Inspection Reports for
Oakdale Care Center
2702 DEBBIE LN, POPLAR BLUFF, MO, 63901-2650
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
105% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
55 residents
Based on a October 2024 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 8
Date: Oct 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify residents or their representatives about transfers and bed hold policies, inadequate discharge summaries, improper catheter care, failure to post nurse staffing information, medication storage issues, unsanitary food handling, improper garbage disposal, and infection control deficiencies.
Complaint Details
The investigation was complaint-driven focusing on issues such as failure to notify residents of transfers, inadequate discharge summaries, improper catheter and incontinent care, failure to post nurse staffing information, medication storage violations, unsanitary food handling, improper garbage disposal, and infection control breaches including PPE misuse and medical waste handling.
Findings
The facility was found deficient in timely notification of resident transfers and bed hold policies, incomplete discharge summaries, improper catheter care and placement, failure to post required nurse staffing information, unsafe medication storage, unsanitary food storage and handling, improper garbage disposal, and inadequate infection prevention and control practices including improper use of PPE and handling of medical waste.
Deficiencies (8)
Failed to notify resident and/or representative in writing of facility-initiated transfer and bed hold policy for Resident #49.
Failed to complete a comprehensive discharge summary for Resident #54.
Failed to ensure urinary catheter drainage bags and tubing were kept off the floor, covered, and properly positioned for Residents #9 and #21.
Failed to post required daily nurse staffing information including total staff and hours worked.
Failed to store medications properly; insulin pens were kept beyond manufacturer recommended use period.
Failed to store and distribute food under sanitary conditions; food items were unlabeled, uncovered, and kitchen areas were unclean.
Failed to ensure dumpster lid was closed and trash was contained to prevent pests and maintain cleanliness.
Failed to implement proper infection prevention and control practices including hand hygiene, PPE use, catheter care, incontinent care, and proper handling and storage of medical waste and trash.
Report Facts
Facility census: 55
Insulin pen days opened: 32
Number of uncovered food items: 35
Number of trash bags observed outside dumpster: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in findings related to improper catheter care, incontinent care, and infection control breaches |
| CNA E | Certified Nursing Assistant | Named in findings related to improper catheter care, incontinent care, and infection control breaches |
| CNA G | Certified Nursing Assistant | Named in findings related to improper catheter care, incontinent care, and infection control breaches |
| LPN B | Licensed Practical Nurse | Named in interviews regarding catheter care and medication storage |
| Director of Nursing | Director of Nursing | Provided interviews regarding catheter care, nurse staffing, and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interviews regarding transfer notifications, catheter care, and infection control |
| Administrator | Administrator | Provided interviews regarding transfer notifications, nurse staffing, medication storage, food handling, garbage disposal, and infection control |
| Dietary Manager | Dietary Manager | Provided interviews regarding food handling and kitchen sanitation |
| Housekeeper I | Housekeeper | Named in observations and interviews regarding trash disposal and infection control breaches |
| Social Services Designee | Social Services Designee | Named in interviews regarding transfer and bed hold notifications, and discharge summaries |
| Corporate Registered Nurse | Corporate Registered Nurse | Named in interview regarding medication storage policy |
Inspection Report
Routine
Census: 59
Deficiencies: 10
Date: Aug 11, 2023
Visit Reason
The inspection was conducted to assess compliance with Medicare and Medicaid regulations, including resident assessments, care planning, medication management, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to issue required Medicare notices, incomplete resident assessments, inadequate care plans, failure to follow physician medication orders, lack of smoking assessments, improper medication storage, incomplete quality assurance meetings, and deficiencies in infection prevention related to tuberculosis screening and Legionella water management.
Deficiencies (10)
Failed to issue Medicare Skilled Nursing Facility Advance Beneficiary Notice and Notice of Medicare Non-Coverage forms timely for sampled residents.
Failed to complete a significant change Minimum Data Set assessment within 14 days of hospice admission for one resident.
Failed to implement care plans with specific interventions tailored to individual needs for multiple residents, including dental issues, smoking, and antipsychotic medication.
Failed to update and revise care plans within 7 days of comprehensive assessment for one resident.
Failed to follow physician's orders to reduce or discontinue Eliquis medication, resulting in multiple missed opportunities.
Failed to assess and complete smoking assessments upon admission and quarterly for several residents.
Failed to limit use of PRN antipsychotic medication to 14 days or document rationale for extension for one resident.
Failed to label and store medications properly, including opened PPD vials without dates and refrigerator temperatures out of range.
Failed to maintain quarterly Quality Assurance & Performance Improvement meetings with all required members.
Failed to perform tuberculosis screening according to policy and failed to implement Legionella water management program.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 15
Missed medication opportunities: 28
Missed medication opportunities: 52
Missed medication opportunities: 22
Facility census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectations for Medicare forms, care plans, medication orders, and smoking assessments | |
| Administrator | Interviewed regarding expectations for Medicare forms, care plans, medication orders, smoking assessments, and QAPI meetings | |
| MDS Coordinator | Interviewed regarding MDS assessments and care plan updates | |
| Registered Nurse B | Interviewed regarding smoking assessments and medication refrigerator procedures | |
| Certified Nursing Assistant C | Interviewed regarding smoking supervision procedures | |
| Certified Nursing Assistant D | Interviewed regarding smoking supervision procedures | |
| Infection Preventionist | Interviewed regarding TB screening and Legionella water management | |
| Maintenance Supervisor | Interviewed regarding Legionella water management program implementation | |
| Certified Medication Technician F | Interviewed regarding medication refrigerator temperature monitoring |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding misappropriation of medications by a staff member at the facility.
Complaint Details
Complaint #MO218704. The investigation substantiated that LPN A stole medications including controlled substances from the facility. LPN A was arrested and employment terminated. Law enforcement found multiple medications and cash in LPN A's possession.
Findings
The facility failed to ensure one resident was free from misappropriation when a Licensed Practical Nurse (LPN A) stole medications, including controlled substances, from the facility. The LPN was arrested after an investigation revealed multiple missing medications and evidence of drug theft.
Deficiencies (1)
Failure to protect a resident from misappropriation of medications by a staff member.
Report Facts
Census: 61
Missing Hydrocodone 5-325: 242
Missing Hydrocodone 7.5-325: 206
Missing Hydrocodone 10-325: 101
Missing Morphine Sulfate Contin 15 mg: 31
Missing Morphine Sulfate Contin 30 mg: 30
Missing Hydromorphone 2 mg: 85
Missing Tramadol 50 mg: 49
Missing Xanax 0.5 mg: 47
Cash found: 1000
Hydrocodone 5-325 found: 123
Hydrocodone 7.5-325 found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication theft and misappropriation findings; arrested and employment terminated |
| Director of Nurses | Director of Nurses | Conducted investigation, discovered missing medications and evidence of theft |
| Administrator | Administrator | Notified of missing medications and involved in investigation |
| LPN B | Licensed Practical Nurse | Reported missing B-12 injections and stated no evidence LPN A was taking medications out of the building |
| Law Enforcement Officer A | Law Enforcement Officer | Interviewed and searched LPN A; found multiple medications and cash |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 15
Date: Mar 24, 2021
Visit Reason
The inspection was conducted based on complaints and allegations regarding multiple aspects of care and compliance at Oakdale Care Center.
Complaint Details
Complaint #MO00169902 involved allegations of failure to notify residents of survey results, failure to maintain advance directives, failure to notify family of changes in condition, failure to report and investigate resident-to-resident abuse, failure to develop baseline care plans, and other care deficiencies.
Findings
The facility was found deficient in multiple areas including failure to notify residents of survey results, failure to maintain current advance directives, failure to notify responsible parties of changes in condition, improper use of physical restraints, failure to check employee disqualification lists, failure to report and investigate resident-to-resident abuse, failure to develop baseline care plans within 48 hours of admission, failure to complete discharge summaries, failure to follow restorative and wound care orders, failure to conduct proper fall assessments and neurological checks, failure to provide dementia care plans, failure to ensure pharmacist recommendations were reviewed and acted upon, failure to implement gradual dose reductions for psychotropic medications, and failure to maintain infection control practices.
Deficiencies (15)
Failed to notify residents of the availability and location of the most recent survey results in an accessible location.
Failed to ensure a current copy of a resident's advance directive was in the medical record.
Failed to notify responsible party of a change in condition or significant change in condition for residents.
Failed to ensure residents were free from physical restraints without physician orders and care plans.
Failed to perform periodic checks of the Employee Disqualification List for current employees.
Failed to timely report an allegation of resident to resident abuse to the state licensing agency.
Failed to thoroughly investigate an allegation of resident to resident abuse.
Failed to develop and implement a baseline resident care plan consistent with the resident's specific conditions, needs, and risks within 48 hours of admission.
Failed to complete a comprehensive discharge summary for a discharged resident.
Failed to follow restorative care and wound care orders for a resident.
Failed to provide a complete assessment after a fall with injury including neurological checks and pain assessments.
Failed to ensure residents diagnosed with dementia had a personalized plan of care addressing their needs.
Failed to ensure attending physician reviewed Consultant Pharmacist's Gradual Dose Reduction recommendations and documented actions.
Failed to ensure attending physician reviewed pharmacist recommendations and documented rationale for continued use of PRN psychotropic medication beyond 14 days.
Failed to maintain infection control practices including hand hygiene, cleaning of durable medical equipment, and wound care procedures.
Report Facts
Census: 59
Deficiencies cited: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN O | Licensed Practical Nurse | Named in wound care and infection control deficiencies |
| Administrator | Named in multiple interviews regarding facility expectations and deficiencies | |
| Director of Nursing | DON | Named in multiple interviews regarding facility expectations and deficiencies |
| Restorative Nurse Aide D | RNA | Named in restorative care deficiency |
| Certified Nurse Assistant Y | CNA | Named in infection control and wound care deficiencies |
| Certified Nurse Assistant Z | CNA | Named in infection control and wound care deficiencies |
| Licensed Practical Nurse AA | LPN | Named in infection control deficiencies |
| Registered Nurse X | RN | Named in infection control deficiencies |
| Physical Therapist C | PT | Named in restraint use deficiency |
| Physical Therapy Assistant B | PTA | Named in restraint use deficiency |
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