Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Oakdale Care Center during CMS and state inspections, most recent first.
Unsafe Food Storage and Unsanitary Kitchen Conditions: Food service staff left uncovered desserts and drinks out, stored prepared foods on counters, thawed frozen food on a cart near a mop bucket, and kept multiple unlabeled or improperly stored food items in the kitchen and dry storage areas. Surveyors also found heavy grime, debris, and buildup on the ice machine, range, can opener, oven, fryer, vents, and dishwashing area, along with damaged refrigeration units, dented cans, and a hole in the wall near food service storage. Staff interviews confirmed food was sometimes left out after meals and cleaning logs had not been maintained for months to a year.
A resident with anxiety and depression had a PRN lorazepam order without the required 14-day stop date, and another resident receiving aripiprazole had no documented diagnosis supporting the antipsychotic use. The DON and Administrator acknowledged that PRN psychotropics should have a 14-day stop date and that all medications should have an appropriate diagnosis.
Expired medications were found in a CMT medication cart for two residents, including atropine with visible residue and hydralazine tablets past expiration. One resident also received atropine well after the expiration date. The DON said staff, pharmacy, and the CMT routinely checked for expired meds, but the expired medication remained in the cart.
The facility failed to maintain sanitary conditions in food storage and distribution, affecting all residents. Observations revealed undated and unlabeled food items, dirty kitchen equipment, and uncovered food and drinks on meal carts. Staff interviews confirmed that these practices were against facility policies.
A facility failed to provide written notification to a resident and their representative regarding a transfer to the hospital. The policy lacked a requirement for written notification, and staff interviews revealed inconsistencies in the notification process. The deficiency involved a resident transferred for medical evaluation and readmitted without documented written notification.
A facility failed to inform a resident and their representative of the bed hold policy in writing during a hospital transfer. Staff interviews revealed inconsistencies in the notification process, with no documentation of written communication provided as required.
A facility failed to complete a comprehensive discharge summary for a resident who was discharged home. The resident's medical record lacked documentation of a discharge summary or recapitulation. The Administrator confirmed that the discharge summary should have been completed, with social services responsible for discharge planning. The Social Services Designee admitted to missing the completion of the discharge summary and acknowledged responsibility for the oversight.
The facility failed to properly manage urinary catheter drainage bags and tubing for two residents, leading to deficiencies in care. A resident's catheter bag was observed touching the floor and being raised above bladder level, while another resident's catheter bag and tubing were frequently on the floor and visible without a privacy cover. Staff interviews confirmed these practices were against facility policy.
The facility did not post the required daily nurse staffing information, including total staff numbers and hours worked by licensed and unlicensed nursing staff, in a prominent location. Observations showed the designated whiteboard was either incomplete or blank over several days. Interviews with the DON and Administrator confirmed the oversight, revealing a failure to update the board with necessary details.
The facility failed to properly store and handle Lantus insulin pens, as two pens were found in the medication cart 32 days after opening, exceeding the manufacturer's 28-day discard recommendation. Staff interviews revealed inconsistencies in understanding the policy, with the Corporate RN emphasizing adherence to manufacturer instructions, while the ADON incorrectly stated a 30-day usage period. The Administrator expected compliance with the policy.
The facility failed to maintain a closed dumpster, leading to repeated observations of the lid being left open and debris scattered around the area. Staff interviews confirmed the expectation that the dumpster lid should be closed and the area kept clean, but these practices were not consistently followed.
The facility failed to follow proper infection control techniques during incontinent care for multiple residents, including not performing hand hygiene and improper glove use. Additionally, trash and biohazard materials were improperly stored, and a resident on contact precautions shared a bathroom with another resident, increasing infection risks.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions. During observations, uncovered desserts and cups of tea were left on a food cart in the dining room, and multiple prepared foods were left uncovered or stored on counters in the kitchen, including roasted chicken, gravy, mashed potatoes, and other items near the reach-in refrigerator. Several food items were also found improperly stored or unlabeled, including cereal containers, cheese slices, sliced potatoes, ham slices, gelatin on cookie sheets, oatmeal, sugar, rice with a black substance on top, and breadcrumbs in an unlabeled container. Frozen hamburger rolls were observed thawing on a lower bread rack near an open mop bucket half filled with dark colored water. The kitchen and food service equipment were observed with extensive buildup and debris. The ice machine had white grime on the exterior and interior plastic surfaces, brown substance in the ventilation louvers, and debris and black grime on the floor and drain line beneath it. The commercial gas range, can opener, stack oven, deep fryer, ceiling diffuser, wall diffuser, and fan all had visible grime, dust, oily buildup, or carbon buildup. In the dishwashing area, the dishwasher exterior had flaky white grime, the floor and plumbing pipes had scattered debris and oily film, and the ceiling over the three-compartment sink drooped down with a crack and a light fixture drooped on one end. There was also a hole in the wall near an electrical outlet in the area used for food service items. Dry storage and refrigeration were also found in poor condition. The freezer had heavy ice formation, the refrigerator had a door gap, damaged gasket, and ice buildup, and bread loaves were stored inside it. Several dented cans were found on the shelf without expiration dates, and other canned goods and bulk food containers were unlabeled. During interviews, the Dietary Manager stated that foods should not be left out on counters, frozen food should be thawed in the refrigerator, the refrigerator gasket needed replacement, the freezer needed cleaning and defrosting, and the kitchen and dishwashing areas needed cleaning. Staff also stated that foods were sometimes left out after meals for residents and that cleaning logs had not been maintained for months to a year.
PRN Psychotropic Orders Lacked Required Stop Date and Antipsychotic Lacked Diagnosis
Penalty
Summary
The facility failed to limit the use of PRN psychotropic medication orders to 14 days for one resident with diagnoses of anxiety and depression. The resident’s physician order sheet showed an order for lorazepam concentrate 0.5 ml by mouth every one hour PRN for pain and shortness of breath, dated 02/28/25, and the record did not include a 14-day stop date. A later GDR note dated 01/06/26 showed the pharmacist requested a decrease in lorazepam, and the physician documented continuing the PRN lorazepam dose due to increased anxiety and agitation related to the disease process, but no stop date was addressed. The facility also failed to ensure an appropriate diagnosis was documented for the use of an antipsychotic medication for another resident. That resident’s record listed diagnoses of DM, acute kidney failure, metabolic encephalopathy, unspecified altered mental status, cognitive communication deficit, and repeated falls, and the physician order sheet showed aripiprazole 5 mg by mouth once daily, dated 11/07/25, with no documentation of a diagnosis for the medication. During interviews, the DON stated most PRN psychotropics should have a 14-day stop date and that all medications should have a diagnosis appropriate for their use, and the Administrator stated there should be a 14-day stop date on any PRN psychotropic medications and that all medications should have an appropriate diagnosis.
Expired Medications Left in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from one of two sampled medication carts, involving medications for two residents. On observation of the Certified Medication Technician medication cart, Resident #11 had a half bottle of atropine 1% drops with a thick white substance stuck to the inside of the bottle, dated 01/25/25 with an expiration date of 07/2025, and Resident #57 had a box of eight tablets of hydralazine 10 mg dated 01/29/25 with an expiration date of 01/28/26. The facility policy titled, Medication Storage In The Facility, stated that outdated, contaminated, or deteriorated drugs and those in containers that are cracked, soiled, or without secure closures would be immediately withdrawn from stock. Record review showed Resident #11 received atropine 1% drops on 12/12/25, which was 134 days after the expiration date. During interviews, the DON stated staff should look every day while in the medication cart for expired medications and said pharmacy had gone through the carts five days earlier as part of quarterly checks. The DON also said she looked through the carts every few weeks for expired medications. The CMT said he/she looked for expired medications on Mondays, and the Administrator said staff and pharmacy routinely checked the medication cart for expired medications and expected the expired medication to be found.
Sanitation and Food Labeling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and distribution, which could potentially affect all 55 residents. Observations on multiple days revealed several issues in the kitchen, including the absence of cleaning logs, debris under food preparation tables, and dirty cooking equipment. Additionally, 20 fluorescent lights in the kitchen were found without covers. The facility's policy required proper labeling of food items, but numerous food items in the refrigerator, freezer, and dry pantry were found undated and unlabeled, including bags of greens, lunch meat, pizza sticks, hot dogs, bread, and various pantry items. Further observations of meal carts in the facility showed uncovered food and drinks being distributed to residents. On different occasions, uncovered cakes, cookies, and drinks were noted on meal carts in various halls. Interviews with the Dietary Manager, Administrator, Assistant Director of Nursing, and a Certified Nursing Assistant confirmed that food and drinks should be covered, and all food items should be dated and labeled. However, these practices were not consistently followed, leading to the identified deficiencies.
Failure to Provide Written Notification for Resident Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and their representative regarding a facility-initiated transfer to the hospital. The deficiency involved one resident who was transferred to the hospital for medical evaluation and subsequently readmitted to the facility. The facility's policy on emergency transfers did not include a requirement for written notification to the resident or their representative, which contributed to the oversight. Interviews with facility staff, including LPNs, the Assistant Director of Nursing, the Administrator, and the Social Services Designee, revealed inconsistencies in the process of notifying residents and their representatives about transfers. Staff members indicated that the charge nurse was responsible for completing the transfer/discharge form, and if the resident was unable to sign, the family or guardian was contacted by two nurses. However, there was no documentation of written notification being provided to the resident or their representative, as required.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to inform a resident, their family, or legal representative of the bed hold policy in writing at the time of transfer to the hospital. This deficiency was identified for one resident out of a sample of 55. The resident was transferred to the hospital and later readmitted to the facility, but there was no documentation indicating that the bed hold policy was communicated in writing at the time of transfer. Interviews with facility staff, including LPNs, the Assistant Director of Nursing, the Administrator, and the Social Services Designee, revealed inconsistencies in the process of notifying residents or their representatives about the bed hold policy. Staff members described a procedure where the charge nurse or resident's nurse was responsible for completing the bed hold form, and if the resident was unable to sign, the family or guardian was to be contacted by two nurses. However, the process was not consistently followed, and there was no evidence of written notification being provided as required.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for a resident who was discharged home. The facility's census was 55, and the deficiency was identified for one resident out of one discharged resident. Upon review of the resident's closed medical record, it was found that there was no documentation of a discharge summary or recapitulation. During interviews, the Administrator acknowledged that the discharge summary should have been completed and stated that social services were responsible for discharge planning, which should begin as soon as residents are admitted. The Social Services Designee admitted to missing the completion of the discharge summary and acknowledged responsibility for the oversight.
Improper Catheter Care and Management
Penalty
Summary
The facility failed to ensure proper management of urinary catheter drainage bags and tubing for two residents, leading to deficiencies in care. For Resident #9, observations revealed that the catheter drainage bag was improperly positioned, touching the wheelchair wheel and the floor. Additionally, a Certified Nursing Assistant (CNA) was observed lifting the catheter drainage bag above the level of the resident's bladder, causing urine to flow back towards the bladder. This action contradicts the facility's policy, which mandates that catheter tubing and drainage bags be kept off the floor and not raised above the bladder level. Resident #21 also experienced improper catheter care. Observations showed that the catheter drainage bag and tubing frequently touched the floor and were visible without a privacy cover, both in the resident's room and in common areas. The catheter drainage bag was seen dragging on the floor as the resident moved in a wheelchair, and the tubing was exposed to other residents, family members, and staff. These observations indicate a failure to maintain the dignity and hygiene standards required for catheter care. Interviews with staff, including a CNA, an LPN, the Director of Nursing (DON), and the Administrator, confirmed that the catheter drainage bags and tubing should not touch the floor or be raised above the bladder level. Despite this understanding, the facility did not ensure compliance with these standards, resulting in the observed deficiencies in catheter care for the residents involved.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a prominent location accessible to residents and visitors. The facility's policy, dated July 2014, mandates that staffing information, including the total number of staff and actual hours worked by both licensed and unlicensed nursing staff, be posted at the start of each shift. However, observations on multiple days revealed that the whiteboard behind the nurse's station, designated for this purpose, was either incomplete or blank. Specifically, the board did not include the total number of staff or the actual hours worked by unlicensed nursing staff directly responsible for resident care. Interviews with the Director of Nursing (DON) and the Administrator confirmed the oversight. The DON acknowledged that the whiteboard was intended for posting the required staffing information but admitted that it did not include unlicensed nursing staff. The Administrator further explained that the board should be updated daily with the date, census, and nursing staff details, including unlicensed staff, but this was not being done. This failure to post the required information was observed over several days, indicating a systemic issue in maintaining compliance with the staffing information posting requirement.
Improper Storage and Handling of Insulin Pens
Penalty
Summary
The facility failed to store medications in a safe and effective manner, specifically regarding the handling of Lantus insulin pens. During an observation, two Lantus pens were found in the nurse medication cart with an opened date of 32 days prior, exceeding the manufacturer's recommended discard period of 28 days after opening. Interviews with facility staff revealed inconsistencies in understanding and implementing the policy for insulin pen expiration. The Corporate RN stated that the facility's policy was to follow the manufacturer's instructions, while the LPN acknowledged the need to date and discard insulin pens within the designated time frame. The ADON incorrectly stated that Lantus was good for 30 days once opened, and the Administrator expected nurses to adhere to the policy regarding insulin pen usage.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that a dumpster was closed at all times and maintained to keep pests out and garbage contained. Observations over several days showed the dumpster lid was repeatedly left open, with trash bags protruding above the top of the dumpster and debris scattered around the area. Specific observations included the dumpster lid being open at various times, and a twenty-foot radius of debris, including gloves, masks, plastic, paper, and plastic silverware, was noted on the ground. Additionally, a black trash bag containing kitchen trash was found on the ground between two recycling dumpsters. Interviews with the Dietary Manager, Maintenance Director, and Administrator confirmed that the dumpster lid should be closed after discarding trash, and staff were responsible for maintaining cleanliness around the dumpster area.
Infection Control Deficiencies in Resident Care and Waste Management
Penalty
Summary
The facility failed to adhere to proper infection control techniques during incontinent care for several residents, including Residents #9, #21, #48, and #205, as well as one resident outside the sample. Observations revealed that staff did not perform hand hygiene before and after providing care, did not change gloves between dirty and clean tasks, and placed soiled items on inappropriate surfaces such as the floor or bedside tables without barriers. These actions were contrary to the facility's policies on handwashing, perineal care, and catheter care, which emphasize the importance of hand hygiene and proper handling of soiled materials to prevent infections. Additionally, the facility failed to properly store and dispose of trash and regulated medical waste. Observations showed that trash barrels were overflowing, and biohazard materials were improperly stored in areas like the emergency eye wash station room and the soiled utility room. Housekeeping staff were observed handling trash without changing gloves or performing hand hygiene, further contributing to the risk of infection spread. The facility lacked a specific policy for infection control practices related to trash and medical waste storage and disposal. Resident #205, who was on contact precautions for ESBL and MRSA, was observed sharing a bathroom with another resident, which is against infection control protocols. Staff did not follow proper PPE protocols when providing care to this resident, and the shared bathroom situation posed a risk of spreading infections. Interviews with staff, including the ADON and DON, confirmed that the resident should not have been sharing a bathroom and that proper PPE should have been used during care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Poplar Bluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor, The | 1.7 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Poplar Bluff | 1.7 mi | ★★★★★ | 2 | 0 |
| Cedargate Health Care Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Westwood Hills Health & Rehabilitation Center | 4.7 mi | ★★★★★ | 6 | 0 |
| Puxico Nursing And Rehabilitation Center | 17.7 mi | ★★★★★ | 5 | 0 |
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