acknowledged that the medication should have been destroyed long before the resident's discharge, and the facility was unable to account for 42 pills of oxycodone, with indications pointing to the LPN's involvement in the medication's disappearance.
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Illustrative
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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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Illustrative
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Nursing homes near Ozark
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ozark Care & Rehab Center | 0.9 mi | ★★★★★ | 5 | 0 |
| Nixa Nursing & Rehab | 5.1 mi | ★★★★★ | 0 | 0 |
| Sunterra Springs Springfield | 7.8 mi | ★★★★★ | 0 | 0 |
| Copper Rock Healthcare | 8 mi | ★★★★★ | 1 | 0 |
| James River Nursing And Rehabilitation | 9.3 mi | ★★★★★ | 1 | 0 |
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