Autumn Oaks Caring Center: Catheter Care Gaps - MO
The inspection, conducted following a complaint, centered on a single resident with a urinary catheter. Physician's orders required catheter care to be completed each shift. That order was reflected on the Treatment Administration Record, or TAR, where staff were expected to sign off after completing the task. Inspectors found entries missing.
A registered nurse interviewed during the inspection said she performs catheter care for the resident personally, but added she doesn't know whether others do. When asked about the blank TAR entries, she offered a theory: it might be the treatment nurse, who doesn't work long shifts and may forget to sign off. She said she believes staff are doing the care. She also noted the resident's catheter gets flushed often, as though the frequency of flushes offered some reassurance about the care more broadly.
The Assistant Director of Nursing described the system more precisely. The treatment nurse completes catheter care once per shift and signs the TAR. Aides can also perform catheter care. But on the question of blank entries, the ADON was direct: from anyone else's standpoint, a blank TAR means the care hasn't been completed. She said she expected staff to complete catheter care as ordered and document it accordingly.
The Director of Nursing said catheter care should happen when staff are changing the resident or emptying the catheter bag. Nurses, the DON said, are ultimately responsible, even when aides perform the task, because nurses are required to visibly oversee the care and sign off on the TAR. If a nurse doesn't see the aide complete it, the nurse should complete it herself and document it. Then came the clearest statement in the entire record: "If the TAR doesn't have documentation, it wasn't done." In the same interview, the DON said she believes the catheter care is being completed.
Those two positions sat side by side without resolution. The TAR was blank. Blank means it wasn't done. And yet: she believes it was done.
The Administrator's interview followed the same pattern. Staff should document catheter care each shift. The treatment nurse or night shift nurse handles it. If there's a blank space on the TAR, he said, they probably forgot to document the care. He expected staff to follow physician's orders and record what they provided.
The phrase "probably forgot to document" appeared to be the facility's working explanation for the gaps. The care happened; someone just didn't write it down. It is a common defense in nursing home inspections, and it is impossible to disprove. It is also, by the standard the DON herself articulated, insufficient. Documentation is the record. Without it, there is no way to know whether a resident received the infection-preventing care a physician ordered for them, shift after shift.
Catheters carry real risks. A urinary catheter that isn't cleaned regularly becomes a direct pathway for bacteria into the bladder. Catheter-associated urinary tract infections are among the most common healthcare-acquired infections, and in elderly residents they can escalate quickly into serious illness. The ordered care exists for a reason.
What the inspection record shows is a facility where the responsibility for catheter care was distributed across nurses, treatment nurses, and aides, with no mechanism that reliably ensured the task was completed or recorded. The registered nurse thought others were probably doing it. The ADON said a blank TAR means it wasn't done. The DON said it wasn't done if it wasn't documented, and also that she believes it was done. The Administrator said staff probably just forgot to write it down.
The resident at the center of this complaint had a catheter that required attention every shift. Whether that attention arrived, consistently, is something the facility's own records cannot confirm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Oaks Caring Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AUTUMN OAKS CARING CENTER in MOUNTAIN GROVE, MO was cited for violations during a health inspection on November 20, 2025.
The inspection, conducted following a complaint, centered on a single resident with a urinary catheter.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.