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Complaint Investigation

Autumn Oaks Caring Center

Inspection Date: November 20, 2025
Total Violations 1
Facility ID 265406
Location MOUNTAIN GROVE, MO
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Inspection Findings

F-Tag F0690

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurses have a place in the electronic health record where the care is recorded;-He/she does catheter care for the resident, but he/she doesn't know if others do it.During an interview on 09/26/25, at 2:17 P.M., Registered Nurse (RN) E said the following:-Staff should be doing catheter care each time peri care is completed;-The TAR has an order for catheter care to be done each shift;-The nurses are responsible for completing catheter care and signing it off as being complete on the TAR;-If the TAR is blank, he/she thinks

it may be the treatment nurse that doesn't work long and may forget to sign it off as being completed;-He/she believes staff are doing catheter care for the resident. He/she also has his/her catheter flushed a lot.During an interview on 09/26/25, at 4:15 P.M., the Assistant Director of Nursing (ADON) said

the following:-The treatment nurse completes catheter care one time per shift. They sign off the TAR saying

the task has been completed. The aides can also do catheter care;-If the TAR is blank, from other's standpoint it would mean the catheter care hasn't been completed;-He/she expected staff to complete catheter care as ordered and check it off has being completed.During an interview on 09/26/25, at 3:11 P.M., the Director of Nursing (DON) said the following:-Staff should be completing catheter care when they're changing the residents or when emptying the catheter bag;-Catheter care is on the TAR to be completed each shift. The nurses are ultimately responsible. The aides can do catheter care, but he/she expected the nurse to visibly oversee the care be completed as they're ultimately responsible for the task being completed and they sign that off on the TAR;-If the nurse doesn't see the aide complete the catheter care, the nurse should be completing the catheter care and signing the TAR:-If the TAR doesn't have documentation, it wasn't done;-Staff are in the resident's room often doing flushes. He/she believes the catheter care is being completed;-Staff should be following the orders for catheter care. During an interview

on 09/26/25, at 3:37 P.M., the Administrator said the following:-Staff should be completing catheter care each shift. The treatment nurse does it each shift or the night shift nurse;-The nurses should be documenting on the TAR when they complete the catheter care;-If there is a blank space on the TAR, they probably forgot to document the care;-He/she expected staff to document the care's provided and follow physician's orders.Complaint 2627706

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📋 Inspection Summary

AUTUMN OAKS CARING CENTER in MOUNTAIN GROVE, MO inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MOUNTAIN GROVE, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AUTUMN OAKS CARING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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