Inspection Reports for
Oakdale Care Center
2702 DEBBIE LN, POPLAR BLUFF, MO, 63901-2650
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
20.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
271% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
20% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 1
Date: Oct 7, 2025
Visit Reason
The document is a plan of correction following a deficiency related to tuberculosis testing procedures at Oakdale Care Center.
Findings
The facility failed to maintain appropriate infection control procedures by not administering the required two-step Mantoux PPD tuberculin test to two residents. The Licensed Practical Nurse/Director of Clinical Services was unaware of the two-step testing requirement for new admissions.
Deficiencies (1)
A433 Operator/Administrator Responsibilities: The facility failed to ensure compliance with tuberculosis testing regulations by not administering the required two-step Mantoux PPD test to residents #1 and #3. The Licensed Practical Nurse/Director of Clinical Services was unaware of the two-step testing requirement for new admissions.
Report Facts
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Misty Ulmer | Administrator | Signed the plan of correction |
| Licensed Practical Nurse/Director of Clinical Services | Named in relation to unawareness of two-step tuberculin testing requirement |
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 2
Date: Nov 14, 2024
Visit Reason
The document is a plan of correction responding to deficiencies identified during a survey conducted on 11/14/2024 at Oakdale Care Center.
Findings
The facility failed to ensure that residents and/or their legally authorized representatives were fully informed of their rights and responsibilities upon admission and annually, and did not provide required policies for resident rights and advance directives. Specifically, one resident's rights admission/annual review and four residents' advance directive reviews were incomplete or missing.
Deficiencies (2)
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review was not met as the facility failed to ensure resident rights were fully informed and did not provide a resident rights policy. One resident's record lacked a signed and dated resident rights document.
19 CSR 30-88.010(10) Advance Directive Requirements were not met as the facility failed to ensure annual review of advance directives for four residents. One resident's record lacked a signed and dated advance directive document.
Report Facts
Facility census: 32
Residents sampled: 4
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 5
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #M000242955 regarding medication errors and other regulatory compliance issues at Oakdale Care Center.
Complaint Details
Complaint #M000242955 involved medication errors and failure to follow physician orders for Resident #5. The complaint was substantiated with documentation of medication errors and improper medication administration. The higher classification was merited due to the extent of the violation.
Findings
The facility was found deficient in multiple areas including failure to check the Employee Disqualification List, incomplete tuberculosis screening for staff, failure to complete semi-annual Community Based Assessments for residents, failure to follow physician orders for catheter care, and medication errors for one resident. No residents were harmed by the deficient practices.
Deficiencies (5)
19 CSR 30-86.047(13)(B) EDL Inquiry: The facility failed to check the Employee Disqualification List for six current employees and did not provide a policy regarding the list.
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure five of six employees were screened for tuberculosis in a timely manner and lacked documentation of annual TB testing.
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually: The facility failed to complete semi-annual Community Based Assessments for four sampled residents and did not provide a policy for CBAs.
19 CSR 30-86.047(47)(A) Physicians Orders Followed: The facility failed to ensure staff followed physician's orders for catheter care for one resident.
19 CSR 30-86.047(55) Medication Errors/Reactions-Report: The facility failed to ensure proper notifications were made following a medication error for one resident and had multiple medication administration errors documented.
Report Facts
Facility census: 36
Number of employees not screened for TB: 5
Number of residents sampled for Community Based Assessments: 4
Number of residents with medication errors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Staff | Interviewed regarding EDL checks and TB screening | |
| Director of Clinical Services | Licensed Practical Nurse | Interviewed regarding catheter care and medication errors |
| Licensed Practical Nurse/Director of Clinical Services | Interviewed regarding medication errors and documentation |
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 20
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident transfer/discharge notices, bed hold policies, discharge summaries, incontinence care, infection control, medication labeling, nurse staffing information, food safety, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to notify residents or representatives of transfers, failure to inform about bed hold policies, incomplete discharge summaries, improper catheter care, inadequate infection control practices, improper medication storage and labeling, failure to post nurse staffing information, and food safety violations. The facility census was 55 at the time of inspection.
Deficiencies (20)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify the resident or resident's representative in writing of a facility-initiated transfer when one resident was transferred to the hospital.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to inform the resident, family, or legal representative of the bed hold policy in writing at the time of transfer for one resident.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary for one discharged resident.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure proper urinary catheter care and placement for sampled residents, including keeping drainage bags off the floor and providing privacy covers.
F732 Posted Nurse Staffing Information: The facility failed to post required daily nurse staffing information including total number of staff and actual hours worked by licensed and unlicensed nursing staff.
F761 Label/Store Drugs and Biologicals: The facility failed to store medications in a safe and effective manner, including improper labeling and storage of insulin pens past expiration.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store and distribute food under sanitary conditions, increasing risk of cross-contamination and food-borne illness.
F814 Dispose Garbage and Refuse Properly: The facility failed to ensure a dumpster was closed at all times and maintained to keep pests out and garbage contained.
F880 Infection Prevention & Control: The facility failed to use proper infection control techniques during incontinent care for sampled residents and failed to properly store trash and medical waste.
A4062 Medication Labeling: The facility failed to label all medications including over-the-counter medications in accordance with professional pharmacy standards.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4086 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection.
A4108 Clinical Records - assessment/interventions: The facility failed to ensure clinical records contained sufficient information reflecting initial and ongoing assessments and interventions.
A4109 Clinical Records - discharge/transfer: The facility failed to ensure clinical records identified discharge or transfer destination.
A6032 Outside Dumpsters Cleanable/Covered: The facility failed to maintain waste containers outside the establishment in a cleanable and covered manner.
A7019 Food Stored in Identifying Containers: The facility failed to store bulk food and other items in containers identifying the food by common name.
A7067 Nonfood Contact Surfaces, Cleaned as Needed: The facility failed to clean nonfood-contact surfaces of equipment as often as necessary.
A7097 Shielding to Protect Food From Broken Glass: The facility failed to provide shielding to protect food from broken glass falling onto food.
A8008 Informed Services/Charges - Alz Disclosure: The facility failed to fully inform residents or representatives in writing of services available and charges related to Alzheimer's special care services.
A8018 Emergency Discharges: The facility failed to provide written notice of discharge and send a copy to the Missouri State Ombudsman in emergency discharge situations.
Report Facts
Facility census: 55
Completion date: Nov 8, 2024
Completion date: Nov 6, 2024
Completion date: Oct 25, 2024
Completion date: Oct 24, 2024
Inspection Report
Life Safety
Census: 55
Deficiencies: 5
Date: Oct 24, 2024
Visit Reason
The inspection was conducted as an Emergency Preparedness and Life Safety Code survey to assess compliance with fire safety and protection regulations.
Findings
The facility failed to maintain fire-rated corridors and proper fire protection measures, including an unprotected opening between the kitchen and dining room, a non-connected fire shutter, grease buildup in kitchen range hood filters, and sprinkler heads obstructed by debris. These deficiencies potentially affected all residents and staff.
Deficiencies (5)
42 CFR 483.90(a) and NFPA 101: The facility failed to maintain fire-rated corridors as required by the Life Safety Code, including an unprotected opening between the kitchen and dining room used as a food service pass-through without a fire curtain or protective measures.
NFPA 101 Cooking Facilities: The facility failed to ensure the kitchen range hood was free of grease and debris, with filters loaded with a greasy buildup, potentially affecting all residents and staff.
NFPA 101 Sprinkler System Maintenance and Testing: The facility failed to maintain the sprinkler system by not ensuring sprinklers were clean and free of corrosion and debris, with sprinkler heads wrapped in rags and loaded with dust.
NFPA 101 Fire Alarm System Requirements: The facility did not have a complete fire alarm system that automatically transmits to the fire department and includes visual and audible alarms throughout the building.
NFPA 101 Sprinkler System Test and Maintenance: The facility failed to properly inspect, maintain, and test the sprinkler system as required for facilities with pre-August 28, 2007 installations.
Report Facts
Facility census: 55
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
Complaint Investigation
Census: 36
Deficiencies: 3
Date: Sep 26, 2024
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to meet food service, menu substitution, and eating preference regulations.
Complaint Details
The visit was complaint-related under complaint #M000241590. The complaint was substantiated as the deficiencies affected residents and merited a higher classification due to the violation's effect on residents.
Findings
The facility failed to provide food prepared and served under safe, sanitary conditions consistent with residents' dietary needs and preferences. The facility also failed to provide meal substitutes of equal nutritional value and did not assess residents' eating and dining preferences in individualized service plans.
Deficiencies (3)
19 CSR 30-88.052(1) Food Prep & Services: The facility failed to consider medical needs and physical abilities of residents regarding meals. Several residents lacked physician diet orders. Food items served were often inappropriate or unappetizing to residents.
19 CSR 30-86.052(6) Menus, Substitutes: The facility failed to provide substitutes to meals of equal nutritional value and complementary to the remainder of the meal. This affected all residents.
19 CSR 30-86.052(9)(A) Eating Preferences in ISP: The facility failed to assess residents' eating and dining preferences in individualized service plans for seven residents. The facility lacked a policy on this matter.
Report Facts
Facility census: 36
Residents sampled: 8
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 2
Date: Aug 20, 2024
Visit Reason
The document is a plan of correction related to deficiencies identified during a facility inspection conducted on August 20, 2024.
Findings
The facility failed to conduct the required minimum of twelve fire drills annually with at least one drill every three months on each shift. The facility also failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition, with several cylinders observed unsecured in resident rooms.
Deficiencies (2)
19 CSR 30-86.022(5)(D) Fire Drill Requirements were not met as the facility failed to conduct a minimum of twelve fire drills per year with at least one drill every three months on each shift. The facility census was thirty-five residents.
19 CSR 30-86.022(17) Oxygen Storage Requirements were not met as the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. Several oxygen cylinders were observed unsecured in resident rooms.
Report Facts
Facility census: 35
Fire drills required: 12
Fire drills documented: 9
Oxygen cylinders observed: 5
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Jan 10, 2024
Visit Reason
The inspection was conducted in response to complaint #MO00228772 regarding the facility's handling of emergency discharges and final accounting of resident funds.
Complaint Details
Complaint #MO00228772 was investigated. The complaint involved failure to notify residents and responsible parties of discharge, denial of readmission after jail release, and failure to provide final accounting of resident funds. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to provide timely written notice of discharge to residents and their representatives, denied readmission following release from jail, and did not provide final accounting of resident funds within five days. These deficiencies affected multiple residents and violated state regulations.
Deficiencies (2)
19 CSR 30-88.010(18) Emergency Discharges: The facility failed to submit written notice of discharge to the resident and responsible party and denied readmission following release from jail. The facility census was 33.
19 CSR 30-88.020(10) Discharge Requirement Within 5 Days: The facility failed to provide a final accounting of resident fund balances within five days to the appropriate parties for two residents.
Report Facts
Facility census: 33
Resident sample size: 8
Residents with fund accounting issues: 2
Refund amount: 489.01
Overcharge amount: 85.6
Unauthorized withdrawal: 403.41
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 6
Date: Sep 26, 2023
Visit Reason
The inspection was conducted to identify deficiencies in the facility related to furniture, room cleanliness, mattress condition, walls, ceilings, windows, light fixtures, vents, and toilet room maintenance.
Findings
The facility failed to maintain furniture, resident rooms, mattresses, walls, ceilings, light fixtures, vents, and resident bathrooms in good repair and cleanliness. Multiple Class III deficiencies were cited based on observations and interviews.
Deficiencies (6)
19 CSR 30-86.032(22) Furniture/Equip, Provide Comfort & Safety. The facility failed to ensure resident use furniture was well maintained and kept in good repair, including torn upholstery on chairs in the living room.
19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily. The facility failed to ensure all resident rooms were kept neat, orderly, and in good repair, including lack of closets and scattered personal belongings in Resident room #201.
19 CSR 30-86.032(26) Mattress Requirements. The facility failed to maintain mattresses in good repair, with a mattress in Resident room #201 covered with large dark brown stains.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean. The facility failed to keep walls and ceilings clean and in good repair, including gray fuzzy substance on kitchen walls and peeling stucco.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable. The facility failed to maintain light fixtures and vents in clean and good repair, including uncovered fluorescent lights and fuzzy vent covers.
19 CSR 30-87.020(41) Toilet Room Requirements. The facility failed to keep resident bathrooms clean and well maintained, including grimy substances and chips in sinks in resident bathrooms.
Report Facts
Facility census: 31
Tandem chairs in living room: 21
Completion dates for corrections: Dates range from 10/06/2023 to 11/11/2023 for various corrective actions
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/Manager | Interviewed regarding repairs and maintenance issues | |
| Administrator | Interviewed regarding kitchen condition and approval of plan of correction |
Inspection Report
Plan of Correction
Census: 59
Deficiencies: 9
Date: Aug 11, 2023
Visit Reason
The inspection was conducted to identify deficiencies in compliance with Medicare and Medicaid regulations and to require a plan of correction for the Oakdale Care Center skilled nursing facility.
Findings
The facility was found deficient in multiple areas including failure to issue required Medicare notices, failure to complete significant change assessments, failure to develop and implement comprehensive care plans, failure to provide adequate smoking assessments and supervision, failure to meet professional standards in services, failure to maintain free of accident hazards, failure to properly label and store medications, failure to maintain infection prevention and control programs, and failure to maintain a quality assessment and assurance committee.
Deficiencies (9)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to issue a CMS Skilled Nursing Facility Advance Beneficiary Notice and Medicare Non-Coverage notices timely to residents.
F637 Comprehensive Assessment After Significant Change: The facility failed to complete a significant change Minimum Data Set assessment within 14 days for a resident admitted to hospice.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement care plans with specific interventions tailored to meet individual resident needs for multiple residents.
F657 Care Plan Timing and Revision: The facility failed to update and revise care plans with specific interventions tailored to meet individual resident needs in a timely manner for several residents.
F658 Services Provided Meet Professional Standards: The facility failed to follow physician's orders for one resident and had multiple missed medication administration opportunities.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to assess and complete smoking assessments upon admission and quarterly for several residents and failed to provide adequate supervision.
F761 Label/Store Drugs and Biologicals: The facility failed to label and store medications in a safe and effective manner, including expired and temperature-sensitive medications.
F868 QAA Committee: The facility failed to maintain a quality assessment and assurance committee with required members and failed to conduct quarterly meetings.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including failure to implement a Legionella water management program and conduct required tuberculosis testing.
Report Facts
Facility census: 59
Missed medication opportunities: 28
Missed medication opportunities: 52
Missed medication opportunities: 22
Medication refrigerator temperature out of range: 3
QAPI meeting attendance: 5
Inspection Report
Life Safety
Census: 59
Deficiencies: 7
Date: Aug 11, 2023
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety regulations and emergency preparedness at Oakdale Care Center.
Findings
The facility failed to maintain the sprinkler system properly, had prohibited portable space heaters in use, and improperly used power strips and extension cords. These deficiencies had the potential to affect all occupants of the building.
Deficiencies (7)
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads clean and free from debris, which could interfere with proper operation during an emergency.
K781 Portable Space Heaters: The facility failed to prevent the use of a portable space heater, which is prohibited in health care occupancies except in nonsleeping staff and employee areas.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure proper use of power strips and prohibited extension cords beyond temporary use, risking safety hazards.
A1097 Heating System, Space Heaters: The building failed to meet heating system requirements by allowing prohibited portable space heaters.
A2034 Sprinkler System-Test/Maintain: The facility failed to inspect, maintain, and test sprinkler systems in accordance with regulatory requirements.
A2058 Fire Drill/Emergency Preparedness - Plans: The facility failed to provide an annual fire department consultation form and maintain an up-to-date emergency plan.
A3030 Electrical Wiring & Equipment Maintained: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 standards.
Report Facts
Facility census: 59
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
Plan of Correction
Census: 43
Deficiencies: 2
Date: Jul 26, 2023
Visit Reason
The inspection was conducted to assess compliance with food preparation and service regulations, including food temperature requirements, at Oakdale Care Center.
Findings
The facility failed to provide nutritionally balanced meals with enough food to serve all residents and failed to maintain food at safe temperatures during meal service. These deficiencies had the potential to affect all residents.
Deficiencies (2)
19 CSR 30-86.052(1) Food Prep & Services, As Ordered: The facility failed to provide a nutritionally balanced meal with enough food to serve all residents. This affected three of six sampled residents.
19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 Degrees/Below: The facility failed to maintain food at a sufficient temperature during meal service, serving breaded fish at an unsafe temperature of 100 degrees Fahrenheit.
Report Facts
Facility census: 43
Residents affected: 3
Sampled residents: 6
Food temperature: 100
Food temperature: 148
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Date: Jun 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident medications by a staff member.
Complaint Details
Complaint #MO218704 was investigated. The complaint was substantiated as multiple medications were found missing and a staff member was arrested for theft.
Findings
The facility failed to ensure one resident was free from misappropriation when a staff member stole the resident's medications. Multiple controlled substances were found missing, and the staff member was arrested and terminated.
Deficiencies (2)
F602: The facility failed to ensure residents were free from misappropriation of medications when a staff member stole medications belonging to a resident. Multiple missing controlled substances were identified during the investigation.
A4055: The facility did not maintain a safe and effective medication system as evidenced by the misappropriation of medications described in F602.
Report Facts
Census: 61
Missing medications: 700
Medication counts: 242
Medication counts: 206
Medication counts: 101
Medication counts: 31
Medication counts: 30
Medication counts: 85
Medication counts: 49
Medication counts: 47
Cash found: 1000
Cash found: 123
Cash found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Staff member arrested and terminated for medication theft |
| Director of Nurses | Conducted investigation and reported findings of medication misappropriation | |
| Administrator | Notified by Director of Nurses and involved in investigation |
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
Plan of Correction
Census: 39
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's medication system and compliance with safe and effective medication administration regulations.
Findings
The facility failed to provide a safe and effective medication system when one resident went without pain relieving medication for 15 days due to delayed prescription refills and communication issues with the pharmacy and physician's office.
Deficiencies (1)
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to ensure all residents received medications timely, as one resident went without pain medication for 15 days due to refill delays and lack of documentation.
Report Facts
Facility census: 39
Days without pain medication: 15
Medication dosage: 5.325
Medication tablets: 30
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Nov 23, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding pest infestation, specifically bed bugs, at Oakdale Care Center.
Complaint Details
Complaint #MO00209773 was investigated. The complaint was substantiated based on observations and interviews confirming bed bug infestations in multiple resident rooms.
Findings
The facility failed to implement effective measures to minimize the presence of pests, particularly bed bugs, affecting multiple resident rooms. Observations and interviews confirmed widespread bed bug infestations with live and dead bugs found in several rooms and on residents.
Deficiencies (1)
19 CSR 30-87.020(39) Inspect/Rodent Control: The facility failed to implement effective measures to minimize the presence of bed bugs and other pests. Multiple rooms showed live and dead bed bugs on beds, walls, and furniture, and residents reported bites and infestations.
Report Facts
Facility census: 33
Bed bugs observed: 20
Bed bugs observed: 10
Bed bugs observed: 5
Bed bugs observed: 3
Bed bugs observed: 3
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 1
Date: Jul 29, 2022
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident with dried blood in his/her ears.
Complaint Details
The visit was complaint-related due to allegations of abuse and neglect involving a resident with dried blood in his/her ears. The investigation was found to be insufficient and not thoroughly conducted.
Findings
The facility failed to conduct a thorough investigation into the injury of unknown origin involving dried blood in a resident's ears. Staff did not document investigations or notify the resident's physician about the injury.
Deficiencies (1)
F610: The facility failed to conduct thorough investigations of alleged abuse or neglect when a resident had dried blood in his/her ears on two occasions. Staff did not document investigations or notify the resident's physician of the injury.
Report Facts
Facility census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director on Nursing | Director of Nursing | Interviewed regarding the investigation of the resident's injury |
| Administrator | Administrator | Interviewed regarding the investigation of the resident's injury |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 7
Date: Jun 23, 2022
Visit Reason
The inspection was conducted to evaluate compliance with fire safety and sprinkler system regulations, including fire drill/evacuation plans, fire alarm system inspections, sprinkler system inspections, emergency lighting, electrical wiring, and water heater safety.
Findings
The facility failed to meet several fire safety and sprinkler system requirements, including lack of annual fire department consultation, incomplete fire alarm system inspections, missing sprinkler system inspections and certifications, malfunctioning emergency lighting, unsafe electrical wiring, and missing water heater pressure relief drip legs. These deficiencies affected all 33 residents present during the inspection.
Deficiencies (7)
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation. The facility failed to request annual consultation and assistance from the local fire unit for review of fire and evacuation plans. The deficiency affected all 33 residents.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications. The facility failed to ensure the complete fire alarm system was tested annually and semi-annually with no current inspections on file. The deficiency affected all 33 residents.
19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. The facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, including missing inspector recalibration markings and no records of required five-year internal piping inspection. The deficiency affected all 33 residents.
19 CSR 30-86.022(12)(B) Emergency Lighting - Power Source. The facility failed to maintain the main emergency lighting in good repair; an emergency light failed to function during testing. The deficiency affected all 33 residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to properly maintain electrical wiring, including an open electrical outlet without a protective cover and lack of bi-annual electrical inspections. The deficiency affected all 33 residents.
State Statute A9998. The facility failed to maintain/install a drip leg on the water heater pressure relief valve, creating a potential hazard. The deficiency affected all 33 residents.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to maintain the sprinkler system, including missing replacement sprinkler heads and lack of UL testing. The deficiency affected all 31 residents present during the December 1, 2022 inspection.
Report Facts
Facility census: 33
Facility census: 31
Parts replacement wait time: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Sigman | General Manager | Named in plan of correction regarding sprinkler system repairs and parts ordering |
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 1
Date: Dec 8, 2021
Visit Reason
The visit was conducted to investigate and address a deficiency related to misappropriation/exploitation of narcotic medication for hospice residents.
Findings
The facility failed to prevent the misappropriation of narcotic medication by a Certified Medication Technician (CMT A) for eight hospice residents. The issue was identified through interviews and record reviews, and corrective actions including disciplinary measures and in-service training were initiated.
Deficiencies (1)
F 602: The facility failed to prevent misappropriation of narcotic medication by a Certified Medication Technician for eight hospice residents. The noncompliance was corrected on 12/6/21 after investigation and staff training.
Report Facts
Number of residents involved: 8
Facility census: 66
Medication diverted: 126
Medication diverted: 98
Medication diverted: 38
Medication diverted: 18
Medication diverted: 17.5
Medication diverted: 15
Medication diverted: 15
Medication diverted: 35
Medication diverted: 19.5
Medication diverted: 20.5
Medication diverted: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in narcotic medication misappropriation findings and corrective actions |
| Director of Nursing | DON | Responsible for medication control and involved in investigation |
| LPN A | Licensed Practical Nurse | Reported narcotic count discrepancies and observations during investigation |
| LPN B | Licensed Practical Nurse | Interviewed regarding narcotic counts and drug testing of CMT A |
| RN B | Registered Nurse | Interviewed about medication handling and shift handover with CMT A |
| Administrator | Interviewed about narcotic count discrepancies and corrective actions |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42-CFR-483-73 related to emergency preparedness and with CDC recommended infection control practices. No deficiencies were cited during this onsite visit.
Inspection Report
Life Safety
Census: 59
Deficiencies: 2
Date: Mar 24, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain fire extinguisher installation according to NFPA 10 standards and failed to maintain appropriate storage for oxygen tanks, potentially affecting all residents and staff.
Deficiencies (2)
K 355 Portable Fire Extinguishers: The facility failed to maintain fire extinguisher installation per regulation; the fire extinguisher in front of the cafe was mounted at 5 feet 5 inches above the ground, exceeding the maximum height of 5 feet.
K 923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain appropriate storage for oxygen tanks; observations showed an empty oxygen tank and an unsupported oxygen tank in the nurse's station, posing safety risks.
Report Facts
Facility census: 59
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 |
Inspection Report
Routine
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 2
Date: Sep 2, 2020
Visit Reason
The inspection was conducted to investigate deficiencies related to the management of residents' personal funds and to review the facility's compliance with regulations regarding fiduciary responsibilities and authorization for use of resident funds.
Findings
The facility failed to use residents' personal funds exclusively for their benefit and without proper written authorization. Withdrawals from residents' trust accounts were made without appropriate authorization from the residents' powers of attorney or guardians, violating regulatory requirements.
Deficiencies (2)
F 567: The facility did not use residents' personal funds exclusively for their benefit and failed to obtain written authorization for withdrawals from residents' trust accounts. Withdrawals were made without proper authorization from the residents' powers of attorney or guardians.
A9002: The operator or designated person did not use the personal funds of residents exclusively for their use and only when authorized in writing by the resident or their designee. This regulation was not met as referenced by F567.
Report Facts
Facility census: 63
Economic Impact Payment deposit: 1200
Withdrawal amount: 1170
Withdrawal amount: 40
Withdrawal amount: 1200
Withdrawal amount: 1200
Reimbursement amount: 1153.62
Reimbursement amount: 478.13
Reimbursement amount: 950.23
Inspection Report
Routine
Deficiencies: 0
Date: Sep 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Date: Aug 4, 2020
Visit Reason
The inspection was a COVID-19 focused emergency preparedness survey and complaint investigation related to pressure ulcer treatment and infection prevention and control.
Complaint Details
Complaint #M0172286 regarding infection prevention and control was investigated and substantiated.
Findings
The facility was found non-compliant with requirements for pressure ulcer prevention and treatment, including inadequate assessment and treatment of a resident's pressure ulcer. The facility also failed to establish and maintain an effective infection prevention and control program, including proper use of PPE and sanitization procedures.
Deficiencies (2)
F686: The facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for a resident with a stage 2 pressure ulcer. Documentation and wound care were inadequate, and the resident did not receive required nutritional support or wound care services.
F880: The facility failed to maintain an infection prevention and control program, including improper use of PPE by staff, failure to sanitize equipment properly, and lack of policies to prevent spread of COVID-19.
Report Facts
Facility census: 67
Facility census: 68
Inspection Report
Routine
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 5/28/20 to assess compliance with CMS and CDC guidelines and 42 CFR 483.73.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 2
Date: Oct 29, 2019
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding catheter care and adherence to physician orders.
Findings
The facility failed to follow physician orders to empty catheter bags each shift and document output for one resident. Documentation was missing for urine output for 58 shifts out of 93, and staff interviews revealed inconsistent catheter bag emptying practices.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders to empty catheter bags each shift and document output for one resident. Documentation was missing for urine output for 58 shifts out of 93.
A4074 Nursing Care per Resident Condition: The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice, as evidenced by deficiency F658.
Report Facts
Shifts without urine output documentation: 58
Facility census: 64
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Aug 2, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding respiratory care and oxygen administration for residents.
Complaint Details
Complaint #MO00158690 triggered the investigation. The complaint was substantiated as the facility failed to obtain physician orders for oxygen administration for residents.
Findings
The facility failed to obtain physician orders to ensure proper oxygen administration for two residents requiring respiratory care, including tracheostomy care and tracheal suctioning. Observations and record reviews confirmed residents were receiving oxygen without physician orders.
Deficiencies (1)
F695 Respiratory care, including tracheostomy care and tracheal suctioning, was not provided according to professional standards. The facility failed to obtain physician orders for oxygen administration for two residents requiring respiratory care.
Report Facts
Facility census: 62
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 3
Date: Jul 17, 2019
Visit Reason
The inspection was conducted to investigate complaint #MO158088 regarding catheter care and infection control practices at Oakdale Care Center.
Complaint Details
Complaint #MO158088 was investigated and substantiated based on observations and record reviews showing improper catheter care and infection control practices.
Findings
The facility failed to ensure proper handling of catheter collection systems, resulting in urine flowing backward into catheters and catheter bags being hung above bladder level or placed on the floor. Staff demonstrated lack of knowledge about proper catheter bag positioning and handling, increasing risk of infection.
Deficiencies (3)
F 690: The facility failed to ensure proper handling technique of catheter collection systems to prevent infection for three sampled residents. Catheter bags were hung above bladder level or placed on the floor, and urine was observed flowing backward into catheters.
A4074: Each resident did not receive nursing care consistent with current acceptable nursing practice as evidenced by improper catheter care. This deficiency is related to complaint #MO158088.
A4085: The facility failed to use acceptable infection control procedures to prevent spread of infection, including improper catheter care and failure to maintain catheter bags below bladder level. This deficiency is related to complaint #MO158088.
Report Facts
Facility census: 61
Number of sampled residents with catheter care issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide (CNA) A | Certified Nurses Aide | Observed handling catheter bag improperly |
| Nurses Assistant (NA) B | Nurses Assistant | Interviewed about catheter bag handling knowledge |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Interviewed about catheter bag handling knowledge |
| Director of Nursing | Interviewed regarding catheter bag positioning and staff training |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 4
Date: Jul 10, 2019
Visit Reason
The inspection was a fire safety inspection conducted on July 10, 2019, to assess compliance with fire safety regulations including smoke partitions, sprinkler systems, emergency lighting, and oxygen storage requirements.
Findings
The facility failed to meet several fire safety regulations including inadequate smoke partitions, lack of proper sprinkler system inspection documentation, emergency lighting not functioning properly, and improper oxygen storage. These deficiencies affected all 33 residents present during the inspection.
Deficiencies (4)
19 CSR 30-86.022(10)(0) Smoke Section Partitions > than 20 beds. The facility failed to ensure each smoke section is separated by one-hour fire rated construction partitions, leaving a six inch opening at the door seam that would allow smoke or fire to pass.
19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. The facility failed to inspect and maintain the sprinkler system according to NFPA 25, 1998 edition, with no current date stamping or inspector markings on sprinkler system pressure gauges.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. The facility failed to maintain emergency lighting in good repair and capable of operating for at least one and one-half hours; an emergency light in the medication room failed to function upon testing.
19 CSR 30-86.022(17) Oxygen Storage Requirements. The facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition; one oxygen cylinder was not stored in an approved rack or secured properly.
Report Facts
Facility census: 33
Inspection Report
Annual Inspection
Census: 59
Capacity: 70
Deficiencies: 15
Date: Apr 25, 2019
Visit Reason
Annual survey inspection of Oakdale Care Center to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity, failure to issue required Medicare notices, inadequate transfer/discharge notifications, failure to recognize significant changes in resident status, incomplete baseline care plans, inadequate infection control practices, and deficiencies in medication management and staff training.
Deficiencies (15)
F550 Resident Rights: The facility failed to ensure the dignity of one resident, including proper assistance with meals and hygiene.
F582 Medicaid/Medicare Coverage: The facility failed to issue required Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notices for three residents.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents and representatives in writing of transfers and discharges for two residents.
F637 Comprehensive Assessment After Significant Change: The facility failed to recognize and assess significant changes in one resident's status.
F655 Baseline Care Plan: The facility failed to develop and implement baseline care plans within 48 hours of admission for multiple residents.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement comprehensive care plans tailored to individual resident needs in a timely manner.
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders to discontinue medication for one resident and failed to review medication transcriptions properly.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide safe transfer techniques and adequate supervision to prevent accidents for two residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide proper care for residents with urinary and fecal incontinence and catheter care.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to ensure Certified Nurse Assistants received required annual in-service training.
F756 Drug Regimen Review, Report Irregular, Act On: The facility failed to ensure proper medication review and documentation for antipsychotic drugs and psychotropic medications.
F758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure appropriate diagnosis and documentation for use of psychotropic drugs for multiple residents.
F803 Menus Meet Resident Nds/Prep in Adv/Followed: The facility failed to follow approved menus and recipes, affecting 18 residents.
F838 Facility Assessment: The facility failed to conduct and review a comprehensive facility-wide assessment, delaying needed services for residents.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices, including proper care of residents with Foley catheters and hand hygiene.
Report Facts
Facility census: 59
Facility total capacity: 70
Sampled residents: 18
Deficiencies cited: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Boren Quipmo | Nurse and MDS Coordinator | Named as in-service nurse and MDS coordinator involved in care plan and assessment deficiencies |
| Director of Nursing | Named in interviews and responsible for monitoring care plans and staff compliance | |
| Assistant Director of Nursing | Named in interviews and responsible for monitoring care plans and staff compliance | |
| Cook C | Named in observation related to food preparation and serving | |
| Licensed Practical Nurse (LPN) D | Named in interview regarding transfer checklist and medication administration | |
| Certified Nurse Aide (CNA) E | Named in interview regarding resident care and dignity | |
| Certified Nurse Aide (CNA) F | Named in observation and interview regarding resident transfers and gait belt use | |
| Certified Nurse Aide (CNA) K | Named in observation regarding infection control and incontinence care | |
| Pharmacist J | Named in interview regarding medication review and psychotropic drug use | |
| Assistant Director of Nursing (ADON) | Named in interview regarding assessments and medication recommendations |
Inspection Report
Life Safety
Census: 59
Deficiencies: 5
Date: Apr 25, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to maintain means of egress free of obstructions, maintain a functioning fire alarm system, prohibit combustible decorations, maintain resident rooms free of overloaded power strips, and maintain correct oxygen cylinder storage. These deficiencies potentially affected all residents and staff.
Deficiencies (5)
K211 Means of Egress - General: The facility failed to maintain exit egress pathways free of obstruction, including a drug exit gate that was difficult to open. This affected all residents and staff.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain a functioning fire alarm initiating device; the fire alarm pull station did not function during testing.
K753 Combustible Decorations: The facility failed to maintain resident rooms free of combustible decorations, including candles, which were observed in multiple locations.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain resident rooms free of overloaded power strips, with power strips observed in use contrary to policy.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain correct oxygen cylinder storage; an unsupported freestanding tank was observed.
Report Facts
Facility census: 59
Inspection Report
Plan of Correction
Census: 30
Deficiencies: 1
Date: Feb 7, 2019
Visit Reason
The inspection was conducted to evaluate compliance with plumbing fixture temperature regulations accessible to residents, specifically regarding hot water temperature control.
Findings
The facility failed to ensure that plumbing fixtures accessible to residents were thermostatically controlled to keep hot water temperatures within the required range of 105-120 degrees Fahrenheit. Observations showed hot water temperatures exceeding 120 degrees Fahrenheit in multiple resident rooms.
Deficiencies (1)
19 CSR 30-86.032(34) Hot Water 105-120 Degrees F: Plumbing fixtures accessible to residents were not thermostatically controlled, resulting in hot water temperatures exceeding 120 degrees Fahrenheit in resident rooms. This posed a potential risk to all residents.
Report Facts
Facility census: 30
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 4
Date: Jan 23, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about wound care and pressure ulcer prevention and treatment at Oakdale Care Center.
Complaint Details
Complaint #MO151709 regarding treatment and services to prevent and heal pressure ulcers was substantiated with findings of deficient care and documentation.
Findings
The facility failed to follow physician's orders and provide proper treatment for wounds on one resident and failed to complete weekly skin assessments and treat pressure ulcers for another resident. Documentation and treatment orders were incomplete or missing, and staff did not consistently follow care plans.
Deficiencies (4)
F658: The facility failed to follow physician's orders and provide treatment for wounds on Resident #4, including incomplete wound care and missing treatment orders for some wound sites.
F686: The facility failed to complete weekly skin assessments and properly identify and treat pressure ulcers for Resident #5, with missing Braden scale assessments and inadequate documentation.
A4074: Nursing care per resident condition was not met, evidenced by deficiencies in wound care and pressure ulcer treatment as cited in F658 and F686.
A4082: Facilities failed to keep residents free from avoidable pressure sores and provide adequate treatment, as evidenced by findings in F686.
Report Facts
Facility census: 66
Number of sampled residents: 7
Number of sampled residents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wound care and skin assessments |
| Registered Nurse A | Registered Nurse (RN) | Responsible for wound care and interviewed about treatment orders |
Inspection Report
Life Safety
Census: 25
Deficiencies: 1
Date: Jun 21, 2018
Visit Reason
The inspection was conducted to review compliance with fire alarm system testing and maintenance requirements as part of a fire safety inspection.
Findings
The facility failed to ensure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition. The semiannual fire alarm system inspection was not performed as required.
Deficiencies (1)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: The facility failed to provide documentation for the semiannual fire alarm system inspection and did not ensure the fire alarm system was tested and maintained as required by NFPA 72, 1999 edition.
Report Facts
Facility census: 25
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 6
Date: Jun 8, 2018
Visit Reason
This document is a Plan of Correction submitted by Oakdale Care Center following a survey conducted on 06/08/2018. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including resident rights and dignity during meal times, care plan timing and revision, services meeting professional standards, skin integrity and pressure ulcer prevention, bowel/bladder incontinence management, and respiratory/tracheostomy care. Specific failures included staff standing while feeding residents, failure to update care plans, failure to follow physician orders, inadequate pressure ulcer care, and lack of physician orders for supplemental oxygen.
Deficiencies (6)
F550 Resident Rights: The facility failed to provide dignity to four residents during meal times as staff stood while feeding them instead of sitting.
F657 Care Plan Timing and Revision: The facility failed to update and revise care plans with specific interventions tailored to residents' needs for two residents.
F658 Services Provided Meet Professional Standards: The facility failed to follow physician's orders for one resident regarding medication.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: The facility failed to report, assess, and treat a wound on a resident's right hip, resulting in pressure ulcer risk.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide appropriate treatment and services for urinary and bowel incontinence for two residents.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to obtain a physician's order for supplemental oxygen therapy for one resident.
Report Facts
Facility census: 60
Extra doses given: 7
Pressure ulcer risk score: 14
Inspection Report
Life Safety
Census: 63
Deficiencies: 4
Date: Jun 8, 2018
Visit Reason
The inspection was a Life Safety Code (LSC) survey to assess compliance with fire safety and emergency egress requirements at Oakdale Care Center.
Findings
The facility failed to meet several provisions of the 2012 Existing Edition of the Life Safety Code, including obstructed means of egress, inadequate maintenance of cooking facilities and kitchen range hood, deficiencies in the sprinkler system, and failure to maintain portable fire extinguishers according to NFPA standards. The facility census was 63 at the time of inspection.
Deficiencies (4)
K211 Means of Egress - General: The facility failed to maintain exit pathways to a public way, with an exit pathway leading to a gate with two chains obstructing egress.
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood to NFPA standards, with no record of monthly checks and accumulation of grease and black carbon on filters.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the fire sprinkler system, with loaded sprinkler heads showing dust and debris and frangible bulbs not clear of fluid.
K355 Portable Fire Extinguishers: The facility failed to maintain all fire extinguishers to NFPA code, with an ABC class fire extinguisher last inspected in 11/2017 and lacking monthly inspections.
Report Facts
Facility census: 63
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