Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Oaks Caring Center during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter did not consistently receive or have documented catheter care as ordered by the physician. Multiple staff interviews revealed inconsistent practices and uncertainty about responsibility for providing and documenting catheter care. The resident reported that catheter care was only provided occasionally, and records showed numerous missed or undocumented care events, contributing to issues with catheter blockages and UTIs.
A resident with multiple medical conditions and on anticoagulant therapy developed extensive bruising, leading to an x-ray order and a temporary hold on medication. Despite facility policy requiring prompt notification, staff did not notify the resident's representative of these significant changes, and documentation confirming such notification was absent. Interviews with staff confirmed awareness of the bruising but could not verify that the family was informed.
Staff did not follow safe transfer procedures for a resident with significant mobility and medical needs, instead using an unsafe 'hug' technique when the resident refused a gait belt. The care plan lacked details on transfer methods, staff assistance required, or the resident's preferences, and staff continued to use improper techniques despite being trained on proper gait belt use.
A resident with dysphagia and on a pureed diet was left unsupervised in a non-resident area with accessible food, leading to a choking incident. The resident accessed the break room where pizza and garlic knots were left unattended by CNAs. Despite being redirected multiple times, the resident consumed non-pureed food, resulting in choking and requiring intubation. Staff failed to secure the area and provide necessary supervision, violating facility policy.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to implement and follow up on recommended interventions. Despite documented concerns about choking and dietary preferences, there was no follow-up on recommendations for a speech therapy consultation or medication review. Interviews with staff revealed a lack of communication and coordination, contributing to the resident's 17% weight loss.
A facility failed to provide a resident with a fully completed SNFABN, omitting the reason Medicare might not pay and the estimated cost. The resident chose to have Medicare billed, but the form lacked crucial information. A CMT explained that if the Social Services Director did not provide the amount, they had to determine it, often resulting in incomplete forms. The Administrator expected staff to complete the form with all necessary information.
A facility failed to refer a resident for a PASARR Level Two evaluation after the resident was diagnosed with a serious mental illness (SMI). The facility's policy required screening for mental disorders upon admission, but did not address new SMI diagnoses. The resident, diagnosed with bipolar disorder and prescribed Seroquel, did not have a Level Two PASARR submitted. The MDSC confirmed the oversight, and the administrator expected a referral for evaluation, which was not made.
A facility failed to ensure residents and their representatives were invited to care plan meetings and did not ensure full IDT participation. For a resident, care plan meetings lacked key IDT members, and there was no documentation of the resident or representative being invited. Family members reported not receiving notifications, and the facility's communication and documentation practices were inconsistent.
A facility failed to provide adequate pressure ulcer care and prevention for two residents. One resident, at risk for pressure ulcers, did not have a care plan with pressure-reducing interventions, and the wound care provider was not notified of an existing ulcer. Another resident, with Parkinson's, was not on a low air loss mattress as ordered, and a new wound was not documented. The facility's lack of communication and documentation led to inadequate care.
A facility failed to provide necessary behavioral health services for a resident with multiple mental health diagnoses, as required by the PASARR Level II evaluation. The resident did not receive a behavior support plan or crisis intervention services, despite these being specified in the evaluation. Interviews revealed that staff were unaware of the requirements, leading to the deficiency.
The facility failed to implement a 14-day stop date for PRN anti-anxiety medications for two residents, as required by federal regulations. One resident with Alzheimer's and anxiety was prescribed alprazolam without a stop date, and another with generalized anxiety disorder was given lorazepam PRN without a stop date. Despite recommendations from the pharmacist, the facility did not address the issue, and the medical director acknowledged challenges with the EMR system in ensuring compliance.
Expired furosemide tablets were found in a medication cart, indicating a failure to adhere to medication storage standards. A CMT confirmed the expiration, while the DON noted that carts should be cleaned and checked for expired medications twice a week, highlighting a discrepancy in practice.
Failure to Provide and Document Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received catheter care as ordered by the physician, and failed to document the provision of this care. The resident, who had diagnoses including neurogenic bladder and paraplegia, was dependent on staff for personal hygiene and had an order for catheter and peri care every shift, twice daily. Review of the Treatment Administration Record (TAR) and other documentation revealed multiple instances where staff did not initial or document completion of catheter care at the required times over a period of two months. Interviews with staff, including CNAs, a CMT, LPN, RN, the ADON, DON, and the Administrator, revealed inconsistent practices and uncertainty regarding who was responsible for completing and documenting catheter care. Some staff reported performing catheter care when emptying the catheter bag or during routine checks, while others were unsure if their colleagues were consistently providing or documenting the care. Several staff members indicated that if the TAR was blank, it likely meant the care was not completed or not documented, and some noted that documentation was the nurse's responsibility. The resident reported that staff emptied the catheter bag but only provided catheter care occasionally, with the last instance being the day before the interview. The resident also mentioned experiencing issues with catheter blockages and urinary tract infections. The facility did not provide a specific policy regarding catheter care, and the lack of documentation and inconsistent practices led to a failure to ensure the resident received catheter care as ordered, which is necessary to prevent urinary tract infections.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to provide timely notification to a resident's family member or representative after significant bruising was identified on the resident, which resulted in an ordered x-ray and temporary medication changes. According to the facility's policy, staff are required to promptly notify the resident, their physician, and their representative of any changes in the resident's condition, including injuries of unknown source, within 24 hours unless otherwise instructed by the resident. In this case, documentation and interviews confirmed that the resident's representative was not notified of the bruising, the x-ray order, or the medication hold, despite multiple opportunities and observations by staff. The resident involved had a history of heart failure, atrial fibrillation, tricuspid valve insufficiency, depression, and was taking an anticoagulant (Eliquis), which increased the risk of bruising. The resident was dependent on staff for most activities of daily living and was at risk for falls and impaired skin integrity. Staff observed extensive bruising on the resident's chest, torso, underarm, arms, and legs, and an x-ray was ordered due to pain, swelling, and bruising. Despite these significant changes in condition, there was no documentation that the resident's representative was notified, as required by facility policy. Interviews with various staff members, including CNAs, LPNs, the ADON, DON, RN, and the Administrator, revealed that while staff were aware of the bruising and discussed it in meetings, none could confirm that the resident's family had been notified. The resident also stated that their child is usually informed of changes in condition, but there was no evidence this occurred in this instance. Facility records, including progress notes and skin assessments, lacked documentation of any notification to the resident's representative regarding the bruising or related medical interventions.
Failure to Use Safe Transfer Methods and Care Plan Resident Preferences
Penalty
Summary
Staff failed to ensure a resident was transferred in a manner that prevented possible injury and did not include the resident's specific transfer needs or preferences in the care plan. The resident, who had a history of heart failure, atrial fibrillation, tricuspid valve insufficiency, depression, and a previous hip fracture, required substantial assistance with transfers and was at risk for falls, pain, and impaired skin integrity. The care plan did not specify the method of transfer, the number of staff required, or address the resident's preferences or refusals related to transfer assistance. Interviews and record reviews revealed that staff were trained to use gait belts for resident transfers, as outlined in facility policy. However, staff reported that the resident often refused the use of a gait belt, stating it was uncomfortable. Instead, staff used an unsafe 'hug' technique, where the resident placed their arms around the staff's neck and the staff lifted the resident under the arms. Multiple staff, including CNAs, LPNs, RNs, and nursing leadership, acknowledged that this method was not appropriate and did not align with facility policy or safe transfer practices. Despite the resident's refusal to use a gait belt, there was no documentation in the care plan regarding the resident's transfer preferences or refusals, nor was there an alternative safe transfer method identified. Staff continued to use the unsafe technique, and leadership confirmed that the resident required a gait belt for all transfers due to weakness. The lack of individualized care planning and failure to follow safe transfer procedures resulted in the area not being free from accident hazards and did not provide adequate supervision to prevent accidents.
Resident Chokes After Accessing Unsupervised Food Area
Penalty
Summary
The facility failed to ensure a safe environment for a resident who required supervision during meals, leading to a serious choking incident. The resident, who had a history of anoxic brain damage and dysphagia, was on a pureed diet with nectar-thick liquids and required supervision while eating. Despite these precautions, the resident was left unsupervised in a non-resident area where food was accessible, resulting in the resident attempting to consume non-pureed food, choking, and subsequently being intubated. On the day of the incident, a Certified Nursing Assistant (CNA) had ordered pizza and garlic knots and left them in the break room. The resident, who had been redirected multiple times from the break room, managed to access the area unsupervised when the CNA left to take other residents outside. The resident was later found in distress, unable to breathe, and required emergency medical intervention. The Heimlich maneuver was attempted by staff but was initially unsuccessful, and the resident's condition deteriorated, necessitating intubation and hospital transfer. Interviews with staff revealed that the break room door, which should have been locked, was left open, allowing the resident to access the food. The Director of Nursing and the Administrator both acknowledged that the staff failed to follow the facility's policy regarding supervision and securing non-resident areas. The incident highlighted a significant lapse in ensuring resident safety and adherence to dietary restrictions, resulting in severe consequences for the resident involved.
Failure to Address Resident's Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to provide adequate care and services to maintain the nutritional status of a resident, leading to significant weight loss. The resident, who had a history of schizoaffective disorder, depression with anxiety, hypothyroidism, and GERD, was admitted with a weight of 128.8 pounds. Despite being identified as at risk for weight loss and dehydration, the facility did not implement or follow up on multiple interventions recommended by healthcare professionals. These included dietary modifications, a speech therapy consultation for swallowing difficulties, and a review of the resident's medication, Topamax, which could contribute to weight loss. The resident expressed concerns about choking on food and medication, which were documented by staff but not followed up with appropriate actions. The resident's preference for softer foods and a pureed diet was noted, yet there was no documented follow-up on these preferences or the recommendations for a speech therapy consultation. Additionally, dental issues were identified, but again, there was no documented follow-up. The resident's weight decreased by 22.2 pounds, a 17% loss, over a period of time, indicating a failure to address the resident's nutritional needs adequately. Interviews with facility staff, including the CNP, Medical Director, DON, and Administrator, revealed a lack of communication and follow-up on documented recommendations. The DON admitted to not reviewing progress notes that contained critical intervention recommendations, and the Administrator could not provide evidence of weekly weight loss meetings that were supposed to address such issues. This lack of coordination and communication among staff contributed to the resident's significant weight loss and the facility's failure to maintain the resident's nutritional status.
Incomplete SNFABN Issued to Resident
Penalty
Summary
The facility failed to issue accurate and fully completed Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to a resident reviewed for beneficiary notice. The resident, admitted for Medicare A services, received an SNFABN indicating their choice to have Medicare billed for an official decision on payment. However, the form lacked documentation on why Medicare might not pay and the estimated cost of services. During interviews, a Certified Medical Technician (CMT) revealed that if the Social Services Director did not provide the amount, the CMT had to determine it, often resulting in the amount not being included on the SNFABN. The CMT verbally communicated the cost per day to residents if they wished to continue services. The facility's Administrator expressed expectations for staff to complete the form with all necessary information to inform residents of service costs.
Failure to Refer Resident for PASARR Level Two Evaluation
Penalty
Summary
The facility failed to refer a resident for a Pre-Admission Screening and Resident Review (PASARR) Level Two evaluation after the resident was diagnosed with a serious mental illness (SMI). The facility's policy, revised in March 2019, required all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASARR process. However, the policy did not address the procedure for when a new SMI diagnosis is given to a resident. The resident in question was admitted and readmitted with a diagnosis of bipolar disorder in partial remission and was prescribed Seroquel, an antipsychotic medication, for bipolar disorder, anxiety disorder, and depression. The Minimum Data Set Coordinator (MDSC) was responsible for all PASARRs and confirmed that the resident's PASARR Level One screening, dated December 31, 2021, did not identify any mental illnesses, resulting in a negative outcome for a Level Two evaluation. Upon reviewing the resident's physician orders and diagnoses, the MDSC acknowledged that the resident was receiving antipsychotic medication for the SMI of bipolar disorder but had not submitted a Level Two PASARR as required. The facility administrator expected that a significant change, such as the diagnosis of bipolar disorder, would have prompted a submission for a PASARR Level Two evaluation, which did not occur.
Deficiency in Care Plan Meeting Participation and Notification
Penalty
Summary
The facility failed to ensure that residents and their representatives were invited to care plan meetings and did not ensure full participation of the Interdisciplinary Team (IDT) in these meetings. Specifically, for one resident, the care plan meetings were attended by limited IDT members, and there was no documentation of the resident or their representative being invited. The facility's policy requires the IDT, along with the resident and their family or legal representative, to develop and implement a comprehensive, person-centered care plan. However, the facility did not adhere to this policy, as evidenced by the absence of key IDT members and the lack of resident or representative involvement in the care planning process. Interviews with family members revealed that they were not consistently notified of care plan meetings, with some family members only attending two or three meetings over several years. The MDS Coordinator indicated that notifications were supposed to be sent with monthly statements, but family members reported not receiving them. The Social Services Director stated that letters were mailed to family members but were not sent by certified mail, and no tracking log was maintained. The Administrator confirmed that while certain staff members were invited to the meetings, attendance was inconsistent, and family members who did not attend were updated via phone. This lack of consistent communication and documentation contributed to the deficiency in care planning for the resident.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for Resident #4, who was at risk for developing pressure ulcers and had a stage three pressure ulcer. The facility did not consistently assess and document the full assessments of the pressure ulcer, nor did they care plan and implement preventative measures. The resident's care plan lacked interventions for pressure-reducing devices, and the wound care provider was not notified of the pressure ulcer on the resident's right posterior thigh. The resident reported that the facility had not offered any pressure-reducing devices, and the Director of Nursing confirmed that the wound care provider had not been made aware of the open area on the resident's thigh. Resident #31 also experienced a deficiency in care related to pressure ulcer prevention. The resident, who had Parkinson's disease, was supposed to have a low air loss mattress and bolsters as per hospice orders. However, the resident was not on a low air loss mattress, and the facility failed to document the new wound on the resident's left inner elbow. The hospice nurse confirmed that the low air loss mattress was delivered and then picked up at the facility's request, and the DON was unaware of why the resident was no longer on the mattress. The facility's failure to provide appropriate pressure ulcer care and prevention for both residents highlights a lack of communication and documentation. The nursing staff did not follow the facility's policy on pressure ulcer care, which includes assessing and documenting risk factors, describing and documenting full assessments of pressure sores, and ensuring the wound care provider is notified. These deficiencies resulted in inadequate care for residents at risk of or with existing pressure ulcers.
Failure to Provide Required Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident, as required by the PASARR Level II evaluation. The resident, who was admitted with diagnoses including bipolar disorder, major depressive disorder, delusional disorder, insomnia, and generalized anxiety disorder, did not receive a behavior support plan or crisis intervention services. The PASARR Level II evaluation specified that the facility should provide a behavior support plan, structured environment, and crisis intervention services, but these were not documented in the resident's medical records. Interviews with facility staff revealed a lack of awareness and understanding of the requirements outlined in the PASARR Level II evaluation. The Minimum Data Set Coordinator admitted to not noticing the need for these services, and the Medical Director expressed an expectation that such services should have been provided. The Administrator was also unaware that the PASARR Level II evaluations indicated specific services that needed to be ensured by the facility. This lack of awareness and failure to implement the necessary behavioral health services led to the deficiency.
Failure to Implement 14-Day Stop Date for PRN Anti-Anxiety Medications
Penalty
Summary
The facility failed to implement a 14-day stop date for the PRN use of anti-anxiety medications for two residents, which is a requirement under federal regulations. Resident #39, who was admitted with diagnoses including Alzheimer's disease, depression, anxiety disorder, and unspecified dementia, was prescribed alprazolam for anxiety. The resident's care plan indicated the use of psychotropic medications, and the physician orders included alprazolam to be administered twice daily with an additional PRN dose. However, there was no documentation in the progress notes regarding the rationale for the continued use of the medication, and the PRN order did not include a 14-day stop date. Interviews with the LPN, pharmacist, and medical director confirmed the absence of the stop date, despite recommendations from the pharmacist to address this issue. Similarly, Resident #64, diagnosed with generalized anxiety disorder, was prescribed lorazepam PRN for anxiety without a stop date. The consultant pharmacist had recommended adding a stop date, but this was not implemented. The medical director acknowledged awareness of the requirement for PRN medications to have a stop date and noted that the transition to an EMR system had complicated the process of ensuring compliance. The facility's administrator expected physicians to adhere to federal regulations, but the deficiency persisted, indicating a lapse in the facility's medication management practices.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to store medications according to standards of practice when expired medications were not removed from a medication cart containing current medications for administration to residents. During an observation, a medication card of furosemide 20 mg tablets, which had expired on 12/03/24, was found in the bottom drawer of the medication cart for Hall 200 and Hall 300. A Certified Medical Technician confirmed the expiration and stated that expired medications were typically given to nurses for destruction, with carts being cleaned weekly and checked for expired medications. However, the Director of Nursing indicated that medication carts should be cleaned and checked for expired medications twice a week, suggesting a discrepancy in practice.
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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.
Illustrative
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Nursing homes near Mountain Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kabul Nursing Homes Inc | 8.6 mi | ★★★★★ | 7 | 0 |
| Rocky Ridge Manor | 13.6 mi | ★★★★★ | 3 | 0 |
| Hartville Care Center | 16.4 mi | ★★★★★ | 0 | 0 |
| Willow Care Nursing Home | 18.2 mi | ★★★★★ | 8 | 0 |
| Houston House | 19.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.