Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Latimer Nursing Home during CMS and state inspections, most recent first.
Staff did not follow enhanced barrier precautions during urinary catheter care for a resident with an indwelling catheter. Observations showed that PPE such as gowns and masks were not used, soiled items were handled improperly, and the catheter was not secured. Staff interviews revealed a lack of knowledge about EBP requirements, and the facility's infection preventionist confirmed inconsistent implementation of infection control policies.
A strong urine odor was repeatedly present on one hall, affecting 14 residents. Staff, including an LPN and a CNA, confirmed the persistent smell, which was traced to specific rooms and mattresses. Despite changing linens and cleaning mattresses, the odor remained, indicating a failure to maintain a clean and comfortable environment.
A resident with chronic pain and multiple sclerosis did not receive their prescribed hydrocodone/acetaminophen at several scheduled times because the facility was waiting for insurance prior authorization. The resident reported severe pain and distress during this period, and nursing documentation confirmed the missed doses and the resident's pain levels.
A resident's admission assessment was not completed within the required fourteen-day timeframe, with documentation showing it was finalized nearly three months after admission. The MDS coordinator confirmed the delay in completing the assessment.
A resident who was totally dependent on staff for ADLs and had urinary incontinence was not provided with timely incontinent care, as evidenced by observation of a saturated brief and strong urine odor. The resident reported infrequent changes, and a CNA confirmed that care was not provided every two hours as required by facility policy, citing being too busy as the reason.
The facility failed to develop and implement a policy and procedure for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems. The maintenance man confirmed the absence of such a policy, although efforts were being made to create one. The administrator identified 23 residents in the facility.
The facility failed to ensure residents were offered the choice to formulate advanced directives for three of six sampled residents. Two residents had no documentation of an advance directive or acknowledgment in their records, and another resident had incomplete documentation regarding the assistance provided by the durable power of attorney.
The facility failed to ensure accurate resident assessments for three residents, including errors in medication documentation, weight records, and omission of significant diagnoses. These inaccuracies were confirmed by the ADON/MDS Coordinator.
The facility failed to implement comprehensive care plans for several residents, including those with bedrails, hospice care, respiratory care, and unnecessary medications. Observations and interviews revealed that assessments and care plans were either missing or incomplete, leading to multiple deficiencies.
The facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side-rails for eight residents reviewed for accident hazards. Observations revealed that bedrails were in use without documented assessments or care plan updates, and staff interviews confirmed the lack of assessments and alternative attempts.
The facility failed to ensure a consultant pharmacist reviewed the medications of each resident monthly, leading to unnecessary medications for four residents. The acting DON did not follow through with the pharmacist's recommendations for gradual dose reductions during several months.
The facility failed to ensure medication cards were labeled with an expiration date for 49 of 55 sampled medication cards. During an inspection, it was observed that many medication card labels had no readable expiration date. A CMA confirmed the inability to read the expiration dates, and the consultant pharmacist was unaware of the issue.
The facility failed to serve food under sanitary conditions for 23 residents. The dietary manager was observed serving lunch trays while wearing the same set of gloves and without proper hand washing between residents. The dietary manager believed that wearing gloves allowed them to avoid hand washing when exiting and entering the kitchen.
The facility failed to ensure regular inspections and proper assessments of bedrails for eight residents, leading to potential safety risks. Observations and interviews revealed that bedrails were in use without proper documentation or inclusion in care plans, and maintenance checks were only conducted when issues were reported or beds were moved.
A resident with cerebral brain stem hemorrhage, anxiety disorder, and depression disorder, requiring total assistance with ADLs, was transported from the shower room to their room by a CNA. During the transfer, the resident's body was exposed to those in the hallway. The CNA admitted they should have used two sheets to cover the resident and did not notice the exposure.
The facility failed to update a care plan for a resident with peripheral vascular disease and a right above-the-knee amputation when the resident developed a right stump wound. Despite a physician's order for wound care treatment, the care plan was not revised, as acknowledged by the new MDS Coordinator.
The facility failed to document a recapitulation of a resident's stay on the discharge summary. The resident was admitted and later discharged to another facility, but the discharge summary lacked a recap of the stay. The MDS Coordinator/ADON acknowledged the issue and indicated future compliance.
The facility failed to develop and implement physician's orders for oxygen tubing care maintenance for two residents on oxygen therapy, despite their medical conditions and assessments indicating the need for such orders. The ADON/MDS Coordinator confirmed the absence of these necessary orders.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Facility staff failed to implement enhanced barrier precautions (EBP) during urinary catheter care for a resident with an indwelling catheter. Observations revealed that staff did not utilize required personal protective equipment (PPE) such as gowns and masks, as outlined in the facility's own EBP policy for residents with devices like urinary catheters. Specifically, a CNA was seen draining a urinary catheter without wearing an isolation gown or mask, using a towel and washcloth that had been on the floor, and carrying soiled items out of the resident's room while still wearing contaminated gloves. The CNA also demonstrated a lack of knowledge regarding EBP requirements. Similarly, an LPN performed catheter care without securing the catheter to the resident's leg and did not use an isolation gown or mask, also indicating unawareness of EBP protocols. Interviews with staff and the infection preventionist (IP) confirmed that the expectation was to use gloves and clean technique, but there was no consistent understanding or implementation of EBP, despite the facility's policy requiring gloves, gowns, and face shields for care involving artificial openings or tubing. The resident involved was cognitively intact and had an indwelling catheter, and reported that staff only wore gloves during care. The lack of visible EBP signage or equipment in the resident's room further demonstrated the facility's failure to follow its own infection control policies.
Failure to Maintain Odor-Free Environment on Resident Hall
Penalty
Summary
A deficiency was identified when a strong urine odor was repeatedly observed on the South hall, which housed 14 residents. Surveyors noted the persistent odor on multiple occasions, and staff interviews confirmed the presence of the smell. An LPN reported that the odor was particularly strong in the morning and intensified when the hopper room door was opened, attributing the smell to residents' urine. A CNA indicated that the odor seemed to originate from specific rooms, and despite changing residents, linens, and cleaning mattresses, the strong urine smell persisted. The CNA also noted that another resident's mattress had a similar odor, and cleaning efforts did not eliminate it.
Failure to Administer Ordered Narcotic Pain Medication Due to Authorization Delay
Penalty
Summary
The facility failed to ensure that a resident received their prescribed narcotic pain medication as ordered by the physician. The resident, who was cognitively intact and had diagnoses including multiple sclerosis and chronic pain, was ordered to receive hydrocodone/acetaminophen every six hours, along with other pain management medications. According to the medication administration record, the resident did not receive the hydrocodone/acetaminophen at multiple scheduled times over a two-day period. Nursing notes indicated that the resident was given ibuprofen for a reported pain level of 7, and later had no complaints of pain, but the prescribed narcotic was not administered as ordered. The administrator confirmed that the facility was waiting for prior authorization from the resident's insurance for the hydrocodone/acetaminophen, resulting in a lapse in administration of the medication. The last dose of the narcotic pain medication was given the evening before the missed doses began. When asked about their pain, the resident expressed significant distress, stating they were "dying without their pain medication" and described their pain as severe. The failure to provide the ordered pain medication was directly related to the delay in obtaining insurance authorization.
Delayed Completion of Admission Assessment
Penalty
Summary
The facility failed to complete an admission assessment for a resident within the required timeframe. Record review showed that the resident was admitted on a specific date, but the admission assessment was not signed as completed until nearly three months later, well past the required fourteen-day period. The MDS coordinator confirmed in an interview that the assessment was not completed in a timely manner. This deficiency was identified for one of twelve sampled residents whose assessments were reviewed, out of a total of 27 residents in the facility.
Failure to Provide Timely Incontinent Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely incontinent care and assistance with activities of daily living (ADLs) for a resident who was totally dependent on staff. Observation revealed that the resident's brief was very saturated with a dark yellow substance and there was a strong urine odor in the room. The resident, who was cognitively intact and had diagnoses including multiple sclerosis and urinary incontinence, reported that bed checks were not performed every two hours and that they were typically changed only once a day. Staff interview confirmed that the resident had not been changed between 6:45 a.m. and a bit after 10:00 a.m., and that the facility policy required changing residents every two hours. The CNA stated they were unable to follow the policy due to being too busy. These findings demonstrate that the facility did not adhere to its own policy for regular incontinent care, resulting in the resident remaining in a saturated brief for an extended period.
Lack of Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop and implement a policy and procedure for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems. This deficiency was identified through observation, record review, and interview. The maintenance man confirmed that the facility did not have a policy and procedure for Legionella at the time of the survey, although they were working on writing one. The administrator identified 23 residents who resided in the facility.
Failure to Offer Advanced Directives to Residents
Penalty
Summary
The facility failed to ensure residents were offered the choice to formulate advanced directives for three of six sampled residents. Resident #17, admitted with hypertension and diabetes, had no advance directive or acknowledgment in their electronic health record or paper chart. Similarly, Resident #20, admitted with diabetes, also lacked any documentation of an advance directive or acknowledgment in their records. The Assistant Director of Nursing (ADON) was unable to provide documentation that these residents had been offered the choice to formulate an advance directive. Resident #25, admitted with diagnoses including convulsions, peripheral vascular disease, anemia, and anxiety disorder, had an admission assessment indicating cognitive intactness and various levels of assistance required for daily activities. Although a document titled 'Acknowledgement of Receipt Advanced Directive/Medical Treatment Decisions' was marked that the resident had chosen to formulate an advance directive by the durable power of attorney, the ADON reported that there was no documentation that the durable power of attorney had assisted the resident in filling out the advance directive. The ADON acknowledged that Resident #17 and #20 should have had an advance directive or acknowledgment in their medical records.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure resident assessments were accurate for three of the 14 sampled residents. Resident #2 was admitted with multiple diagnoses including diabetes mellitus type II and depressive disorder. A quarterly assessment inaccurately documented that the resident was taking both anti-anxiety and anti-depressive medications, whereas the resident was only on anti-depressive medication. The ADON/MDS Coordinator confirmed this was a mistake. Resident #5, who had diagnoses including transient cerebral ischemic attack and depressive disorder, had a quarterly assessment that incorrectly recorded the resident's weight as 131 pounds instead of the accurate 121 pounds. The ADON/MDS Coordinator acknowledged this as a typographical error. Resident #16, admitted with a diagnosis of malignant neoplasm of the bone among other conditions, had a significant change assessment that failed to document the malignant neoplasm cancer. The ADON/MDS Coordinator confirmed that this diagnosis should have been included in the assessment. These inaccuracies in resident assessments were identified through record reviews and interviews, highlighting a failure in the facility's process to ensure accurate documentation. The errors included incorrect medication documentation, typographical errors in weight records, and omissions of significant diagnoses. These deficiencies were confirmed by the ADON/MDS Coordinator during interviews, indicating lapses in the accuracy of resident assessments, which are critical for providing appropriate care and treatment plans for the residents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a comprehensive care plan for several residents, leading to multiple deficiencies. For instance, five residents with bedrails did not have proper assessments or care plans documenting the use of bedrails. These residents had various diagnoses, including cerebral palsy, multiple fractures, hip fracture, malignant neoplasm, and convulsions. Observations revealed that these residents were either unable to remove or lower the bedrails themselves or used them to prevent falls, yet no assessments were conducted, and the bedrails were not included in their care plans. The ADON/MDS Coordinator admitted to the lack of assessments and care plans for bedrails and was unaware of the requirement for such assessments until recently discovering it in the EHR system. Additionally, the facility failed to include hospice care in the care plan for a resident with dementia, depressive disorder, encephalopathy, and Parkinson's disease, despite a physician's order to admit the resident to hospice. The ADON/MDS Coordinator acknowledged that hospice care should have been included in the care plan. Furthermore, two residents on oxygen therapy did not have their respiratory care documented in their care plans. One resident with diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure, and another with dementia, depressive disorder, encephalopathy, and Parkinson's disease, were both on oxygen, but this was not reflected in their care plans. The facility also failed to document the use of unnecessary medications in the care plans of three residents. One resident with dementia, depressive disorder, encephalopathy, and Parkinson's disease was on anti-psychotics, another with malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, and HTN was on Lasix, and a third resident with congestive heart failure, ischemic cardiomyopathy, and atrial fibrillation was on Brilinta. The ADON/MDS Coordinator admitted that these medications should have been included in the care plans but were not. The MDS Coordinator, who was new to the position, acknowledged still learning about care plans and what should be included.
Failure to Assess and Document Bedrail Use
Penalty
Summary
The facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side-rails for eight residents reviewed for accident hazards. The residents involved had various diagnoses including cerebral palsy, chronic pain syndrome, anxiety disorders, cardiomegaly, multiple fractures, anorexia, dementia, osteoarthritis, hip fractures, multiple sclerosis, convulsions, atrial fibrillation, mood disorders, depressive disorder, encephalopathy, Parkinson's disease, malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, hypertension, bilateral hip replacements, right knee replacement, peripheral vascular disease, and anemia. Observations revealed that bedrails were in use without documented assessments or care plan updates, and staff interviews confirmed the lack of assessments and alternative attempts. For instance, one resident with cerebral palsy and chronic pain syndrome was observed with bedrails on each side of the bed, but no assessment for bedrails was found, and the bedrails were not added to the care plan. Another resident with multiple fractures and dementia was observed with a half bedrail raised, but again, no assessment was documented. Similar deficiencies were noted for other residents, with staff members stating that bedrails were used to prevent falls or assist with mobility, yet no formal assessments or care plan updates were conducted. The ADON/MDS Coordinator admitted to being unaware of the requirement for bedrail assessments and alternative attempts prior to their use.
Failure to Ensure Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure a consultant pharmacist reviewed the medications of each resident in the facility monthly for four of five sampled residents reviewed for unnecessary medications. Resident #2, who was admitted with diagnoses including diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure, was documented as taking antianxiety, antidepressants, and diuretics. Resident #10, admitted with diagnoses such as fracture of hip, multiple sclerosis, and mood disorder, was taking antipsychotics and opioids. Resident #16, with diagnoses including malignant neoplasm of the bone and myocardial infarction, was taking opioids and diuretics. Resident #21, with Alzheimer's, diabetes, and anxiety, was taking an anti-anxiety, anti-coagulant, insulin, and an anti-depressant. The facility did not provide a policy and procedure for drug regimen review, and the acting DON did not follow through with the gradual dose reductions recommended by the pharmacist during the months of May, June, July, and August 2024. The deficiency was identified when the DON returned to the facility in September 2024 after a short leave of absence and discovered that the pharmacist had completed the monthly reviews, but the acting DON had not implemented the recommended gradual dose reductions. This failure to follow through with the pharmacist's recommendations led to the deficiency in ensuring that the medications of each resident were reviewed and adjusted as necessary to avoid unnecessary medications.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure medication cards were labeled appropriately with an expiration date for 49 of 55 sampled medication cards. During an inspection of the medication carts, it was observed that 30 of 34 medication card labels for female residents and 19 of 21 medication card labels for male residents had no readable expiration date. CMA #1 confirmed the inability to read the expiration dates and admitted they would have to guess the expiration dates. The consultant pharmacist was unaware of the missing expiration dates on the labels.
Failure to Serve Food Under Sanitary Conditions
Penalty
Summary
The facility failed to serve food under sanitary conditions for 23 residents who ate meals prepared by the kitchen. On 05/02/24 at 12:12 p.m., the dietary manager was observed serving lunch trays to the residents in the dining room while wearing gloves. The dietary manager exited the kitchen with a food tray, placed the food tray on the table for the resident in the dining area, and then re-entered the kitchen to collect another food tray for another resident, all while wearing the same set of gloves and without proper hand washing in between residents. At 12:23 p.m., the dietary manager stated they believed that wearing gloves allowed them to exit and enter the kitchen without washing their hands to serve the residents in the dining area. They also mentioned they would start handing the food trays to the aides without leaving the kitchen to avoid cross-contamination.
Failure to Conduct Regular Bedrail Inspections and Assessments
Penalty
Summary
The facility failed to ensure regular inspections of resident beds equipped with side rails for eight residents. Observations revealed that bedrails were present and in use without proper assessments or documentation in the care plans. For instance, one resident with cerebral palsy and chronic pain syndrome was observed using bedrails without an assessment or inclusion in the care plan. Another resident with multiple fractures and dementia was also found using bedrails without proper assessment or documentation. Similar deficiencies were noted for other residents with various diagnoses, including dementia, osteoarthritis, hip fractures, and malignant neoplasm of the bone, among others. Additionally, the facility's maintenance practices were found lacking, as the maintenance personnel stated that bedrails were only checked when a problem was reported or when beds were moved. This lack of regular inspection and documentation poses a significant risk to resident safety, as evidenced by the observations and interviews conducted during the survey. The absence of documented alternatives and risk assessments for side rail use further underscores the facility's failure to adhere to safety protocols and regulatory requirements.
Failure to Ensure Resident Dignity During Transfer
Penalty
Summary
The facility failed to ensure a resident was treated with dignity during a transfer. A resident with cerebral brain stem hemorrhage, anxiety disorder, and depression disorder, who required total assistance with most ADLs, was observed being transported from the shower room to their room by a CNA. During this transfer, the resident's body was exposed to those in the hallway. The CNA acknowledged that they should have used two sheets to cover the resident's lower body and admitted they did not notice the exposure while transporting the resident.
Failure to Revise Care Plan for Resident with Stump Wound
Penalty
Summary
The facility failed to revise the care plan for a resident with peripheral vascular disease and a right above-the-knee amputation. The resident's care plan, dated 02/23/24, noted a potential for skin issues but was not updated when the resident developed a right stump wound. A physician's order dated 03/26/24 documented a wound care treatment of silvadene cream to the right stump daily. On 05/02/24, the resident's wound care treatment was observed, and on 05/03/24, the MDS Coordinator acknowledged that the care plan should have been revised to include the new wound. The MDS Coordinator mentioned being new to the position and still learning about care plans.
Failure to Document Recapitulation on Discharge Summary
Penalty
Summary
The facility failed to document a recapitulation of a resident's stay on a discharge summary for one of two sampled residents whose closed records were reviewed. The resident was admitted on an unspecified date and discharged to another facility on February 5, 2024. Upon review, it was found that there was no recapitulation of the resident's stay in the facility on the discharge summary. The MDS Coordinator/ADON reported on May 3, 2024, that they had recently received an example of how a discharge summary should be documented and stated that they would be documenting a recap of the resident's stay going forward.
Failure to Implement Oxygen Tubing Care Maintenance Orders
Penalty
Summary
The facility failed to develop and implement physician's orders for oxygen tubing care maintenance for two residents who were on oxygen therapy. Resident #2, who was admitted with diagnoses including diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure, had a quarterly assessment indicating cognitive intactness and dependency on most ADLs, but lacked physician orders for oxygen equipment maintenance. Similarly, Resident #13, admitted with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease, had a significant change assessment documenting memory problems and moderate assistance required for all ADLs, but also lacked physician orders for oxygen equipment maintenance. The ADON/MDS Coordinator confirmed that there were no orders guiding the nursing staff on when to change the oxygen equipment, which should have been in place according to the facility's procedures.
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Illustrative
What surveyors actually found near you
We read the 10 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Wilburton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tidwell Living Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Beare Manor | 14.3 mi | ★★★★★ | 0 | 0 |
| Talihina Manor | 20 mi | ★★★★★ | 0 | 0 |
| New Hope Retirement & Care Center | 24.1 mi | ★★★★★ | 8 | 0 |
| Mcalester Nursing & Rehab | 24.7 mi | ★★★★★ | 2 | 0 |
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