Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Okemah Care Center during CMS and state inspections, most recent first.
Oxygen tubing was not properly labeled or dated for two residents receiving O2 therapy. An LPN confirmed one resident’s tubing label was dated beyond the expected weekly change interval and confirmed another resident’s tubing had no label or date, while the DON stated tubing should be changed weekly and labeled and dated.
The facility failed to maintain the temperature log for a medication refrigerator used for stored meds. During a medication room tour, the log had no entries for several consecutive days, and the refrigerator was observed at 42 degrees F. The DON stated night shift was assigned to complete the checks and documentation and that there had been prior issues with the log being completed; the DON said it should be done daily.
Enhanced barrier precautions were not followed during resident care when an LPN exited a room wearing the same gown and gloves used for catheter care, carried soiled items down the hall, and discarded soapy water in a common bathroom before removing PPE. In a separate observation, the LPN did not change gloves or wear a gown during wound care for another resident. The infection preventionist confirmed the precautions were not followed, and the administrator identified nine residents on enhanced barrier precautions.
A resident with bipolar, mood disorder, and schizoaffective disorder eloped from the facility. Although interventions were implemented following the incident, the care plan was not updated to reflect these changes. The administrator later confirmed that the care plan should have been revised.
The facility failed to use privacy curtains for two residents during care, leading to privacy breaches. One resident with cerebral palsy was observed uncovered in bed without adequate curtain coverage. Another resident with a pressure ulcer and dementia was exposed during pericare and wound care, with staff acknowledging the curtain should have been used.
The facility failed to complete required Braden skin assessments and weekly skin assessments for two residents. One resident with a Stage 4 pressure ulcer did not have documented assessments since April, despite being at high risk. Another resident, at risk for pressure ulcers, had incomplete and unsigned assessments, with no documentation since April. The facility's policy for weekly skin assessments was not followed, and a resident's heel condition was not documented.
The facility failed to monitor side effects of antidepressants for four residents, despite having a policy in place. A resident with depressive disorder was not monitored for side effects of Trazadone and Escitalopram. Another resident with recurrent depressive disorder was not monitored for Pristiq and Trintellix side effects. A third resident with mood disorder and anxiety was not monitored for Lexapro side effects, and a fourth resident with bipolar disorder was not monitored for Bupropion and Trazodone side effects. Interviews confirmed the lack of documentation for side effect monitoring.
The facility did not ensure the dietary manager was certified, as required by state regulations. The dietary manager, who started in March 2022, was enrolled in a certification course but had not taken the exam. This affected the food services for 42 residents.
The facility failed to maintain kitchen sanitation and food safety, affecting 42 residents. Observations revealed mold-like substances, unclean areas, unlabeled food items, and a malfunctioning dishwasher lacking sanitization fluid. Staff interviews highlighted gaps in cleaning schedules and supply ordering issues.
A facility failed to accurately document a resident's code status, showing them as a full code despite having a signed DNR. Staff interviews revealed inconsistencies in updating the code status list, with the last update occurring the previous year. This highlights a lack of a reliable system for maintaining current documentation.
The facility failed to maintain a clean and homelike environment, with unaddressed water spills and accumulated dirt and dead insects in common areas. Additionally, strong urine odors persisted in the rooms of two residents, with staff failing to take timely action to address these issues.
A resident in the facility did not have a comprehensive activity care plan, as required by facility policy. The resident expressed dissatisfaction with the lack of activities, noting that bingo occurred infrequently and that they often had nothing to do but watch TV. The activities calendar lacked specific times and locations, and staff confirmed that activities were infrequent. The facility's MDS coordinator admitted that activities were not care planned individually for all residents, contributing to the deficiency.
A facility failed to administer tube feeding bolus according to a physician's order for a resident with anorexia and cachexia. The resident's meal intake percentages, crucial for determining tube feeding administration, were inconsistently documented, leading to potential non-compliance with the physician's order. An LPN noted blanks in medical records for eating and fluid intake tasks, indicating incomplete or late documentation, which contributed to the deficiency.
The facility failed to ensure a medication error rate below 5% when a CMA did not instruct two residents to chew their prescribed 81 mg aspirin tablets, as required by physician orders. This was confirmed by a Corporate Nurse Consultant.
The facility failed to ensure proper PPE use during care for a resident with a Stage 4 pressure ulcer, as one CNA did not wear PPE while assisting with care. Additionally, a syringe used for tube feeding was improperly stored without a protective barrier, posing a risk of contamination. An LPN confirmed the syringe should have been covered and placed on a napkin to dry.
Oxygen Tubing Not Labeled or Dated
Penalty
Summary
The facility failed to ensure oxygen tubing was labeled and dated for two residents receiving oxygen therapy. Resident #26 was observed using oxygen tubing with a label dated 02/13/26, and Resident #36 was observed using oxygen tubing with no label and no date. The facility’s Oxygen Concentrator Maintenance instructions stated that all tubing would be changed weekly and as needed for soiling, and that tubing would be dated and initialed when completed. An LPN confirmed that Resident #26 was using oxygen and that the tubing label was dated 02/13/26, stating they thought it was to be changed weekly. The same LPN later confirmed that Resident #36 was using oxygen and that there was no label on the tubing, stating they did not know when it had been changed. The DON stated that oxygen tubing should be changed weekly and should be labeled and dated.
Medication Refrigerator Temperature Log Not Maintained
Penalty
Summary
The facility failed to maintain the temperature log for one of one medication refrigerators observed for proper temperature controls for medication storage. During a tour of the medication room with CMA #1, the temperature log sheet for February 2026, located on the front of the medication refrigerator, had no documentation for 02/20/26, 02/21/26, 02/22/26, and 02/23/26. The refrigerator was observed at 42 degrees Fahrenheit. The facility policy stated that medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept on a refrigerator with a thermometer to allow daily temperature monitoring. The DON stated that the night shift is assigned to complete the temperature checks and documentation and that there had been issues with the log sheet being completed in the past; the DON also stated it should be done daily.
Enhanced Barrier Precautions Not Followed During Catheter and Wound Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not follow enhanced barrier precautions during resident care. During catheter care for a resident with a supra-pubic catheter related to a neurogenic bladder, the LPN donned a gown and gloves, completed care, then exited the room still wearing the same PPE. The LPN carried soiled washcloths and an emesis basin of soapy water down the hall, discarded the soapy water in a common bathroom five rooms away, continued to the dirty linen hopper, and only removed the gown and gloves while returning to the resident room. The resident had diagnoses including renal insufficiency, diabetes, and depression, and was on enhanced barrier precautions because of the indwelling catheter. The facility also failed to ensure enhanced barrier precautions were followed during wound care for another resident. During wound care, the LPN was observed removing soiled dressings, performing wound care, and applying clean dressings without changing gloves between tasks and without donning a gown. The LPN stated gloves should have been changed and hand hygiene performed between removing the soiled dressings and doing wound care, and that a gown should have been worn for enhanced barrier precautions. The infection preventionist stated the precautions were not followed during the wound care observation, including glove changes, hand hygiene, and wearing a gown. The administrator identified nine residents with enhanced barrier precautions.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to update the care plan for a resident who had eloped, despite interventions being put in place following the incident. The resident, who had diagnoses including bipolar disorder, mood disorder, and schizoaffective disorder, eloped on 10/29/24. An incident report was documented on 10/30/24, noting the elopement and the implementation of new interventions. However, there was no documentation of these interventions in the resident's care plan. On 12/27/24, the administrator acknowledged that the care plan should have been updated.
Failure to Use Privacy Curtains for Resident Care
Penalty
Summary
The facility failed to ensure the use of privacy curtains for two residents, leading to a breach of privacy. Resident #9, diagnosed with cerebral palsy and severe intellectual disabilities, was observed on multiple occasions lying uncovered in bed without the privacy curtain being pulled. The curtain in the room did not extend fully, leaving the resident exposed. Staff, including a CNA and the Administrator, confirmed that the curtain did not provide adequate privacy, and the resident was exposed from the hallway. Resident #21, who had a pressure ulcer, dementia, and depressive disorder, was also observed without the privacy curtain being used during care. The resident was exposed to the hallway while receiving pericare and wound care from staff, including a CNA and an LPN. Despite having a roommate, the privacy curtain was not pulled during the care procedures. Staff acknowledged that the curtain should have been used during such treatments, indicating a failure to maintain resident privacy.
Failure to Complete Required Skin Assessments
Penalty
Summary
The facility failed to ensure that Braden skin assessments and weekly skin assessments were completed for two residents reviewed for wound care. Resident #21, who had a diagnosis of a Stage 4 pressure ulcer on the right buttock, did not have documented weekly skin assessments since April 19, 2024, despite being at high risk for pressure ulcers as per a Braden Scale assessment dated December 29, 2023. LPN #1, responsible for these assessments, admitted that they did not complete weekly skin assessments if the resident had outside wound care visits unless another issue was identified. The Director of Nursing confirmed that LPN #1 was responsible for completing and documenting these assessments in the computer. Resident #13, diagnosed with Alzheimer's disease and cognitive impairment, was also at risk for pressure ulcers according to a Braden Scale assessment. However, their skin assessments were incomplete, unsigned, and contained blanks. The last documented skin assessment was in April 2024, despite the resident having a healed wound as of March 28, 2024. The Corporate Nurse Consultant confirmed that the policy for weekly skin assessments and Braden assessments was not followed, and no skin assessments had been completed since April 2024. Additionally, Resident #13's left heel was observed to have dry flaky skin and a scabbed area, which was not documented in the nurse notes.
Failure to Monitor Antidepressant Side Effects
Penalty
Summary
The facility failed to monitor for side effects related to the use of antidepressants for four residents who were part of a sample reviewed for unnecessary medications. The facility's policy on monitoring antidepressants was not followed, as there was no documentation of side effect monitoring for the residents involved. Resident #1, diagnosed with depressive disorder and depression, was prescribed Trazadone and Escitalopram Oxalate, but there was no documentation of side effect monitoring for several months. Similarly, Resident #3, with recurrent depressive disorder, was prescribed Pristiq and Trintellix, but their treatment administration records lacked documentation of side effect monitoring, despite the care plan specifying the need to monitor for specific side effects. Resident #32, diagnosed with unspecified mood disorder and anxiety, was prescribed Lexapro and Lamotrigine, but there was no documentation of side effect monitoring for Lexapro. Resident #40, with bipolar disorder, was prescribed Bupropion and Trazodone, but side effect monitoring was not documented for these medications. Interviews with the Corporate Nurse Consultant and an LPN confirmed the lack of side effect monitoring, which was supposed to be documented on the treatment administration record. This oversight indicates a failure to adhere to the facility's policy on monitoring antidepressant side effects, potentially leading to the administration of unnecessary drugs.
Non-compliance with Dietary Manager Certification
Penalty
Summary
The facility failed to ensure that the designated dietary manager met the state requirements for dietary management. The dietary manager, who began their role in March 2022, was not certified as a dietary manager. Documentation showed that the dietary manager was enrolled in a course for certification, with a transaction dated March 2022 and module grades recorded in December 2022. However, there was no evidence that the dietary manager had taken the certification exam. The administrator confirmed that the dietary manager had not completed the certification process. This deficiency affected the food and nutrition services provided to 42 residents receiving meals from the kitchen, out of the 43 residents residing in the facility.
Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that promotes food safety and sanitation, affecting 42 residents who received services from the kitchen. Observations during an initial tour revealed several deficiencies, including a black substance along the back trim of the sink, a black wet substance on the floor under the sink and dishwasher, and a rusty metal box overflowing with suds. Additionally, there were two metal knives and a blue-handled wrench on the floor next to canned goods, and debris was found under the shelf with cans. Food items such as desserts and bread were not labeled or dated, and milk containers lacked opening dates. A three-tiered cart had food debris on all corners and shelves, and the dishwasher temperature did not reach the required 120 degrees, with no dishwashing wash or sanitation fluid available. Interviews with staff revealed gaps in the cleaning schedule and a lack of awareness regarding the need to date opened bread. The dietary manager acknowledged the presence of mold-like substances and unclean areas under the dishwasher. The dishwasher was tested twice, showing no sanitization detected on the strip, and the sanitizer and wash buckets were found empty. The dietary manager mentioned issues with ordering supplies from the dishwasher company, leading to delays and back orders, which contributed to the lack of necessary cleaning agents.
Inaccurate Code Status Documentation for Resident
Penalty
Summary
The facility failed to maintain an accurate process for identifying a resident's code status, specifically for one resident among ten reviewed. The resident in question had a signed Do Not Resuscitate (DNR) order dated May 13, 2022, which was documented in their hard chart. However, an undated form titled 'Full Code' was observed on the inside of a cabinet door at the nurse's station, incorrectly indicating that the resident was a full code. This discrepancy highlights a failure in the facility's process to ensure that the resident's code status was accurately communicated and updated. Interviews with staff revealed inconsistencies in the understanding and execution of the process for updating code status lists. An LPN stated that the list was updated monthly or every other month, while the Director of Nursing confirmed the resident's DNR status but acknowledged the incorrect full code listing. A corporate nurse consultant admitted that the list was not accurate and should be updated with any change in the care plan. The failure to update the list since the previous year further underscores the lack of a reliable system to ensure accurate and current documentation of residents' code statuses.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by observations of unclean conditions in the dining and television rooms. On multiple occasions, a puddle of water was observed on the floor near a coke machine in the television room, posing a potential hazard to residents, including one in a wheelchair. Despite being aware of the water, staff members, including CNAs and the dietary manager, did not take action to clean the area or notify housekeeping. Additionally, the windows in both the dining and television rooms were found to have accumulated dust, dirt, dead flies, and mouse droppings, which were not addressed by the staff. The facility also failed to prevent lingering urine odors in the rooms of two residents. Strong urine odors were noted in the hallway and in the rooms of these residents on several occasions. In one instance, a corporate nurse consultant identified a wet brief in the trash as the source of the odor in one resident's room. Despite these observations, the odors persisted over multiple days, indicating a lack of timely and effective cleaning and maintenance practices by the facility staff.
Failure to Develop Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for activities for a resident, identified as Resident #38, who was reviewed for activities. The facility's policies require that care plans incorporate goals and objectives to achieve the resident's highest level of independence and that these plans are reviewed and revised at least quarterly. However, it was found that Resident #38 did not have an activities care plan, and the MDS coordinator confirmed that activities were not care planned individually for all residents, only for specific cases such as level 2 PASRR, bedridden, or during COVID isolation. Observations and interviews revealed that Resident #38 expressed dissatisfaction with the lack of activities, stating that there was nothing to do but sit, sleep, and watch TV. The resident mentioned that bingo occurred only once a month and that they occasionally went out for a van ride twice a year. The activities calendar lacked times and locations for the activities, and the activity director admitted to forgetting to include these details. The activity director also stated that Resident #38 declined activities and preferred watching TV, participating in bingo 2-3 times a month depending on their mood. Further interviews with staff, including a CNA and the activity director, indicated that activities were infrequent, occurring maybe once a week, and that the resident sometimes participated in bingo. The administrator acknowledged the lack of specific times on the activities calendar and noted that some listed activities, such as a podiatrist visit, were not actual activities. Despite these issues, there were no complaints from residents about the activities. The corporate nurse consultant stated that they would expect each resident to have an activity care plan, highlighting the deficiency in the facility's care planning process.
Failure to Administer Tube Feeding According to Physician's Order
Penalty
Summary
The facility failed to administer tube feeding bolus according to the physician's order for a resident diagnosed with anorexia and cachexia. The resident had a physician's order for Osmolite to be given four times a day, with specific instructions to hold the feeding if the resident consumed more than 50% of their meal. However, discrepancies were found in the documentation of the resident's meal intake percentages, which were crucial for determining whether the tube feeding should be administered. The lack of documentation on specific dates in May 2024, as noted by the Corporate Nurse Consultant, indicated that the facility did not consistently record the resident's meal intake, leading to potential non-compliance with the physician's order. Additionally, the facility's policy on intake, measuring, and recording, which required accurate documentation of fluid intake, was not adhered to. An LPN acknowledged the presence of blanks in the medical records for tasks related to eating and fluid intake, suggesting that either the tasks were not completed or were documented late. This lack of documentation and adherence to the facility's policy contributed to the failure in providing appropriate pharmaceutical services to meet the resident's needs, as required by the physician's orders.
Medication Administration Error
Penalty
Summary
The facility failed to maintain a medication error rate below 5% as observed during a medication administration review. Two residents, one with hypertension and mood disorder and another with atherosclerosis of native arteries of extremities, were involved in the deficiency. Both residents had physician orders for an 81 mg chewable aspirin tablet to be administered once daily. However, during medication administration, the Certified Medication Aide (CMA) did not instruct either resident to chew the aspirin tablet as required. This oversight was confirmed by a Corporate Nurse Consultant, who stated that the medication should be chewed unless otherwise directed by a physician.
Inadequate PPE Use and Improper Syringe Storage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during care provision for a resident with a Stage 4 pressure ulcer, dementia, and depressive disorder. During an observation, two CNAs were present in the room with the resident, who was exposed without privacy. One CNA did not wear PPE while assisting with positioning and changing the resident's shorts, despite the requirement for enhanced barrier precautions (EBP) for residents with indwelling medical devices or wounds. The CNA admitted to not receiving training on PPE use for EBP at the facility, although they had been trained at a previous job. Additionally, the facility failed to store a syringe used for tube feeding in a manner that prevents cross-contamination for a resident with unspecified congestive heart failure. Observations revealed a tube feeding syringe placed on a dresser without a protective barrier, with the plunger end exposed. An LPN confirmed that the syringe should have been covered and placed on a napkin to dry, and that food should not have been left in the room. The LPN acknowledged that the syringe was improperly left open, posing a risk of contamination.
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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 Okemah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartway At Colonial Park Health And Rehab | 2.1 mi | ★★★★★ | 0 | 0 |
| Rainbow Terrace Care Center | 11.6 mi | ★★★★★ | 0 | 0 |
| Fountain View Manor, Inc | 17.9 mi | ★★★★★ | 7 | 0 |
| Heartway At Henryetta Health And Rehab | 18.2 mi | ★★★★★ | 0 | 0 |
| Parkland Manor Living Center | 22.1 mi | ★★★★★ | 5 | 0 |
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