Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcmahon-tomlinson Nursing Center during CMS and state inspections, most recent first.
The facility failed to report an allegation of abuse to the state agency within the required 2-hour timeframe after a cognitively intact resident with CHF was found on admission to have bruises on the thighs and near the rib cage. APS arrived to investigate an abuse allegation involving this resident and informed facility staff of the investigation. The Administrator, DON, ADON, and Skilled Nurse Manager met, concluded the bruising was caused by a lift sling and not abuse, and decided not to report the allegation, believing that APS involvement as a state agency meant no separate report to OSDH was required.
A resident with congestive heart failure and intact cognition was found on admission to have multiple bruises on the thighs and near the rib cage. APS notified facility staff that they were present to investigate an abuse allegation involving this resident. The Administrator, DON, ADON, and skilled nurse manager met, determined the bruising was caused by a lift sling, and decided not to report or further investigate the abuse allegation, believing that APS involvement as a state agency meant the allegation did not need to be reported to the state health department as required by facility policy.
Missed Wound Care Led to Worsening Lower Extremity Wound: A resident with diabetes, CAD, severe cognitive impairment, and dependence for all ADLs had ordered daily wound care for multiple right lower extremity wounds. Staff failed to complete the ordered care for several days, and the wound later had a strong odor, necrotic tissue, slough, blisters, and black discoloration. The incident was substantiated as neglect, and the resident later required a R BKA after vascular studies showed severe PAD.
Missed wound care and incomplete wound monitoring led to worsening right lower extremity wounds. A resident with severe cognitive impairment, diabetes, CAD, immobility, and a low Braden score had wounds to the right foot, ankle, and lower leg. The care plan and MD order required daily treatment and weekly measurements, but wound care was missed on multiple days, weekly measurements were not consistently documented, and the physician was not contacted when the wound needed further evaluation. The wound progressed from a stage 2 to a stage 3 with necrotic tissue, drainage, and foul odor, and the resident later required a right BKA.
A facility failed to accurately code the MDS for a resident who had pneumonia from Legionella. Despite the hospital discharge report indicating the Legionella diagnosis, the Medicare-5 day MDS assessment did not include it. The MDS coordinator admitted the oversight, stating it was not seen on the discharge report, contrary to facility policy.
The facility failed to update the care plan for a resident diagnosed with Legionella. The DON/IP believed the issue was resolved and did not update the care plan, despite the facility's policy requiring updates after hospital readmission.
A facility failed to implement effective infection control practices, leading to a resident contracting pneumonia from Legionella. The Water Management Program lacked documentation of preventative measures, and housekeeping staff were not consistently instructed to run water in sinks and showers. Water testing for Legionella was only conducted after the case was identified.
The facility failed to ensure accurate assessments for two residents. One resident's fall with injury was documented as non-injury, and another resident's discharge to a private home was incorrectly documented as a hospital discharge. The errors were confirmed by the DON and MDS Coordinator upon review.
The facility failed to update care plans with appropriate interventions after multiple falls for two residents. Despite several unwitnessed falls, the care plans for both residents were not revised to include new interventions, as confirmed by the DON.
The facility failed to ensure neurological checks were completed after unwitnessed falls for a resident with altered mental status, dementia, and anxiety. Despite being at high risk for falls, the resident experienced multiple unwitnessed falls where neurological checks were either not started, incomplete, or not restarted after subsequent falls. The DON confirmed these deficiencies, indicating a significant lapse in care.
The facility failed to ensure proper respiratory care for three residents by not labeling and dating oxygen tubing and not administering respiratory medications per standard practice. One resident was observed using outdated oxygen tubing, another received a breathing treatment without a nurse present and had unlabeled tubing, and a third had unlabeled and undated oxygen tubing.
The facility failed to ensure proper communication and assessment for a resident requiring dialysis services. The Hemodialysis Communication Record was found to be incomplete or missing information for multiple dialysis events, affecting the resident's care. The DON acknowledged the lapses in documentation and communication.
The facility failed to ensure RN coverage for 8 hours per day, 7 days a week, on nine specific dates within a 92-day period. The Administrator confirmed the lack of RN coverage, affecting the care of 97 residents and contributing to a one-star rating.
The facility failed to ensure that extended release medications were not crushed for two residents, leading to a medication error rate of 6.94%. The errors involved the administration of crushed Metoprolol Succinate and Potassium Chloride extended release medications, contrary to physician orders.
The facility failed to maintain proper infection control measures, including not changing gloves during perineal care, not sanitizing medical equipment between residents, and not sanitizing hands between resident interactions during medication administration.
A resident with a history of falls and multiple diagnoses was observed without the required fall mats, despite the care plan specifying their use. Both a CNA and an LPN confirmed the absence of fall mats, and the DON stated that staff had discontinued their use, believing the resident was no longer a fall risk. This failure to follow the care plan and facility policy resulted in a deficiency.
The facility failed to specify time frames for medication regimen reviews, resulting in a delayed response to a review for a resident prescribed venlafaxine for depression. The physician's response to a February 2024 review was not received until April 2024, as confirmed by the DON.
The facility failed to monitor side effects for a resident prescribed anticoagulant therapy, despite having a policy in place. The resident's records lacked documentation of side effect monitoring, and the DON confirmed the policy was not followed.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the state agency within the required 2-hour timeframe for one resident. The facility’s Abuse and Neglect policy dated 09/12/25 stated that the facility shall immediately report allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. Resident #1 was admitted on 12/05/25 with a diagnosis of congestive heart failure, and the admission assessment documented that the resident’s cognition was intact with a BIMs score of 15. A skilled assessment on the same date showed the resident had bruises on the right lateral thigh, left inner thigh, and near the rib cage. According to interview and record review, an APS investigator reported going to the facility on 12/05 and informing staff they were there to investigate an allegation of abuse for Resident #1. The DON stated that on 03/05/26 a meeting was held with the Administrator, DON, ADON, and Skilled Nurse Manager regarding the allegation of abuse and the bruising. They discussed and investigated the bruising and concluded it was caused by the lift sling and determined it was not abuse, deciding that an investigation into the allegation of abuse would not be reported. The Administrator later reported that APS had come to the facility and informed them they were there to investigate an allegation of abuse for Resident #1, and that the facility believed they did not have to report the allegation because APS is part of a state agency. The Administrator acknowledged that the abuse allegation should have been reported to OSDH and investigated.
Failure to Investigate and Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was investigated and reported as required for one resident. The facility’s Abuse and Neglect policy, dated 09/12/25, required immediate reporting of allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. Resident #1 was admitted on 12/05/25 with a diagnosis of congestive heart failure, and the admission assessment documented intact cognition with a BIMS score of 15. A skilled assessment on the same date identified bruises on the resident’s right lateral thigh, left inner thigh, and near the rib cage. On 12/05, an APS investigator came to the facility and informed staff they were there to investigate an allegation of abuse for Resident #1. The DON later reported that a meeting was held regarding this allegation, attended by the Administrator, DON, ADON, and Skilled Nurse Manager, during which they discussed and investigated the bruising and concluded it was caused by a lift sling and not abuse. Based on this internal conclusion, they decided not to report or further investigate the allegation of abuse. The Administrator reported that APS had informed them they were conducting an investigation concerning an allegation of abuse for the resident, and acknowledged they believed they did not have to report the allegation because APS is part of a state agency, despite the facility policy requiring immediate reporting and investigation.
Missed Wound Care Led to Worsening Lower Extremity Wound
Penalty
Summary
The facility failed to ensure wound care was provided per physician orders for one resident with multiple wounds to the right lower extremity. The resident had a history of diabetes mellitus, coronary artery disease, severe cognitive impairment, and dependence on staff for all activities of daily living. The care plan identified pressure ulcer development related to immobility and low Braden score, and the treatment record showed a physician order for daily wound care to the right foot, right ankle, and back of the right leg using hydrogel, Meplix transfer dressing, abdominal pad, and Kerlix. Documentation showed the wound care was not performed as ordered on three consecutive days, and the wound care nurse admitted the omission. A health status note later described the dressing as soiled, the wound as having a strong odor and having grown significantly in size, with necrotic tissue, slough, blisters, black discoloration, and a foul odor. The wound was documented as stage 3 with large measurements to the top of the right foot, inner foot, and posterior leg to ankle. A physician note described an open wound with significant odor, maceration, discharge, and inability to palpate pulses in the right lower extremity. An incident report substantiated an allegation of neglect and stated the wound progressed from stage 2 to stage 3 after the missed wound care. A vascular study showed severe peripheral arterial disease with possible significant stenosis, and the resident was later admitted to the hospital and underwent a right below-knee amputation. The DON stated the missed wound care caused worsening of the wound and was found to be neglect by the nurse, while the physician stated the wound appeared vascular and developed quickly.
Missed wound care and incomplete wound monitoring led to worsening right lower extremity wounds
Penalty
Summary
The facility failed to follow physician orders and the resident’s care plan for wound care for a resident with severe cognitive impairment, diabetes mellitus, coronary artery disease, immobility, and a low Braden score. The resident had wounds to the right foot, right ankle, and back of the right leg, and the care plan required weekly treatment documentation with measurements, tissue type, and exudate. A physician ordered daily wound care on the right foot, right ankle, and back of the right leg, including cleansing, hydrogel, Meplix transfer abdominal pad, Kerlix, and observation for skin changes. Record review showed the resident’s skin condition worsened over time. A health status note described chronic bruising to the right foot that opened into a sore after the resident was observed pressing the heel of the foot against the other foot. Subsequent skin and wound evaluations documented an in-house acquired intact blister to the right lateral foot and an in-house acquired stage 2 pressure wound to the right medial foot. Later notes described necrotic tissue, drainage, peeling skin, ruptured blisters, black discoloration, and a strong foul odor, with the wound later classified as stage 3 and measured across multiple areas of the right foot and lower leg. The record also showed missed wound care and missing documentation. The treatment administration record and incident report showed wound care was not performed on multiple days as ordered, and the nurse admitted not performing the wound care. The report stated the wound progressed from stage 2 to stage 3 and substantiated neglect. Additional notes showed the wound care nurse did not document weekly measurements as required, and the physician was not contacted when the wound required further evaluation. The resident was later admitted to the hospital and underwent a right below-the-knee amputation.
Inaccurate MDS Coding for Legionella Diagnosis
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) was coded accurately for a resident who was discharged from the hospital for skilled services. The resident had diagnoses including pneumonia from Legionella, high blood pressure, and non-Alzheimer's dementia. A hospital discharge report indicated the resident was admitted for altered mental status due to pneumonia from Legionella. However, the Medicare-5 day MDS assessment did not reflect the Legionella diagnosis. The MDS coordinator acknowledged that the resident was discharged to the hospital and returned, and the MDS assessment was completed for skilled services. They admitted that the Legionella diagnosis was not incorporated into the MDS as it was not seen on the hospital discharge report, which was against facility policy to list it under other diagnoses.
Failure to Update Care Plan for Legionella Diagnosis
Penalty
Summary
The facility failed to update the care plan for a resident who was diagnosed with Legionella. According to the facility's policy, the interdisciplinary team is required to review and update the care plan when a resident is readmitted from a hospital stay. However, in this case, the Director of Nursing/Infection Preventionist (DON/IP) reported that they believed the issue had been resolved and therefore did not update the care plan. This oversight occurred despite the policy requirement and the resident's recent diagnosis of Legionella.
Inadequate Water Management Leads to Legionella Case
Penalty
Summary
The facility failed to implement effective infection prevention and control practices, specifically in identifying high-risk areas and ensuring the flushing of unused water outlets to prevent the spread of waterborne illnesses such as Legionella. The facility's Water Management Program, dated 03/05/25, outlined the need for identifying risk factors, establishing control measures, and maintaining detailed records of testing and monitoring results. However, the maintenance director admitted to having only water and air temperature records, with no documentation of preventative measures or cleaning schedules. The housekeeping staff were supposed to run water while cleaning rooms, but this was not consistently done prior to the Legionella case. A resident was admitted to the hospital with altered mental status due to pneumonia from Legionella, highlighting the deficiency in the facility's water management practices. Interviews with housekeeping staff revealed that they were not routinely instructed to run water in sinks and showers while cleaning, and there was no prior in-service training related to this practice before the Legionella case. The maintenance director confirmed that water testing for Legionella was only conducted in the affected resident's room after the case was identified, indicating a lack of proactive measures to prevent such occurrences.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents. One resident with a diagnosis of weakness had a fall resulting in a laceration, but the assessment inaccurately documented the fall as non-injury. The Director of Nursing confirmed the error upon review. Another resident with a diagnosis of sepsis was discharged to a private home, but the discharge assessment incorrectly documented the discharge as to a hospital. The MDS Coordinator confirmed the discrepancy upon review of the discharge notes.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that interventions were added to the care plans of two residents after multiple falls. Resident #38, who had diagnoses including type 2 diabetes mellitus, urinary incontinence, and hypertensive heart disease, experienced several unwitnessed falls on 04/15/23, 12/04/23, 03/30/24, and 03/31/24. Despite these incidents, no new interventions were documented in the resident's care plan since 01/12/22. The Director of Nursing (DON) confirmed that the care plan had not been updated with new fall interventions as required by the facility's policy on assessing falls and their causes, revised in 03/2018. Similarly, Resident #41, who had diagnoses including altered mental status, dementia, and anxiety, experienced multiple unwitnessed falls between 01/16/24 and 03/15/24. Although the resident's care plan was revised on 03/13/24, no specific interventions were updated to address the falls. The DON confirmed that the care plan had only been updated on 04/10/24, after the surveyor's inquiry. This failure to update care plans with appropriate interventions after falls is a clear deficiency in the facility's adherence to its own policies and procedures for fall prevention.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure neurological checks were completed after unwitnessed falls for one resident reviewed for falls. The resident had multiple diagnoses, including altered mental status, dementia, and anxiety, and was identified as being at high risk for falls. Despite this, the facility did not consistently perform or document the required neurological checks following several unwitnessed falls. For instance, on 01/16/24, there was no documentation that neurological checks were started after an unwitnessed fall. On 01/24/24, neurological checks were started but were incomplete, and they were not restarted after a second fall on the same day. Similar issues were noted on 02/02/24, where checks were only partially completed, and on 02/22/24, where checks were inconsistently documented. Additionally, on 03/15/24, following a witnessed fall, the neurological assessment was incomplete. The Director of Nursing (DON) confirmed these deficiencies, acknowledging that neurological checks were either not started, not restarted after subsequent falls, or not accurately completed. The facility's policies on neurological assessments and fall assessments were not adhered to, leading to incomplete or missing documentation of neurological checks. This failure to follow protocol and ensure proper monitoring after falls represents a significant lapse in the care provided to the resident, who was already at high risk for falls and had a complex medical history.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents by not adhering to the policy of labeling and dating oxygen tubing and not administering respiratory medications per standard practice. Resident #14, who had diagnoses including macular degeneration and osteoporosis, was observed using oxygen tubing dated 02/26, which was not changed as per the physician's order to change it every two weeks. LPN #1 confirmed the tubing was outdated and did not follow the physician's orders. Resident #64, who required oxygen therapy and had a diagnosis of dependence on supplemental oxygen, was observed receiving a breathing treatment without a nurse present, and there was no assessment for self-administration of medication. Additionally, the oxygen tubing was not labeled with a date. LPN #1 confirmed the tubing was not labeled and that the resident did not have an order to self-administer medication. Resident #143, diagnosed with chronic respiratory failure and dependence on supplemental oxygen, was observed with oxygen tubing that was not labeled or dated, contrary to the physician's orders and facility protocol. LPN #3 confirmed the tubing should be changed and dated every Sunday and placed in a plastic bag when not in use.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper communication and assessment for a resident requiring dialysis services. Specifically, the facility did not maintain adequate communication between the dialysis center and the nursing staff, and pre- and post-dialysis assessments were not consistently completed. The facility's Hemodialysis Communication Record, which is divided into pre-dialysis, dialysis center, and return to facility assessments, was found to be incomplete or missing information for multiple dialysis events. For instance, pre-dialysis assessments lacked information for two out of 14 events and only contained vital signs without a physical assessment for six out of 14 events. Similarly, dialysis center assessments were missing for three out of 14 events and lacked physical assessments for 11 out of 14 events. Return to facility assessments were incomplete for eight out of 14 events and only contained vital signs and weights without a physical assessment for four out of 14 events. Resident #63, who had diagnoses including end-stage renal disease and dependence on renal dialysis, was directly affected by these deficiencies. The resident received dialysis three times per week but reported being unaware of any monitoring being conducted. The Director of Nursing (DON) acknowledged that the communication forms were not being fully completed and should be maintained in the resident's hard chart. The DON also stated that staff only documented in a progress note if the resident did not return from dialysis, further indicating lapses in the required documentation and communication processes.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage was provided for 8 hours per day, 7 days a week, for nine specific dates within a 92-day period. The facility's policy, revised in August 2022, mandates that an RN provides services for at least eight consecutive hours every 24 hours, seven days a week. However, a review of time documents revealed that there was no RN coverage for the required duration on the dates of 10/01/23, 10/07/23, 10/15/23, 10/22/23, 11/11/23, 11/19/23, 12/03/23, 12/09/23, and 12/17/23. The Administrator confirmed the lack of RN coverage on these dates, affecting the care of 97 residents residing in the facility. This deficiency contributed to the facility receiving a one-star rating.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that extended release medications were not crushed for two residents, leading to a medication error rate of 6.94%. Resident #6, who had diagnoses including high blood pressure, edema, and atrial fibrillation, was administered crushed Metoprolol Succinate extended release 12.5 mg and Potassium Chloride extended release 20 milliequivalents, despite a physician order indicating that extended release medications should not be crushed. Similarly, Resident #23, who had a diagnosis of high blood pressure, was administered crushed Metoprolol Succinate extended release 25 mg, contrary to the physician's order that extended release medications should not be crushed and that alternatives should be sought from the pharmacy if necessary. During the medication pass observation, CMA #1 was seen crushing and administering these extended release medications to both residents. When questioned, CMA #1 confirmed that they had crushed the extended release medications for both residents. The Director of Nursing (DON) also confirmed that extended release medications should not be crushed unless the physician is aware, but acknowledged that Potassium extended release and Metoprolol extended release should not be crushed. This failure to adhere to medication administration protocols resulted in a medication error rate exceeding the acceptable threshold.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff maintained proper infection control measures during the provision of perineal care and personal hygiene for a resident. A CNA was observed not changing gloves while providing perineal care, cleaning the resident's eyes and mouth, and performing other hygiene tasks. The CNA admitted to not changing gloves during the entire process, which was confirmed as a violation of the facility's infection control policy by the DON. Additionally, a CMA was observed not sanitizing a blood pressure cuff and pulse oximeter between uses on multiple residents. The CMA admitted to not sanitizing the equipment after each use, which was against the facility's policy. The DON confirmed that staff should sanitize equipment between residents to prevent cross-contamination. Furthermore, another CMA was observed not sanitizing their hands between residents during medication administration. The CMA handled various medical tasks and equipment without washing or sanitizing their hands, which was against the facility's hand hygiene policy. The CMA acknowledged the lapse and cited the absence of hand sanitizer on the medication cart as a reason. The DON confirmed that hand hygiene should be maintained between resident interactions to prevent the spread of infections.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions were implemented for a resident with a history of falls. Resident #14, who had diagnoses including macular degeneration, lesion of the plantar nerve, and osteoporosis, was observed in bed without the required fall mats on each side. The care plan dated 11/22/23 specified the use of fall mats, but these were not in place during the observation on 04/09/24. Both a CNA and an LPN confirmed that the fall mats should have been in place according to the care plan, but they were not. The Director of Nursing (DON) stated that staff felt Resident #14 was no longer a fall risk, which led to the discontinuation of the fall mats without proper documentation or care plan update. The facility's policy on assessing falls and their causes, revised in 03/18, mandates that appropriate interventions be recorded in the resident's medical record to prevent future falls. However, this policy was not followed for Resident #14. The comprehensive assessment dated 03/25/24 indicated that the resident was dependent for transferring from bed to chair and had moderately impaired cognition, further emphasizing the need for fall prevention measures. The failure to implement and maintain these interventions as per the care plan and facility policy resulted in a deficiency in ensuring a safe environment for the resident.
Failure to Specify Time Frames for Medication Regimen Review
Penalty
Summary
The facility failed to identify specific time frames for the steps regarding the medication regimen review (MRR) in their policy, leading to a delay in addressing a medication review for a resident diagnosed with depression. The resident was prescribed venlafaxine for depression, and a medication regimen review conducted in February 2024 requested the physician to consider a dose reduction or provide a rationale for not doing so. However, the physician's response was not received until April 5, 2024. The Director of Nursing (DON) confirmed that the policy did not specify time frames for non-urgent MRRs and acknowledged the delay in addressing the February 2024 MRR. The deficiency was identified during a review of the facility's records and interviews with the DON.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure side effect monitoring was in place for a resident prescribed anticoagulant therapy. The resident had diagnoses including pulmonary embolism, hypertensive heart disease, and peripheral vascular disease, and was prescribed Apixaban. Despite the facility's Anticoagulation-Clinical Protocol policy requiring monitoring for adverse drug reactions, the Treatment Administration Record and Active Order Summary did not document any side effect monitoring for the resident. The Director of Nursing confirmed that the policy was not followed, as there was no side effect monitoring in the orders or the Treatment Administration Record.
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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 Lawton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montevista Rehabilitation And Skilled Care | 1.3 mi | ★★★★★ | 0 | 0 |
| Willow Park Health Care Center | 1.4 mi | ★★★★★ | 2 | 2 |
| Lawton Post Acute & Rehab | 3 mi | ★★★★★ | 7 | 4 |
| Marlow Nursing & Rehab | 27.9 mi | ★★★★★ | 10 | 0 |
| Gregston Nursing Home, Inc. | 28.4 mi | ★★★★★ | 9 | 0 |
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