Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to update one sampled resident’s
(Resident #36) care plan for weight loss and to update one sampled resident’s (Resident
#35) care plan for infections/isolation out of 18 sampled residents. The facility census
was 76 residents.
Record review of the facility’s Care Plan Information Update dated 05/2006 showed care
plans must be updated as changes occur, not just quarterly.
1. Record review of Resident #36’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool required to be completed by facility staff for care planning)
dated 3/1/19 showed the resident:
-Was severely cognitively impaired.
-Required set up help with eating and
-Weighed 118 pounds.
Record review of the resident’s weight log on 3/13/19 showed he/she weighed 118 pounds.
Record review of the resident’s weight log on 4/30/19 showed he/she weighed 112 pounds.
Record review of the resident’s RD’s Progress Notes dated 4/30/19 showed:
-The resident had a significant weight loss of six pounds in one month.
-The weight loss did follow a gain with a recent hospital stay and
-He/she recommended the resident would start a house supplement twice a day with meals and
further monitor weight and intake.
Record review of the resident’s nutrition Care Plan on 5/13/19 showed:
-The resident required a mechanical soft diet and nectar thick liquids due to a [DIAGNOSES
REDACTED].
-The resident’s weight loss was not updated on the care plan.
During an interview on 5/14/19 at 12:31 P.M. Licensed Practical Nurse (LPN) C (also the
MDS Coordinator) said the nurse would update the care plan to reflect the weight loss and
intervention.
During an interview on 5/15/19 12:02 P.M. the Director of Nursing (DON) said:
-The weight loss should be updated by the MDS Coordinator to the resident’s care plan and
-This was completed by reviewing the physician’s telephone orders.
2. Record review of Resident 35’s face sheet showed he/she was admitted to the facility on
[DATE] with the [DIAGNOSES REDACTED].
Record review of Resident’s Quarterly MDS dated [DATE] showed the resident:
-Was moderately impaired cognitively.
-Required extensive assist of two for toileting.
-Was independent for wheelchair locomotion.
-Was always incontinent or urine.
-Was taking a diuretic (any drug that elevates the rate of urination).
-Had a urinary tract infection [MEDICAL CONDITION] within the past 30 days; and
-Had a [DIAGNOSES REDACTED].
Record review of the resident’s medical record showed he/she had the following Multi Drug
Resistant Organism (MDRO) infections:
-On 1/28/19, UTI with Escherichia coli (E coli- a germ commonly found in the bowel),
extended spectrum beta-lactamase (ESBL – a chemical produced by bacteria that break down
several types of antibiotics making the infection harder to treat).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
-On 2/8/19, UTI with ESBL producing E coli.
-On 3/4/19, UTI with [MEDICATION NAME] resistant [MEDICATION NAME] (VRE).
-On 3/30/19, [MEDICATION NAME] (an antibiotic) for ESBL producing E coli wound infection
of right lower posterior leg, for ten days.
-On 4/3/19, [MEDICATION NAME] for an additional four days for UTI with ESBL; and
-As of 5/15/19, the ordered re-culture had not been done to clear resident of urinary
infections.
Record review of the resident’s care plan showed, he/she did not have a care plan for
infection/isolation.
During an interview on 5/15/19 at 12:38 P.M. LPN A said:
-He/she had been at the facility for five months.
-The MDS Coordinators do the care plans.
-To his/her knowledge the MDS Coordinators are the only ones that modified the care plans;
and
-A MDRO infection/isolation should be care planned.
During an interview on 05/15/19 12:02 P.M. the DON said:
-Nurses did not necessarily do the care plan updates; and
-MDRO infection/isolations should be care planned and updated.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility failed to ensure two sampled
residents (Resident #33 and Resident #36) with weight loss received a nutritional
supplement as recommended by the Registered Dietitian (RD) out of 18 sampled residents.
The facility census was 76 residents.
1. Record review of Resident #33’s Face Sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated 3/2/29
showed the resident:
-Was cognitively intact.
-Required set up help with eating; and
-Weighed 230 pounds.
Record review of the resident’s Care Plan updated 3/14/19 showed he/she:
-Was on a regular no added salt diet related to hypertension; and
-Had a potential for complications related to diabetes.
Record review of the resident’s weight log showed he/she weighed 230 pounds on 2/1/19.
Record review of the resident’s weight log showed he/she weighed 219 pounds on 3/13/19.
Record review of the resident’s RD note dated 3/29/19 showed:
-The resident’s current weight was 219 pounds – down 11 pounds in one month.
-His/her documented meal intake remained good.
-The RD spoke with the resident in his/her room.
-He/she reported that he/she had teeth recently pulled.
-He/she had been fitted for new dentures.
-He/she did not want a textured diet.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
-He/she was willing to take a supplement; and
-The RD recommended to start providing the resident with Med Pass (a nutritional shake
that provides additional calories and protein) 60 milliliters (ml) three times daily with
his/her medications and further monitor his/her weight and intake.
Record review of the resident’s Nurse’s Note dated 4/3/19 at 1:38 P.M. showed:
-A fax was sent to the residents physician stating the RD was at the facility and
recommended Med Pass 60 ml three times daily; and
-The nurse was awaiting a response from the resident’s physician.
Record review of the resident’s Physician’s Orders Sheet (POS) dated 4/22/19 through
5/21/19 showed no physician’s order for the RD recommended Med Pass 60 ml three times
daily.
Observation and interview on 5/9/19 at 12:40 P.M. showed:
-The resident was seated in a chair in his/her room with a meal tray in front of him/her
finishing his/her lunch.
-He/she consumed one half of a lunch meat sandwich, all of a serving of chicken noodle
soup, a glass of juice and half a glass of water; and
-He/she said staff ask him/her whatever he/she wants and bring it to him in his/her room.
Observation and interview on 5/13/19 at 8:30 A.M. showed:
-The resident was seated in his/her room with his/her meal tray.
-He/she consumed all of his/her scrambled eggs, one slice of toast, and one sausage patty;
and
-He/she said he/she gets all he/she wants to eat and staff bring him/her what he/she
wants.
During an interview on 5/14/19 at 1:12 P.M. the resident said:
-He/she gets what he wants and only eats what he/she wants to eat; and
-He/she was big and needed to lose weight.
During an interview on 5/14/19 at 2:00 P.M. The Director of Nursing (DON) said he/she had
been having a hard time getting physicians to respond to RD recommendations.
During an interview on 5/14/19 at 2:03 P.M. the DON said:
-He/she could have contacted the physician more regarding the RD recommendation for the
resident to receive the Med Pass supplement; and
-More follow up could have occurred from him/her or from his/her designee.
2. Record review of Resident #36’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s significant change MDS dated [DATE] showed he/she:
-Was severely cognitively impaired.
-Required set up help with eating and
-Weighed 118 pounds.
Record review of the resident’s Care Plan dated 3/1/19 showed he/she required a mechanical
soft diet and nectar thick liquids due to a [DIAGNOSES REDACTED].
Record review of the resident’s weight log on 3/13/19 showed he/she weighed 118 pounds.
Record review of the resident’s weight log on 4/30/19 showed he/she weighed 112 pounds.
Record review of the resident’s RD’s Progress Notes dated 4/30/19 showed:
-The resident had a significant weight loss of six pounds in one month.
-The weight loss did follow a gain with a recent hospital stay and
-He/she recommended the resident would start a house supplement twice a day with meals and
further monitor weight and intake.
Observation on 5/9/19 at 8:41 A.M. showed:
-The resident was in the dining room in his/her wheelchair.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-The resident ate 100% of his/her biscuits and gravy and most of his/her orange juice and
milk and
-The resident did not receive a house supplement with his/her meal.
Observation on 5/9/19 at 11:50 A.M., showed:
-The resident was in his/her wheelchair in the dining room.
-The resident ate 75% of his/her lunch meal and
-The resident did not receive a house supplement with his/her meal.
Record review of the resident’s POS on 5/13/19 showed:
-The POS was dated 4/22/19 through 5/21/19 and
-There were not physician’s orders for the house supplement recommendations made by the RD
on 4/30/19.
During an interview on 5/13/19 at 7:40 A.M. Certified Medication Technician (CMT) A said:
-He/she did not pass out any house supplements to the resident.
-He/she did not have any physician’s orders on the resident’s (Medication Administration
Record (MAR) to administer a house supplement to the resident and
-The nurses were responsible for following up on the RD’s recommendations, obtaining the
physician’s orders for the house supplement, and adding it to the resident’s MAR.
During an interview on 5/14/19 at 12:31 P.M., Licensed Practical Nurse (LPN) C said:
The RD gave a printed list of the recommendations to the Director of Nursing (DON) and the
DON would call the physician for the orders.
-Sometimes the nurse would call the physician for the physician’s orders.
-He/she was told to call and get an order for [REDACTED].
-This usually happens quickly to get interventions in place.
During an interview on 5/15/19 12:02 P.M., the DON said:
-He/she or a designee should contact the physician to go over the RD recommendations and
implement the weight loss intervention.
-The intervention should be implemented within a few days.
-He/she or the designee should write a physician’s order and document the orders on the
POS and the CMT’s MAR and
-He/she was not aware of the resident having a weight loss.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assess the
appropriateness of side/bed rail use on a quarterly basis, obtain and update the consent
for side/bed rails, to include showing alternates attempted that failed to meet the
resident’s needs prior to the use of side/bed rails, for one resident (Resident # 34) out
of 18 sampled residents. The facility census was 76 residents.
The facility did not have a policy on the use of side/bed rails.
1. Record review of Resident #34’s face sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE], with the following Diagnoses: [REDACTED].
-Muscle wasting; and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-Abnormal posture.
Record review of the resident’s medical record showed:
-Physical Restraint Consent dated 5/12/09:
–Restraint type was two ¼ length side/bed rails for bed mobility, check frequently to
ensure proper function and safety.
–To promote independence in bed mobility.
–To assist with upper body strength with positioning; and
–Resident signed consent on 5/20/2009.
Record review of the resident’s Bed Rail/Assist Bar Evaluation dated 9/2/18 and 12/3/18
showed:
-To be used to assist with bed mobility.
-Resident was able to get in and out of bed.
-Resident had problems with trunk control due to stroke.
-Resident used bed/side rails for positioning and
-Bed/side rail assisted resident to sit up.
-Summary of findings, showed:
–On 9/2/18, ¼ side/bed rails on both sides of bed.
–Resident had requested side/bed rails.
–Side/bed rails were indicated and served as an enabler to promote independence.
–On 12/3/18, ¼ side/bed rails on both sides of bed.
–Resident had requested side/bed rails; and
–Side/bed rails were indicated and served as an enabler to promote independence.
Record review of the resident’s comprehensive care plan, revised showed there was no
side/bed rail care plan showing why the resident needed the rails and any risks associated
with having bed/side rails.
During an interview on 5/15/19 at 8:14 A.M., the Occupational Therapist (OT) said:
-He/she had only been at the facility for five months.
-The resident’s evaluation had been done prior to his/her employment.
-If a resident insisted on side/bed rails, the resident and/or resident representative
would sign a waiver.
-Some residents just want the side/bed rails and don’t want to try anything else and
should be documented.
-A therapy evaluation would be done and work through all other methods including but not
limited to:
–Hi/low bed;
–Wedges;
–Fall mats; and
–A bed cane.
During an interview on 5/15/19 at 9:35 A.M., the Therapy Director said, after a full
evaluation:
-Determined if there were any environmental fixes:
–Bed up against the wall;
–A Lo bed;
–Fall mats;
–Bed cane;
-Worked with the resident in therapy on:
–Strengthening;
–Bed positioning, head of bed up;
–Bed mobility;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
–Transfers;
–Determine why resident wanted the side rails;
-Assist with side/bed rail trials to determine appropriateness;
-Do not automatically re-evaluate the resident for appropriateness of side rails;
-Must have had a referral from the staff for resident to be re-evaluated;
–Resident must have showed a decline in abilities;
–The device was not working;
-Therapy documented in notes daily what strategies had been tried; and
-Therapy plan was updated every tenth visit.
During an interview on 5/15/19 at 11:10 A.M., Licensed Practical Nurse (LPN) A said:
-Side/bed rail evaluations should been done annually and
-Should always try alternatives before side/bed rails are used.
During an interview on 5/15/19 at 12:04 P.M., the Director of Nursing (DON) said he/she
expected:
-Residents to be evaluated upon admission and re-evaluated annually for the need of
side/bed rails.
-Therapy to evaluate for least restrictive device.
-Other options/alternatives were to be tried, failed and documented before side/bed rails
were used; and
-The use of side/bed rails should be care planned.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure Pro Re
Nata (PRN – prescribed as needed) [MEDICAL CONDITION] medications (drugs that affect brain
activities associated with mental processes and behavior) were limited to a duration of 14
days, ensure the physician indicated the duration of extended PRN anxiolytic medications
(anti-anxiety drugs used to inhibit anxiety) for two sampled residents (Resident #50 and
#49); failed to document on behaviors and non-pharmacological interventions prior to
administering PRN [MEDICAL CONDITION] medications for one resident (Resident #50)
prescribed PRN [MEDICAL CONDITION] medications; and to ensure one sampled resident’s
(Resident # 33) medication regimen was free from an antipsychotic medication without
adequate indication for use out of 18 sampled residents. The facility census was 76
residents.
Record review of the facility’s Psychoactive ([MEDICAL CONDITION]) Drug Therapy policy,
dated April, 2006 showed:
-Physician orders [REDACTED].
–Medication name and strength.
–Route of administration.
–Frequency of administration.
–Target behavior.
-Psychoactive medications will have an approved indication for their use.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-Each resident will have a care plan identifying the reason for the medication and
behavioral interventions to be implemented by each discipline. Each resident will be
monitored quantitatively and have objectively documented behaviors; and
-Nurses will document as incidents occur, the type and frequency of behaviors,
interventions implemented, precipitating events and the resident’s response to the
interventions provided.
1. Record review of Resident #50’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].>-Dementia (decline in
mental ability severe enough to interfere with daily life) without Behavioral Disturbance
and
-Unspecified Mood Disorder (a condition thought to be connected with a chemical imbalance
of the brain) with symptoms of sleep problems, feelings of hopelessness, low self-esteem,
poor eating habits and/or fatigue.
Record review of the resident’s Behavioral Care Plan, dated 11/9/18 showed:
-The resident had a history of [REDACTED].
-Behaviors were usually easily redirectable.
-Goals were for the resident to not yell at facility staff or visitors and to not injure
himself/herself secondary to wandering,
-Interventions included:
–When the resident wandered provide comfort measures for basic needs (such as pain,
hunger, toileting and temperature) and remove resident from other resident rooms and
unsafe environments and
–When the resident was verbally abusive ignore the behavior, refocus conversation, try
tasks later, remove the resident from group activities and provide a calm environment.
Record review of the resident’s Comprehensive Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning), dated 4/16/19
showed:
-The resident was severely cognitively impaired.
-The resident showed no signs of inattention (difficulty focusing), disorganized thinking
(incoherent conversation or illogical flow of ideas) or altered level of consciousness
(easily startled or lethargic).
-The resident had no physical behaviors directed toward others (such as hitting, pushing
or grabbing), no verbal behaviors directed toward others (such as screaming, cursing or
threatening others) and had no behaviors not directed at others (such as pacing, disrobing
in public or disruptive sounds).
-The resident did not reject cares or wander and
-The resident took an antipsychotic and an antidepressant (medication to treat depression,
a mood disorder characterized by low mood, a feeling of sadness and a general loss of
interest in daily activities) within the past seven day period.
Record review of the resident’s Physician order [REDACTED].
-Beginning on 4/26/19 orders for Hospice Services (care for individuals in the final
phases of a terminal illness with the focus on comfort and quality of life rather than
cure) and
-[MEDICATION NAME] (generic for [MEDICATION NAME], an anxiolytic medication), two (2)
milligrams (mg)/per cubic centimeter (cc) – give 0.5 mg (0.25 cc) every four hours PRN for
restlessness or anxiety. The initial order did not specify a limited, 14 day duration.
Record review of the resident’s Medication Administration Record [REDACTED]
-The resident’s 4/26/19 order for [MEDICATION NAME], 2 mg/cc, 0.5 mg (0.25 cc) dose, every
four hours for restlessness or anxiety.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-The back of the MAR indicated [REDACTED].M. the resident received [MEDICATION NAME] 0.25
ml (ml – fluid dose versus cc, which is a solid form of medication) by opening/orally
(PO)/sublingually (SL – applied under the tongue) for restlessness. The result was
documented as not effective and
-The resident received [MEDICATION NAME] PRN on 5/5/19 at 6:30 A.M. The back of the MAR
indicated [REDACTED].
Record review of the resident’s Nurses’ Notes, dated 5/3/19 and 5/5/19, showed:
-There was no documentation related to what the resident was doing or saying prior to the
PRN [MEDICATION NAME] administrations that indicated he/she was restless or anxious and
-There was no documentation of non-pharmacological interventions attempted prior to the
use of the PRN anxiolytic medication on 5/3/19 and 5/5/19.
Record review of the resident’s telephone physician’s orders [REDACTED].
-[MEDICATION NAME], 2 mg/ml – give 1 mg/0.5 every two hours PRN for anxiety. There was no
duration specified for the PRN order;
-[MEDICATION NAME] (an antipsychotic that decreases excitement in the brain and used to
treat [MEDICAL CONDITION] (mental disorders characterized by disconnection from reality)
syringe 2 mg/0.4 ml every six hours PRN for [MEDICAL CONDITION] (a disturbed state of mind
characterized by restlessness, incoherent thought and speech and illusions (perceptions of
an experience in a manner that causes misinterpretations of reality).
-[MEDICATION NAME] Concentrate 2 mg/ml – give 1 mg/0.5 ml every two hours PRN for [MEDICAL
CONDITION] and
-Neither [MEDICATION NAME] order was limited to 14 days.
Record review of the resident’s POS, dated 4/22/19 through 5/21/19 showed:
-The 4/26/19 order for [MEDICATION NAME] PRN was discontinued on 5/6/19 and changed to
reflect the telephone order. The POS did not specify the reason for the PRN [MEDICATION
NAME] or the duration of the order and
-Orders beginning 5/6/19 were written for [MEDICATION NAME], with dosage written as in the
telephone order. The POS did not specify indications for use or limit either [MEDICATION
NAME] order to 14 days.
Record review of the resident’s MAR, dated 4/22/19 through 5/21/19 showed:
-The resident received PRN [MEDICATION NAME] on 5/6/19 at 7:45 P.M. The back of the MAR
indicated [REDACTED].
-The resident received [MEDICATION NAME] Concentrate, 2 mg/ml at 1 mg/0.5 ml dose on
5/9/19 at the following times 8:15 A.M., 2:25 P.M. and 7:00 P.M.
-The MAR indicated [REDACTED]
-The back of the resident’s MAR indicated [REDACTED].M. administration. The 2:25 P.M. dose
was administered PO for restlessness with no documentation of the medication’s
effectiveness. The 7:00 P.M. dose was administered PO for restlessness, and at 10:00 P.M.
the resident was noted to be sleeping.
Record review of the resident’s Nurses’ Notes for 5/6/19 through 5/9/19 showed:
-There were no documented observations the resident was becoming increasingly anxious or
that any non-pharmacological interventions were attempted prior to the 7:45 P.M. PRN
administration of [MEDICATION NAME] on 5/6/19 and
-There were no written Nurses’ Notes for 5/9/19 and therefore, no documentation indicating
signs of [MEDICAL CONDITION] requiring the use of the PRN [MEDICATION NAME] Concentrate.
Record review of the resident’s telephone Physician Orders, dated 5/10/19 showed a
clarification order that specified the [MEDICATION NAME] 0.4 ml/2 mg IM every six hours
PRN and [MEDICATION NAME] Concentrate 0.5 ml/1 mg PO/SL every two hours PRN were both
justified for [MEDICAL CONDITION]. No duration was indicated for the PRN antipsychotic on
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
5/10/19.
Record review of the resident’s POS, dated 4/22/19 through 5/21/19 showed on 5/10/19 the
two 5/6/19 [MEDICATION NAME] orders were re-written on the POS to reflect justification
for use due to [MEDICAL CONDITION]. No duration was indicated on either 5/10/19
[MEDICATION NAME] order.
Record review of the resident’s MAR, dated 4/22/19 through 5/21/19 showed:
-On 5/10/19 at 9:00 P.M. the resident received 0.5 ml of [MEDICATION NAME] Concentrate (2
mg/ml). The MAR indicated [REDACTED]. The back of the MAR indicated [REDACTED].
-On 5/11/19 the resident received [MEDICATION NAME] Concentrate at 10:30 P.M. The back of
the MAR indicated [REDACTED].
-On 5/13/19 the resident received [MEDICATION NAME] Concentrate at 8:00 P.M. The back of
the MAR indicated [REDACTED]
-On 5/13/19 the resident received PRN [MEDICATION NAME], 2 mg/ml at 0.5 ml (1 mg) at 10:30
P.M. The back of the MAR indicated [REDACTED].
Record review of the resident’s Nurses Notes, dated 5/10/19 through 5/13/19 showed:
-There were no written Nurses’ Notes for 5/10/19, and therefore, no documentation
indicating signs of [MEDICAL CONDITION] requiring the use of the PRN medication.
-Nurses’ Notes on 5/11/19 and 5/13/19 did not document signs of [MEDICAL CONDITION] around
the time of the PRN [MEDICATION NAME] Concentrate administrations and did not show any
non-pharmacological interventions attempted prior to the PRN administrations and
-Nurses’ Notes on 5/13/19 did not document signs of anxiety near the time of the PRN
[MEDICATION NAME] administration or show non-pharmacological interventions attempted prior
to the use of the PRN anxiolytic.
During an interview on 5/14/19 at 1:56 P.M. Certified Nurse Assistant (CNA) E said:
-Most of the resident’s behaviors were during the night shift.
-Sometimes the resident would point and say he/she needed to change the alternator or help
someone out.
-The resident had grabbed his/her arm before and slammed it on the table and
-The resident tried to stand, forgetting his/her foot won’t support him/her.
During an interview on 5/14/19 at 2:01 P.M. Registered Nurse (RN) A said:
-The resident had behaviors such as continuously trying to get out of his/her bed or chair
and would lightly slap care givers and
-Target behaviors should be documented when a resident received PRN medications for
anxiety and [MEDICAL CONDITION].
During an interview on 5/15/19 at 9:14 A.M. Licensed Practical Nurse (LPN) A said:
-The resident’s behaviors were mostly trying to stand and not realizing he/she was a high
fall risk.
-A week or two prior the resident threw a chair at his/her television and broke it.
-He/she resisted care by turning away from care givers and putting his/her hands up.
-The resident was easily redirected from all behaviors except from trying to stand.
-The resident’s [MEDICAL CONDITION] PRN medications were prescribed since he/she had been
on hospice services and
-The facility physician prescribed PRN [MEDICAL CONDITION] medications for up to 14 days
at a time.
During an interview on 5/15/19 at 12:00 P.M. the Director of Nursing (DON) said:
-PRN antianxiety medications should be written for 14 days. The physician needed to
physically see the resident before deciding if he/she will continue the PRN antianxiety
medication.
-For someone taking an antianxiety medication nursing needed to document in the progress
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
notes what distress looked like for that resident and
-PRN antipsychotic medications should be written for no more than 14 days. The physician
must see the resident before writing another PRN antipsychotic order.
2. Record review of Resident #49’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s undated admission POS showed the following physician
ordered medication dated 4/10/19 for [MEDICATION NAME] 2 milligrams/milliliters (mg/ml):
administer 0.25 ml sublingual (under the tongue) every two hours PRN for anxiety.
Record review of the resident’s MDS dated [DATE] showed the resident:
-Was moderately cognitively impaired and
-Received antianxiety medication.
Record review of the resident’s care plan dated 4/11/19 showed he/she was at risk for
adverse consequences related to receiving a PRN antianxiety medication for the treatment
of [REDACTED].
Record review of the resident’s POS dated 4/22/19 showed the following physician ordered
medication dated 4/10/19 [MEDICATION NAME] 2 mg/ml: administer 0.25 ml sublingual (under
the tongue) every two hours PRN for anxiety.
Observation on 5/9/19 at 12:53 P.M. showed the resident was in his/her wheelchair, was
looking out the front door, and was calm.
Observation on 5/10/19 at 12:29 P.M. showed the resident was in the dining room in his/her
wheelchair and was calm.
Record review of the resident’s MAR indicated [REDACTED].
During an interview on 5/14/19 at 12:31 P.M. LPN C said:
-If the resident had not used the anti-anxiety PRN for 60 days he/she would call the
physician and
-He/she was not aware of a timeframe for use of anti-anxiety medications.
During an interview on 5/15/19 12:02 P.M. the DON said:
-Anti-anxiety medications were to be written for 14 days.
-The resident’s physician needed to assess the resident for the use of the anti-anxiety
and
-The resident’s physician needed to re-assess the use of the anti-anxiety again after 30
days of use.
3. Record review of Resident #33’s Face Sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Record review of his/her Psychology Progress Notes dated 1/31/19, 3/7/19, and 4/4/19
showed:
-His/her [DIAGNOSES REDACTED].
-His/her affect (external expression of emotion) was depressed and anxious.
-Hallucinations and delusions were not circled; and
-Confusion was circled.
Record review of the resident’s quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Had no behavioral symptoms.
-Had no hallucinations (perceptual experiences in the absence of real external sensory
stimuli).
-Had no delusions (misconceptions or beliefs that are firmly held contrary to reality).
-Had [DIAGNOSES REDACTED].
-Received antipsychotic (a class of medication primarily used to manage delusions,
hallucinations, paranoia or disordered thought) medication daily.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
Record review of the resident’s Care Plan updated 3/14/19 showed:
-He/she was at risk for adverse consequences related to receiving antipsychotic medication
for treatment of [REDACTED].
-Staff instruction to monitor him/her for adverse (undesired/harmful) effects of
[MEDICATION NAME]; and
-No identification of specific behaviors or symptoms related to indications for use of
antipsychotic medication.
Record review of the resident’s Nursing Progress Note dated 12/12/18 through 5/4/19
showed:
-Documentation dated 4/5/19 at 2:40 P.M. that he/she was confused and
-No documentation of delusions or hallucinations; and
-No documentation of behavior problems.
Record review of the resident’s Nursing Progress Note dated 5/4/19 showed:
-He/she came to the nurse at dinner and requested to speak with a psychologist to talk
about some things.
-The nurse told the resident that he/she would notify the Social Services Designee (SSD).
-The nurse asked the resident if there was anything that the resident would like to talk
about with him/her; and
-The resident replied that he/she would be OK.
Observation and interview on 5/9/19 at 12:40 P.M. showed:
-The resident was seated in a chair in his/her room with a meal tray in front of him/her
finishing his/her lunch; and
-He/she said staff ask him/her whatever he/she wants and bring it to him in his/her room.
Observation and interview on 5/13/19 at 8:30 A.M. showed:
-The resident was seated in his/her room was dressed and alert, with his/her meal tray;
and
-He/she said he/she gets all he/she wants to eat and staff bring him/her what he/she
wants.
During an interview on 5/15/19 at 11:37 A.M. the LPN MDS Coordinator said:
-The resident received the antipsychotic mediation [MEDICATION NAME]; and
-[MEDICATION NAME] was not an appropriate medication for a resident for a [DIAGNOSES
REDACTED].
During an interview on 5/15/19 at 11:37 A.M. the DON said [MEDICATION NAME] was not an
appropriate medication for a resident for a [DIAGNOSES REDACTED].

F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that residents are free from significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure one
supplemental resident (Resident #17) was free of significant medication errors out of 18
sampled residents. The facility census was 76 residents.
1. Record review of Resident #17’s Face Sheet showed he/she:
-Was admitted to the facility on [DATE]; and
-Had a [DIAGNOSES REDACTED].
Record review of the residents quarterly Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
2/15/19 showed he/she:
-Had mild cognitive impairment.
-Had a [DIAGNOSES REDACTED].>-Received daily injections.
Record review of the residents physician’s orders [REDACTED].
-Accuchecks three times daily with meals and
-Inject [MEDICATION NAME] (a fast acting Insulin) 9 units subcutaneously (sub-q under the
skin) before meals.
Record review of the resident’s Medication Administration Record [REDACTED]
-Accuchecks three times daily with meals; and
-[MEDICATION NAME] 9 units sub-q before meals.
During an interview on 5/13/19 at 7:07 Certified Medication Technician (CMT) A said:
-He/she starts Accuchecks at 6:00 A.M. and
-He/she completed the resident’s Accucheck and administered the resident’s [MEDICATION
NAME]at 6:30 A.M. on 5/13/19.
Observation on 5/13/19 at 7:08 A.M. showed:
-The resident was seated in the common area and
-His/her breakfast had not yet been served.
Record review of the [MEDICATION NAME] website on 5/13/19 showed:
-[MEDICATION NAME] is a rapid-acting insulin; and
-Inject [MEDICATION NAME] within five to 10 minutes before a meal.
During an interview on 5/15/19 at 9:30 A.M. Registered Nurse (RN) A said:
-Morning Accuchecks were done at 6:30 A.M and insulin was given about 30 minutes later.
-He/she expected the CMT to give the resident’s insulin when the resident’s meal arrived.
-Breakfast was served between 8:00 A.M. to 8:30 A.M.
-The CMT needed to give the resident’s [MEDICATION NAME]closer to the meal time; and
-Rapid-acting insulin need to be given closer to when the resident ate, no more than 30
minutes before eating.
During an interview on 5/15/19 at 12:00 P.M., the Director of Nursing (DON) said:
-Accuchecks should be given 30 minutes before meals.
-Rapid-acting insulin should not be given more than 30 minutes before residents begin
eating meals and
-Giving a rapid-acting insulin more than 30 minutes before a resident begins eating would
be a medication error.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
medications and medical supplies were disposed of prior to the expiration date and removed
from the delivery system, to ensure open dates were on opened multi-dose medications, and
to ensure medications were stored per pharmacy directions. The facility census was 76
residents.
Record review of the United States Food and Drug Administration (U.S. FDA) began requiring
an expiration date on prescription and over the counter medications in 1979 stating The

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
medicine expiration date is a critical part of deciding if the product is safe to use and
will work as intended.
Record review of the Medications, Storage of Policy dated 3/2015 and unsigned showed:
-No discontinued, outdated, or deteriorated drugs or biological’s may be retained for use.
All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with
established guidelines;
-Drugs must be stored at appropriate temperature levels; and
-Drugs stored in a refrigerator must be stored between 36 and 46 degrees Fahrenheit.
1. Observation showed the following medications and supplies had expired:
-On 5/13/19 at 6:37 A.M., of the Certified Medication Technician (CMT) cart showed:
–One bottle of [MEDICATION NAME] Allergy 24 Hour (nasal spray for allergies [REDACTED].
-On 5/13/19 at 7:11 A.M., of the medication room showed:
–One bottle urinalysis reagent strips, expired 3/5/19; and
–One box of saliva alcohol test strips, expired 10/12/18.
During an interview on 5/13/19 at 7:00 A.M., CMT A said he/she checked expiration dates:
-Weekly for prescribed medications; and
-Monthly for Over-The-Counter medications.
During an interview on 5/13/19 at 7:15 A.M., Licensed Practical Nurse (LPN) B said, he/she
went through the medication room monthly and checked for expired items.
During an interview on 5/13/19 at 11:00 A.M., LPN A said he/she expected:
-Not to find expired medications on the cart or in the medication room; and
-At a minimum, monthly medication room and medication cart checks for expired medications.
During an interview on 5/15/19 at 12:04 P.M., the Director of Nursing (DON) said he/she
expected the medication room and medication carts to be checked every shift for expired
items.
2. Observation on 5/13/19 at 6:37 A.M., of CMT’s medication cart, showed the following
medications without open dates:
-One bottle of [MEDICATION NAME] suspension (a steroid eye drop) 1 percent (%).
-One bottle of [MEDICATION NAME] suspension (a steroid eye drop) 0.5%.
-Two bottles of [MEDICATION NAME] suspension (a medication to treat high pressure inside
the eye) 0.005%.
-One bottle of [MEDICATION NAME] suspension (medication to treat fungal infections); and
-One bottle of Clearlax (a laxative) 17 grams (gm-a unit of measure).
During an interview on 5/13/19 at 7:00 A.M., CMT A said he/she should check for open dates
monthly.
During an interview on 5/13/19 at 11:00 A.M., LPN A said he/she expected every multi-dose
vial/bottle to have an open date.
During an interview on 5/15/19 at 12:04 P.M., the DON said he/she expected open dates to
be on all multi-dose vials/bottles.
3. Observation on 5/13/19 at 6:37 A.M. showed two vials of [MEDICATION NAME] suspension
0.005% eye drops, were not refrigerated despite being clearly labeled with a refrigerate
label from the pharmacy.
During an interview on 5/13/19 at 7:00 A.M., CMT A said he/she was unsure if [MEDICATION
NAME] was to be refrigerated.
During an interview on 5/13/19 at 11:00 A.M., LPN A said he/she expected medications with
refrigerate labels to be refrigerated.
During an interview on 5/15/19 at 12:04 P.M., the DON said, he/she expected [MEDICATION
NAME] to be refrigerated as well as other medications with refrigerate labels attached.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, the facility failed to determine
whether sanitary conditions were met for food contact surface areas and non-food contact
areas before, during and after food preparation. This deficient practice of not
determining whether or not food contact surfaces were sanitary, could potentially, promote
microorganisms and bacterial growth which could adversely affect the health and well-being
of the residents and staff who partook of the meals prepared by the dietary staff. The
facility census was 76 residents at the time of the survey.
1. Observations in the kitchen on 5/13/19 between 5:03 A.M. and 7:38 A.M., showed:
-At 5:12 A.M., Dietary Assistant (DA) A, wiping down food preparation countertops and a
food serving cart with a cleaning cloth from a sanitizing solution mixture before placing
resident beverages directly on top of them; and
-At 5:20 A.M., DA A was asked to test the sanitizing solution mixture for the proper
strength level and he/she tested it with the wrong chemical test strips (tests strips used
for the dishwashing machine to measure chlorine levels instead of the sanitizing solution
mixture).
During interview on 5/13/19 at 5:22 A.M., the DA A said he/she did not usually test the
sanitizing solution mixture and could not locate the correct chemical test strips.
During interview on 5/13/19 at 5:24 A.M., the Dietary Cook (DC) A said:
-He/she was aware of how to test for the appropriate bio-chemical sanitizing levels of the
solution mixture.
-The kitchen was out of the chemical test strips for approximately one week, and he/she
had not tested the solution mixture for that length of time.
-The last chemical test one week ago indicated the sanitizing solution mixture was
approximately 200 parts per million (ppm – a chemical solution measurement indicating a
strength level for a sanitizing concentration and water solution mixture) and
-He/she was aware that the appropriate chemical levels should be in between a range of
200-250 ppm and that the chemical test strips should change color to a light green to
indicate the appropriate chemical level of the solution mixture.
During interview on 5/13/19 at 5:37 A.M., the Dietary Manager said that the chemical test
strips were ordered approximately two weeks ago and had not arrived.
During interview on 5/13/19 at 10:52 A.M., the Dietary Manager said they had received
chemical test strips from another facility, tested the sanitizing solution mixture and, it
was in the appropriate sanitizing range indicated by the color change of the test strips.
Review of the dietary’s cleaning schedule (undated) showed the kitchen microwave oven,
serving carts, and food preparatory countertops were to be cleaned daily.
Review of the 2013 edition of the Review of the 2013 edition of the Food and Drug
Administration (FDA) Food Code, Chapter 3-304.15, showed,
(A) Cloths in-use for wiping FOOD spills from TABLEWARE and carry-out containers that
occur as FOOD is being served shall be:
(1) Maintained dry; and
(2) Used for no other purpose.
(B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be:
(1) Held between uses in a chemical sanitizer solution at a concentration specified under

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
§ 4-501.114; and
(2) Laundered daily as specified under 4-802.11(D).
(C) Cloths in-use for wiping surfaces in contact with raw animal FOODS shall be kept
separate from cloths used for other purposes.
(D) Dry wiping cloths and the chemical sanitizing solutions specified in Subparagraph
(B)(1) of this section in which wet wiping cloths are held between uses shall be free of
FOOD debris and visible soil.
(E) Containers of chemical sanitizing solutions specified in Subparagraph (B)(1) of this
section in which wet wiping cloths are held between uses shall be stored off the floor and
used in a manner that prevents contamination of FOOD, EQUIPMENT, UTENSILS, LINENS,
SINGLE-SERVICE, or SINGLE-USE ARTICLES.
Review of the 2013 edition of the FDA Food Code, Chapter 4-501.116, showed, The
effectiveness of chemical sanitizers is determined primarily by the concentration and pH
of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the
concentration of the chemical sanitizer solution.
Review of the 2013 edition of the FDA Food Code, Chapter 4-502.11, showed, A utensil or
food temperature measuring device can act as a source of contamination to the food it
contacts if it is not maintained in good repair. Also, if temperature or pressure
measuring devices are not maintained in good repair, the accuracy of the readings is
questionable. Consequently, a temperature problem may not be detected, or conversely, a
corrective action may be needlessly taken.
Review of the 2013 edition of the FDA Food Code, Chapter 4-602.11, showed, Microorganisms
may be transmitted from a food to other foods by utensils, cutting boards, thermometers,
or other food-contact surfaces. Food-contact surfaces and equipment used for
time/temperature control for safety foods should be cleaned as needed throughout the day
but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on
those surfaces.
Review of the 2013 edition of the FDA Food Code, Chapter 4-702.11, showed, UTENSILS and
FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.
Review of the 2013 edition of the FDA Food Code, Chapter 5-501.114, showed, A chemical
SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact
times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11
Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use
instructions, P and shall be used as follows:
(C) A quaternary ammonium compound solution shall:
(1) Have a minimum temperature of 24oC (75oF), P
(2) Have a concentration as specified under § 7-204.11 and as indicated by the
manufacturer’s use directions included in the labeling, P and
(3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no
greater than specified by the EPA-registered label use instructions; P
(D) If another solution of a chemical specified under (A) (C) of this section is used, the
PERMIT HOLDER shall demonstrate to the REGULATORY AUTHORITY that the solution achieves
SANITIZATION and the use of the solution shall be APPROVED;
Review of the 2013 edition of the FDA Food Code, Chapter 5-501.116, showed, Concentration
of the SANITIZING solution shall be accurately determined by using a test kit or other
device.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
isolation cart was outside the resident’s room; to ensure hand washing before resident
contact for one resident (Resident # 35) out of 18 sampled residents and to ensure
facility wide infection control surveillance logs were maintained for twelve months to
monitor, track, and identify trends of infections in the facility. The facility’s census
was 76 residents.
Record review of the facility’s Body Substance Precautions System dated (MONTH) 2012, and
unsigned, showed:
-Virulent or antibiotic resistant strains of bacteria such as [MEDICAL CONDITION] (MRSA),
[MEDICATION NAME] resistant [MEDICATION NAME] (VRE) or gram-negative bacteria may colonize
body orifices or moist body surfaces without symptoms. These organisms can be easily be
transmitted from resident to resident on the hands of personnel; and
-Handwashing remains the single most effective means of preventing disease transmission.
Record review of the Nurse Assistant in a Long-Term Care Facility Student Reference
revised in (MONTH) 2001 showed:
-Wash hands before and after contact with the resident.
-Gloves do not eliminate the need to wash your hands; they just provide a barrier between
you and potentially infectious microorganisms; and
-Handwashing is so simple but often neglected. Take time to protect everyone-yourself,
your family, coworkers and the residents.
1. Record review of Resident 35’s face sheet showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION].
Record review of Resident’s Quarterly Minimum Data Set (MDS – a required, federally
mandated assessment tool completed by facility staff for care planning) dated 3/5/19
showed the resident:
-Was moderately impaired cognitively;
-Required extensive assist of two for toileting;
-Was independent for wheelchair locomotion;
-Was always incontinent or urine;
-Was taking a diuretic (any drug that elevates the rate of urination);
-Had a urinary tract infection [MEDICAL CONDITION] within the past 30 days; and
-Had a [DIAGNOSES REDACTED].
Observation of the resident’s room showed the isolation supply cart was between two red
isolation disposal tubs (one for dirty linen and the other for dirty trash) on the
following dates/times:
-On 5/9/19 at 8:30 A.M.
-On 5/10/19 at 9:00 A.M.
-On 5/13/19 at 7:43 A.M.; and
-On 5/14/19 at 9:56 A.M.
Record review of the resident’s medical record showed he/she had the following Multi Drug
Resistant Organism (MDRO) infections:
-On 1/28/19, UTI with escherichia Coli (E coli- a germ commonly found in the bowel),
extended spectrum beta-lactamase (ESBL – a chemical produced by bacteria that break down
several types of antibiotics making the infection harder to treat).
-On 2/8/19, UTI with ESBL producing E coli.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 16)
-On 3/4/19, UTI with [MEDICATION NAME] resistant [MEDICATION NAME] (VRE).
-On 3/30/19, [MEDICATION NAME] for wound infection of right lower posterior leg.
-On 4/3/19, [MEDICATION NAME] for additional four days for UTI with ESBL; and
-As of 5/15/19, re-cultured had not been done to clear resident of urinary infections.
Observation on 5/13/19 at 7:43 A.M. of pericare with Certified Nursing Assistant (CNA) A
and CNA B showed:
-Neither CNA A nor CNA B washed their hands prior to providing care for the resident.
-CNA A got clothes and washcloths out of the resident’s closet.
-Washcloths were placed into 2 clean trash bags, one with soap and water and one with
water only.
-Both CNA’s, with contaminated hands donned (put on) gown and gloves.
-With contaminated hands/gloves lifted resident with the assist of a Sit-To-Stand Lift
(equipment designed to help residents who lack the strength or muscle control to rise to a
standing position).
-Neither CNA A nor CNA B washed the front of the resident.
-With contaminated gloves, CNA A washed the resident’s bottom from front to back four
times to clean the resident of stool.
-His/her wheelchair pad had liquid on top of the gel pad.
-With contaminated hands, CNA B fastened the new brief on the resident, pulled up clean
pants, and sat down onto the wet contaminated gel cushion of the wheelchair; and
-CNA A took the Sit-To-Stand mechanical lift out of the resident’s room prior cleaning it
down.
During an interview on 5/13/19 at 8:00 A.M. CNA A and CNA B said:
-Usually there are Stop signs on the resident’s doorway if the resident was on isolation.
-They hadn’t seen the signs for almost a year.
-They needed to wash hands prior to resident care.
-They needed to wash the front peri-area if the resident had been incontinent of urine.
-They needed to wash the wheelchair gel pad prior to sitting the resident down.
-The isolation cart was not to be placed in the resident’s room; and
-An isolation cart needed to be removed, cleaned/replaced immediately if found in a
resident’s room.
During an interview on 5/15/19 at 12:04 P.M., the Director of Nursing (DON) said he/she
expected:
-A sign on the door frame to Please See Nurse for any resident on isolation.
-An isolation cart to be outside the resident’s room.
-The isolation cart would be removed, cleaned and placed outside the room if found in the
resident’s room;
-The resident’s care plan to include isolation and
-Isolation would continue until a repeat culture returned indicating isolation was no
longer required.
At the time of exit on 5/15/19, the facility had still not provided the Isolation Policy
after being requested two times.
2. Record review of the facility’s facility-wide tracking and trending Infection Control
Logs showed they were completed only from (MONTH) (YEAR) to (MONTH) 2019.
During an interview on 1/23/18 at 11:30 P.M., the Director of Nursing (DON) said:
-He/She started as DON at the facility five weeks ago; and
-Previous to December, (YEAR), there were no Infection Control Logs for tracking and
trending purposes.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265710

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

OAK GROVE NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

2108 SOUTH MITCHELL
OAK GROVE, MO 64075

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Implement a program that monitors antibiotic use.

Based interview and record review, the facility failed to establish an infection
prevention and control program (IPCP) that included an antibiotic stewardship program that
addressed antibiotic use protocols and a system to monitor antibiotic use. The facility
census was 76 residents.
Record review of the facility Antibiotic Stewardship Program policy, undated showed:
-The Antibiotic Stewardship Program will include tools, policies and procedures to guide
nursing home staff toward more responsible and effective use of antibiotics.
-The leadership team (department managers) will set standards for antibiotic prescribing
practices for all clinical providers; and
-No standards for antibiotic use or protocols were included or attached to the policy to
address the judicious use of antibiotics.
1. Record review of facility available infection tracking information for (MONTH) (YEAR)
through (MONTH) 2019 showed no Antibiotic Stewardship program data including:
-No data gathered and analyzed regarding correlating specific resident symptoms with
bacterial susceptibility and antibiotic use.
-No resident data regarding length of antibiotic use.
-No data regarding if infections had resolved following antibiotic use.
-Data was compiled regarding resident names, room numbers, infection type (i.e.
respiratory tract, urinary tract, wound), the infection organisms and antibiotic used; and
-Resident symptoms and bacterial counts (important information needed in decision making
regarding antibiotic use) and antibiotic sensitivity results (information that ensures the
correct antibiotic is used to effectively treat the infection) were not recorded and
analyzed.
Record review of the facility’s Resident Census and Conditions of Residents report dated
5/9/19 showed the facility had six residents currently on antibiotics.
During an interview on 5/15/18 at 10:30 A.M. the Director of Nursing (DON) said:
-He/she started as DON at the facility five weeks ago.
-A facility nurse had recently been assigned the Antibiotic Stewardship program; and
-The facility had some resident data available in the Infection Control Log notebook and
in their computer software but no Antibiotic Stewardship Program for review by the survey
team.