Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Community Health Center during CMS and state inspections, most recent first.
Infection control practices were not followed during wound and ostomy care. A resident with infected leg wounds was seen in the dining room with the wounds uncovered, and an RN applied wound treatment without cleansing the wounds first. For another resident, the RN used the same gloves after applying Medihoney and then touched the resident’s sock, book, and cards. During colostomy care, the DON wore multiple pairs of gloves at one time, which the IP stated was not acceptable practice.
The facility failed to complete accurate comprehensive assessments for 3 residents. One resident was observed on O2 with an order for 2 liters NC, but the assessment did not show oxygen use; another resident had bilateral hand contractures and difficulty holding a drumstick, but the quarterly assessment did not note upper extremity impairment; and a third resident had a documented stage 3 pressure ulcer and later received wound care, but the annual assessment did not show the pressure ulcer. The MDS coordinator stated these findings should have been documented on the residents’ assessments.
A facility failed to develop comprehensive care plans for two residents. One resident had hospice services ordered and diagnoses including neurocognitive disorder with Lewy bodies, breast cancer, asthma, and atrial fibrillation, but the care plan did not include a hospice care plan. Another resident with cerebral palsy, developmental speech disorder, profound intellectual disabilities, and dystonia was observed with contractures in both hands, but the care plan did not identify the contractures or include related interventions.
PRN Psychotropic Medication Used Beyond 14 Days: A resident with depression and a seizure disorder was prescribed lorazepam PRN for anxiety, restlessness, and/or agitation with no end date. The MAR showed the medication was administered on multiple occasions, and the DON stated the psychotropic should have been limited to 14 days with a stop date and new order obtained.
Incorrect Insulin Dose Administered: A resident with DM received the wrong sliding-scale dose of Fiasp after a finger stick blood sugar of 190. An RN administered 9 units instead of the ordered 6 units and later stated they did not know they had given the incorrect dose and would notify the DON of the med error.
A facility failed to obtain informed consent for psychotropic medications prescribed to a resident with major depressive disorder and dementia. The resident's health record lacked documentation of consent for buspirone and citalopram, contrary to facility policy. The DON and IP could not find the consents or education records, and the DON admitted the consents had not been done.
A resident with cerebral palsy and severe cognitive impairment was observed with a lap belt in their wheelchair without a physician's order or proper assessment and monitoring. The facility's policy requires an assessment and a physician's order for restraints, which were not followed. The resident was unable to respond to instructions to undo the seat belt, and no documentation of monitoring was found.
A resident with cerebral palsy and dystonia was observed with a wheelchair seat belt that they could not undo, indicating it was a restraint. The facility failed to document this restraint in the resident's annual MDS assessment, as confirmed by the DON and MDS Coordinator.
A facility failed to label and date oxygen tubing for a resident requiring respiratory care, contrary to its policy. The resident, admitted with acute respiratory failure, was observed using oxygen without the tubing being labeled or dated. Staff confirmed the oversight, and the DON acknowledged the requirement for labeling.
A facility failed to ensure a timely response to a pharmacist's request for a gradual dose reduction of tramadol for a resident with major depressive disorder and peripheral vascular disease. The request was not sent to the physician as required by policy, leading to a deficiency in the medication regimen review process.
Infection Control Failures During Wound and Ostomy Care
Penalty
Summary
Wound care and infection control practices were not consistently followed for a resident with infected leg wounds. Resident #5 was observed in the dining room with wounds on both legs uncovered. Later, RN #1 donned a gown and gloves and applied Silvercel to the right leg wound, wrapped it, changed gloves, and then applied Silvercel to the left leg wound and wrapped it, but did not cleanse the wounds before applying treatment. The resident’s record showed a chronic non-pressure ulcer and a physician order for a midline catheter for IV antibiotics for a pseudomonas wound infection. The RN stated the resident had showered before breakfast and therefore the wound was not cleansed before treatment. The DON stated the resident was positive for pseudomonas in the wound and was to receive IV antibiotics, and the infection preventionist stated the resident should not have been out of the room without dressings on the wounds. Wound care for another resident was also provided in a manner that did not prevent contamination, and ostomy care involved improper glove use. RN #1 cleansed and treated Resident #10’s left ankle wounds, but after applying Medihoney with gloved fingers, the RN did not change gloves before touching the resident’s sock, book, and cards. The RN later acknowledged the gloves should have been changed or removed before touching those items. In addition, the DON was observed providing colostomy care to Resident #8 while wearing multiple pairs of gloves at one time, including having gloves underneath pairs that were doffed during the procedure. The infection preventionist stated that wearing multiple pairs of gloves during direct care or colostomy care was not acceptable practice and that staff must only wear one pair at a time.
Inaccurate Comprehensive Assessments for Oxygen Use, Upper Extremity Impairment, and Wound Status
Penalty
Summary
The facility failed to ensure accurate comprehensive assessments for 3 of 12 sampled residents reviewed for accurate assessments. Resident #18 was observed lying in bed with oxygen at two liters, and a physician’s order dated 09/03/25 directed oxygen at two liters per nasal cannula to keep oxygen levels greater than 89%. However, the significant change assessment dated 03/23/26 for this resident, who had diagnoses including malignant neoplasm of breast, Lewy bodies neurocognitive disorder, atrial fibrillation, and asthma, did not indicate that oxygen was used. Resident #21 was observed participating in a music activity while seated in a geriatric chair and had difficulty holding a drumstick because of contractures in both hands, yet the quarterly assessment dated 03/15/26 showed no impairment to the upper extremities. Resident #10 was observed with a bandage on the left lower extremity and later received wound care to the left ankle; a skin evaluation dated 02/13/26 documented a stage three pressure ulcer on the left lateral foot that was present on admission, but the annual assessment dated 02/14/26 did not show that a pressure ulcer was present. On 04/08/26, the MDS coordinator stated oxygen use for Resident #18, upper extremity impairment for Resident #21, and Resident #10’s wound should have been documented on their comprehensive assessments.
Incomplete Care Plans for Hospice and Contractures
Penalty
Summary
The facility failed to develop a comprehensive care plan for 2 of 12 sampled residents reviewed for care plans. The facility’s policy stated the interdisciplinary team would conduct a comprehensive assessment of each resident’s functional capacity and that the care plan would include measurable objectives and timetables to meet medical, nursing, and psychosocial needs, with revisions at quarterly review/assessment. Resident #18 was observed lying in bed with oxygen at two liters. A significant change assessment dated 03/23/26 showed diagnoses including neurocognitive disorder with Lewy bodies, malignant neoplasm of breast, asthma, and atrial fibrillation, and a physician’s order dated 03/23/26 showed the resident was admitted to hospice services. The care plan did not include a hospice care plan for this resident. Resident #21 was observed seated in a geriatric chair participating in a music activity and having difficulty holding a drumstick because of contractures in both hands. The care plan, updated 12/29/25, showed the resident required total assistance with all activities of daily living, but it did not show that contractures were present in both hands. A diagnoses report dated 04/08/26 showed diagnoses including cerebral palsy, developmental speech disorder, profound intellectual disabilities, and dystonia. The MDS coordinator stated the hospice care plan should have been included for Resident #18 and interventions for contractures should have been included for Resident #21’s hands.
PRN Psychotropic Medication Used Beyond 14 Days
Penalty
Summary
The facility failed to ensure an as needed psychotropic medication was not used for more than 14 days for Resident #4. A physician order dated 01/12/26 prescribed lorazepam oral concentrate 2 mg/ml, with directions to give 0.5 ml by mouth every four hours as needed for anxiety, restlessness, and/or agitation, and the order had no end date. The medication administration record for 03/2026 showed the resident received lorazepam on 03/06/26, 03/08/26, and 03/14/26. An annual assessment dated 03/19/26 showed the resident was admitted with diagnoses including depression and seizure disorder. During interview on 04/08/26, the certified medication aide stated the resident received lorazepam as needed for anxiety, and the DON stated a psychotropic medication should be limited to 14-day use and that the lorazepam order should have had a stop date of 01/26/26 with a new order obtained.
Incorrect Insulin Dose Administered
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when a resident with diabetes mellitus received the wrong insulin dose. During observation on 04/07/2026, RN #1 checked Resident #24’s finger stick blood sugar and obtained a result of 190, then administered 9 units of Fiasp FlexTouch insulin subcutaneously to the resident’s right lower abdomen. The resident’s physician order for sliding-scale Fiasp specified 6 units for a blood sugar of 181 to 220, which matched the resident’s blood sugar result. RN #1 later stated they did not know they had administered 9 units instead of 6 units and said they would notify the DON of the medication error.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for a resident diagnosed with major depressive disorder and dementia with behavioral disturbances. The resident was prescribed buspirone and citalopram, but the clinical health record lacked documentation of informed consent for these medications. The facility's policy required family notification and explanation of the effects and risks of psychotropic drugs, but the Director of Nursing (DON) and Infection Preventionist (IP) could not locate the consents or evidence of education in the resident's health record. The DON acknowledged that the consents had not been completed.
Failure to Ensure Proper Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident who was physically restrained had a physician's order, was assessed, and monitored. The facility's policy requires an assessment to determine the safety and protective needs of the resident before applying restraints, and a physician's written order specifying the type and reason for the restraint. Additionally, the policy mandates that restraints be released every two hours for at least ten minutes. However, these procedures were not followed for a resident diagnosed with cerebral palsy and dystonia, who was observed with a lap belt around their waist while in a wheelchair. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, was seen with the lap belt on multiple occasions. A registered nurse stated that the lap belt was used because the resident moved a lot and was fidgety, but admitted there was no physician order for its use and no documentation of monitoring. The resident was unable to respond to instructions to undo the seat belt, and the Director of Nursing could not locate an assessment for the use of the wheelchair seat belt.
Failure to Accurately Code Physical Restraints on MDS
Penalty
Summary
The facility failed to ensure that physical restraints were accurately coded on the Minimum Data Set (MDS) assessments for a resident diagnosed with cerebral palsy and dystonia. During an annual resident assessment, the use of a chair restraint for the resident was not documented. Observations on two separate occasions revealed the resident in a wheelchair with a black belt around their waist, featuring a quick release buckle. Despite instructions from the Director of Nursing (DON) and Infection Preventionist, the resident was unresponsive and unable to undo the seat belt, indicating it was a restraint. The MDS Coordinator confirmed that if a resident cannot undo their wheelchair seat belt, it is considered a restraint. However, the DON acknowledged that the use of the wheelchair seat belt was not coded in the resident's annual assessment.
Failure to Label and Date Oxygen Tubing
Penalty
Summary
The facility failed to adhere to its own policy and professional standards of care regarding the labeling and dating of oxygen tubing for a resident requiring respiratory care. Resident #20, who was admitted with acute respiratory failure and major depressive disorder, was observed using supplemental oxygen without the tubing being labeled or dated as per the facility's policy. The policy required that oxygen device tubing be changed every 30 days, specifically on the 15th of the month during the night shift, and that the tubing be stored in a bag when not in use. During observations and interviews, it was noted that the oxygen tubing and saturator for Resident #20 were not labeled with the date of change, which was confirmed by both a CNA and an RN. The Director of Nursing also acknowledged that the tubing should have been labeled with the date it was changed.
Failure to Respond to Medication Regimen Review
Penalty
Summary
The facility failed to ensure a timely response to a medication regimen review for a resident who was prescribed tramadol for pain management. The facility's policy required that the consultant pharmacist document any potential or actual medication therapy problems and communicate them to the primary physician and the Director of Nursing (DON) within seven working days. However, a gradual dose reduction (GDR) request made by the pharmacist on 05/22/24 was not sent to the physician, nor was there any documented response from the physician in the clinical health record. This oversight was discovered when the medical records personnel found the GDR request in a stack of paperwork, indicating it had not been processed as per the facility's policy. The resident involved had diagnoses including major depressive disorder and peripheral vascular disease, and was receiving tramadol 50 mg every six hours as needed for pain. The DON confirmed that the policy was not followed, as the GDR should have been sent to the physician within seven days, and a response should have been provided within two weeks. The physician was expected to provide a report to the facility within one month after the report was sent. The failure to adhere to these timelines resulted in a deficiency in the medication regimen review process for the resident.
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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 Wakita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anthony Community Care Center | 19.6 mi | ★★★★★ | 0 | 0 |
| Baptist Village Of Enid | 29.5 mi | ★★★★★ | 2 | 0 |
| Attica Long Term Care Facility | 30.1 mi | ★★★★★ | 1 | 1 |
| Kiowa Hospital District Manor | 32 mi | ★★★★★ | 9 | 1 |
| Garland Road Nursing & Rehab Center | 32.4 mi | ★★★★★ | 9 | 2 |
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