Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lane Nursing & Ventilator Care during CMS and state inspections, most recent first.
The facility failed to implement proper infection control measures for residents with tracheostomy and PEG tubes. Observations showed that rooms lacked EBP indicators, and staff only used EBP for residents with specific infections. The ADON, also the infection preventionist, believed EBP for these residents was not mandatory, leading to inadequate PPE use during tracheostomy care.
The facility failed to ensure that power strips were not used to supply power to medical devices for three residents requiring tracheostomy care. A resident's flowby and suctioning machines, another's nebulizer and suctioning machine, and a third's ventilator were all plugged into power strips instead of directly into wall outlets. The DON confirmed the lack of a policy on power cord use and acknowledged the devices should have been plugged into wall outlets.
The facility did not maintain RN coverage for eight consecutive hours, seven days a week, as required. A review of staffing reports from April to June 2024 showed multiple dates with no RN hours documented. The interim administrator confirmed the absence of documentation for these dates, affecting 43 residents.
The facility failed to maintain the dignity of two residents during care procedures. A resident with anoxic brain damage received vent care without privacy measures, as the RT left the door and curtain open, citing the roommate's preference. However, the roommate later stated they would not mind if the curtain was closed. Another resident with encephalopathy and a stage four pressure ulcer received peri-care from an LPN who left the curtain open. The LPN later acknowledged the need for privacy, and the ADON confirmed that dignity should always be considered during care.
The facility did not complete quarterly MDS assessments for three residents as required by policy. The MDS Coordinator admitted the assessments were not started, and the ADON confirmed this was a policy violation.
A facility failed to document the use of devices for managing a resident's hand contractures in the care plan. The resident, diagnosed with contracture and coma, was observed with contracted hands but without protective devices. Staff confirmed using rolled cloths or 'carrots' to manage contractures but were unsure if this was documented. The ADON acknowledged the lack of documentation despite the practice to prevent progression and injury.
A facility failed to ensure proper hand hygiene during wound care for a resident with a stage four pressure ulcer. An LPN changed gloves multiple times without washing or disinfecting hands between changes, as confirmed by the ADON. Additionally, the facility lacked a waterborne pathogen plan, as acknowledged by the administrator and ADON.
The facility did not complete weekly skin assessments for a resident with paraplegia and a sacral pressure ulcer, as required by both the facility's policy and a physician's order. The ADON confirmed that assessments prior to late August 2024 were missing, highlighting a failure to adhere to the prescribed schedule.
The facility did not complete required AIMS assessments for a resident on antipsychotic medication, as per their policy. The resident, diagnosed with unspecified psychosis and anxiety disorder, was prescribed quetiapine fumarate. Only one AIMS assessment was documented, despite the policy requiring assessments every three months.
A resident with a history of impulsive behavior verbally abused another resident, causing fear and anxiety among residents. Staff reported frequent confrontational behavior from the resident, leading to police involvement. Despite attempts to manage the situation, the facility failed to protect residents from abuse.
A facility failed to ensure the required number of staff were present when operating mechanical lifts for a resident with chronic pain, anxiety, and pulmonary edema. The resident's care plan required a two-person assist for transfers using a Hoyer lift. An incident occurred where the resident slid off the chair and onto the floor while being transferred by only one staff member. Interviews with six CNAs revealed that none had received in-service training on the use of mechanical lifts. The DON confirmed that two people were required to use a mechanical lift.
The facility failed to report an alleged violation of resident-to-resident abuse to the state agency. An incident occurred where one resident threatened and attempted to run over another resident with an electric wheelchair. Despite documentation and an investigation by the administrator, the incident was not reported as required by the facility's Abuse Prohibition Policy and Procedure.
Inadequate Infection Control for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, particularly concerning residents with indwelling medical devices such as tracheostomy and PEG tubes. During multiple tours of the facility, it was observed that rooms occupied by residents with these devices lacked signs or indicators that the residents were on Enhanced Barrier Precautions (EBP). This oversight was noted despite previous contact from the Oklahoma State Department of Health's Healthcare-associated Infections and Antimicrobial Resistance program, which had identified the facility's lack of EBP use. Staff interviews revealed a lack of understanding and implementation of EBP for residents with tracheostomy and PEG tubes. Licensed Practical Nurses (LPNs), Certified Medication Aides (CMAs), and a Certified Nursing Assistant (CNA) indicated that they only used EBP for residents with specific infections, as identified by signs outside the residents' rooms. They were unaware of the need for EBP for residents with indwelling medical devices unless there was an infection present. The facility's Assistant Director of Nursing (ADON), who also served as the infection preventionist, confirmed that EBP was not used for residents with tracheostomy or PEG tubes unless they had infections. The ADON believed that EBP for these residents was recommended but not mandatory. This misunderstanding led to inadequate infection control measures during tracheostomy care, as observed with three residents, where only gloves and handwashing were used without additional PPE such as masks and gowns.
Improper Use of Power Strips for Medical Devices
Penalty
Summary
The facility failed to ensure that power strips were not used to supply power to medical devices for three residents who required tracheostomy care. Resident #17 was observed with their flowby machine and suctioning machine plugged into a gray power strip. Resident #21 had their nebulizer and suctioning machine connected to a gray power strip. Resident #24's ventilator was plugged into a black power strip. The facility's Director of Nursing (DON) acknowledged the absence of a policy regarding the use of power cords and confirmed that medical devices should have been plugged directly into wall outlets. These observations were made during a survey, and the facility had 23 residents with tracheotomies at the time.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days per week, as required. A review of the PBJ Staffing Report for the period from April 1, 2024, to June 30, 2024, revealed multiple dates where no RN hours were documented. Specifically, there was no RN coverage on April 6, 7, 20, 27, 28; May 5, 11, 12, 18, 19, 26, 27; and June 1, 2, 8, 9, 16. During an interview on October 22, 2024, the interim administrator confirmed the lack of documentation for RN coverage on these dates. The facility housed 43 residents at the time of the deficiency.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of two residents during care procedures. Resident #8, who has anoxic brain damage and chronic respiratory failure, was receiving vent care from RT #1. During this procedure, RT #1 did not close the door, the curtain blocking the doorway, or the curtain between Resident #8 and their roommate, Resident #29. RT #1 stated they left the door open to hear if someone called them and left the curtain open because the roommate preferred it that way. However, Resident #29 later stated that it would not bother them if the curtain was closed during care. Resident #38, diagnosed with encephalopathy and a stage four pressure ulcer of the sacral region, was receiving peri-care from LPN #2. During this care, the curtain between Resident #38 and their roommate was left open. LPN #2 acknowledged afterward that they should have closed the curtain to maintain the resident's dignity. The ADON confirmed that resident dignity should always be considered during care, and both RT #1 and LPN #2 should have ensured privacy by closing doors and curtains.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed for three of the fourteen sampled residents. The facility's policy, dated October 2010, mandates that resident assessments be conducted and submitted in accordance with federal and state timeframes. However, a review of resident records revealed that the quarterly MDS assessments for these residents were past the creation and submission dates. During an interview, the MDS Coordinator acknowledged that the assessments for the three residents had not been started, attributing this oversight to their mistake. The Assistant Director of Nursing (ADON) confirmed that all MDS assessments needed to be completed timely, and the failure to start these assessments was a violation of the facility's policy.
Failure to Document Contracture Management in Care Plan
Penalty
Summary
The facility failed to ensure that a resident's use of devices for contractures was included in the care plan, leading to a deficiency. Resident #8, who had diagnoses including contracture and unspecified hand and coma, was observed with contracted hands but without any devices to prevent worsening of the contractures. The care plan dated 08/14/24 lacked documentation regarding the presence or care for hand contractures. On subsequent observations, rolled cloths were noted inside the resident's contracted hands. Staff members, including a CNA and a CMA, confirmed the use of rolled cloths or 'carrots' to manage contractures but were unsure if this practice was documented in the care plan. The ADON acknowledged the absence of documentation in the care plan and physician orders, despite the staff's practice of using these devices to prevent progression and injury.
Inadequate Hand Hygiene and Absence of Waterborne Pathogen Plan
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for a resident with a stage four pressure ulcer of the sacrum. An LPN was observed changing gloves multiple times during the wound care process but did not wash or disinfect their hands between the removal of dirty gloves and the application of new ones. This oversight occurred despite the LPN's acknowledgment of not washing or disinfecting their hands at any point during the procedure. The Assistant Director of Nursing (ADON) confirmed that the LPN did not follow proper care protocols, which required hand hygiene between glove changes. Additionally, the facility lacked a waterborne pathogen plan. The administrator, after reviewing records, could not find evidence of such a plan and indicated they would consult with the maintenance supervisor. The ADON confirmed the absence of a waterborne pathogen plan, highlighting a gap in the facility's infection control measures.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that weekly skin assessments were completed for a resident with paraplegia and a pressure ulcer in the sacral region. According to the facility's Pressure Ulcer Risk Assessment policy, skin assessments should be conducted weekly to identify any changes. A physician's order specified that these assessments were to be completed every Thursday. However, a review of the resident's electronic health record (EHR) showed that weekly skin assessments were documented only from late August to early October 2024. The Assistant Director of Nursing (ADON) confirmed that skin assessments for the resident prior to late August 2024 could not be located, indicating a lapse in adherence to the prescribed assessment schedule.
Failure to Complete AIMS Assessments for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that AIMS assessments were completed for a resident receiving antipsychotic medication, specifically quetiapine fumarate, as per the facility's policy. The policy required that the Abnormal Involuntary Movement Scale (AIMS) or a similar test be administered upon initiation of antipsychotic medication therapy and every three months thereafter. However, for one resident with diagnoses including unspecified psychosis and anxiety disorder, only one AIMS assessment was documented in the electronic health record, completed on 08/28/24. No other assessments could be located, indicating non-compliance with the facility's protocol for monitoring antipsychotic medication effects.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving two residents. Resident #3, who has diagnoses including epilepsy, anxiety, and stroke, was subjected to verbal abuse by Resident #1. Resident #1, who has a history of impulsive behavior, played loud music and sang loudly in the hallway, disturbing Resident #3's sleep. When Resident #3 requested that the music be turned down, Resident #1 responded with derogatory language, calling Resident #3 'fat' and a 'bitch.' This behavior was not an isolated incident, as staff members, including a CNA and two LPNs, reported that Resident #1 frequently used vulgar language and was confrontational towards both residents and staff. The social services director and the facility administrator confirmed that Resident #1's behavior caused fear and anxiety among other residents, with some residents reportedly crying due to the confrontations. The facility's response to these incidents included attempts to redirect Resident #1 and separate him from other residents. However, the behavior persisted, leading to multiple police interventions. The facility's administrator acknowledged the ongoing issue and noted that a discharge order had been issued for Resident #1, who was appealing the decision. Despite these measures, the facility's failure to protect Resident #3 from verbal abuse constituted a deficiency in ensuring a safe and abuse-free environment for all residents.
Failure to Ensure Adequate Staffing for Mechanical Lift Use
Penalty
Summary
The facility failed to ensure the required number of staff were present when operating mechanical lifts for a resident with chronic pain, anxiety, and pulmonary edema. The resident's care plan, dated 08/11/23, specified a two-person assist for transfers using a Hoyer lift. On 03/05/24, an incident occurred where the resident slid off the chair and onto the floor while being transferred with a Hoyer lift by only one staff member. Interviews conducted on 03/11/24 with six CNAs revealed that none had received in-service training on the use of mechanical lifts. The Director of Nursing confirmed that two people were required to use a mechanical lift.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged violation of resident-to-resident abuse to the state agency for two residents. Resident #1, who had a diagnosis of depression and intact cognition, was involved in an incident where another resident in an electric wheelchair (Resident #3) threatened and attempted to run over them. The incident was documented by the social service note and the facility administrator, but it was not reported to the state agency as required by the facility's Abuse Prohibition Policy and Procedure. Resident #1 was not afraid of Resident #3 despite the altercation. Resident #3, who also had a diagnosis of depression and intact cognition, accused Resident #1 of being a pedophile and expressed hostility towards them. The administrator documented the incident and initiated an investigation but did not report it to the state agency. The administrator did not consider the yelling and cussing to be abusive, which led to the failure to report the incident as required by the facility's policy.
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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 Inola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Nursing Center | 9.6 mi | ★★★★★ | 20 | 1 |
| Claremore Skilled Nursing And Therapy | 12.5 mi | ★★★★★ | 5 | 0 |
| Rolling Hills Care Center | 13.2 mi | ★★★★★ | 2 | 0 |
| Emerald Care Center Claremore | 13.7 mi | ★★★★★ | 7 | 0 |
| Memory Care Center At Emerald | 13.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.