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 The Oaks Healthcare Center during CMS and state inspections, most recent first.
A facility failed to coordinate with a contracted hospice provider regarding a resident's code status change to DNR. The hospice provider did not notify the facility or provide the signed DNR document, resulting in the resident being transferred to the hospital as a full code and receiving interventions inconsistent with the updated code status. Facility staff were unaware of the change until after the hospital transfer.
The facility failed to maintain the dignity of two residents with dementia by not providing clean clothing and appropriate dining assistance. One resident was observed with food debris on their clothing and blanket, while another was assisted with their meal by a CNA who stood, contrary to facility protocol. Staff admitted to not following proper procedures, impacting the residents' dignity.
A facility failed to maintain a medication error rate below five percent, resulting in a 6.9% error rate. A CMA administered albuterol sulfate without waiting the required one minute between puffs and gave two sprays of aller-flo fluticasone in each nostril, contrary to the physician's order. The DON and CMA supervisor expected adherence to medication administration protocols, but the supervisor had not trained the CMA involved, contributing to the errors.
The facility failed to secure medications on two medication/treatment carts, with one LPN repeatedly leaving the 300 hall cart unattended and unlocked. The 400 hall cart was also found unlocked and unattended. Despite the facility's policy requiring carts to be locked, staff interviews revealed inconsistent adherence to this protocol.
The facility failed to ensure proper hand hygiene in the kitchen and did not cover food delivered to residents on the C hall. Staff were observed not washing hands upon entering the kitchen and handling food without proper hygiene. Additionally, meal trays were delivered with uncovered items, contrary to facility policy.
The facility failed to ensure proper infection control, as staff did not use PPE during care for two residents, and catheter bags were in contact with the floor. Clean laundry was transported without covers, and the facility had not implemented a water management program to prevent waterborne pathogens. Staff were unaware of EBP requirements due to missing signage.
The facility failed to provide education and offer influenza and pneumococcal immunizations to two residents, one with coronary artery disease and another with diabetes mellitus. Documentation was missing, and the corporate nurse acknowledged the oversight, noting that a previous infection preventionist was responsible for this task.
The facility failed to provide COVID-19 vaccine education and offer to four residents, as there was no documentation of these actions. A resident with dementia, another with coronary artery disease, and two with diabetes mellitus were not documented as having received the necessary education or vaccine offer. The infection preventionist responsible for these tasks could not locate the required documentation.
A facility failed to assess a resident for self-administration of medication. The resident, diagnosed with chronic obstructive pulmonary disease, was observed self-administering Albuterol without a documented assessment in their clinical record. The facility's policy requires an interdisciplinary team to determine the appropriateness and safety of self-administration, which was not followed. The LPN and DON confirmed the oversight.
A facility failed to notify a resident's guardian about the resident's suicidal ideation, despite the resident expressing a desire to die due to frustration. The resident, diagnosed with major depressive disorder, schizophrenia, and anxiety, was placed under one-on-one observation, but no documentation of guardian notification was found. Staff were aware of the situation, but communication and documentation were lacking.
A facility failed to assess and monitor a dialysis port for a resident with renal failure, as required by their care plan. Despite the facility's policy on hemodialysis access care, there was no documentation of pre and post-dialysis assessments for several months. Interviews revealed that the facility did not perform necessary assessments before or after dialysis sessions, and monitoring of the central catheter was not documented, leading to a deficiency in care.
A facility failed to obtain physician-ordered labs for a resident with multiple health conditions, including diabetes and end-stage renal disease. Although the medication administration record indicated that the labs were completed, the clinical record lacked the lab reports. An LPN admitted the labs were not completed despite documentation stating otherwise.
A facility improperly discharged a resident with Alzheimer's and other conditions due to the use of authorized electronic monitoring in their room. The facility's policy allows discharge only under specific conditions, but the discharge was initiated citing misuse of surveillance cameras, which is against the Nursing Home Care Act. The DON admitted the facility could meet the resident's needs and was unaware of the legal requirements regarding video surveillance.
A resident with severe cognitive impairment was assaulted by another resident after dining services, resulting in a chokehold incident. Witnesses reported that the aggressor was agitated by noises made by the victim during meal service. The facility's failure to provide comprehensive staff training on de-escalation and resident-to-resident behaviors contributed to the incident.
A facility failed to provide a written summary of grievance investigations to a resident's POA, despite having a policy requiring such documentation. The facility only communicated verbally, which was confirmed by the administrator, contradicting their grievance policy.
A facility failed to report an allegation of abuse involving a CNA and a resident to the OSDH. The incident was reported to the administration as a rumor, and the administrator conducted an informal inquiry but did not report it to the state due to uncertainty about its validity. This inaction violated the facility's abuse policy, which requires reporting all suspected abuse to appropriate agencies.
The facility failed to investigate an alleged abuse incident involving a resident and a CNA. Despite reports of inappropriate behavior, the facility did not conduct a thorough investigation or document findings. The administrator did not report the incident to the OSDH, citing uncertainty about the nature of the allegation.
A facility failed to update a resident's care plan with a physician's order. The resident, diagnosed with dementia and stage 3 chronic kidney disease, had a specialist's order to drink water and avoid coke and tea. This order was not added to the care plan, and the DON was unsure why it was overlooked.
A facility failed to implement a physician's order for a resident with dementia and stage 3 chronic kidney disease. The order, faxed by a Urologic Specialist, instructed the resident to drink water and avoid coke and tea, but it was neither documented nor executed. The DON acknowledged the oversight without an explanation.
Failure to Coordinate Hospice Code Status Communication
Penalty
Summary
The facility failed to coordinate care with a contracted hospice service provider for a resident who was admitted to hospice services. Despite the resident and their family previously declining to change the resident's cardiac code status from full code, a Do Not Resuscitate (DNR) document was later signed by the resident's guardian outside the facility, with a hospice representative as a witness. However, the facility was not notified of this change, nor was a copy of the signed DNR provided to the facility by the hospice provider. Subsequently, the resident experienced a decline in condition, exhibiting sluggishness and audible secretions, and was transferred to the emergency room as a full code. During transport, the resident was intubated, sedated, and paralyzed by emergency medical technicians. It was only after this event that the facility staff became aware of the signed DNR document and updated the resident's code status in the medical record accordingly. Interviews with facility staff revealed that there was no established process for ensuring timely communication of code status changes from the hospice provider to the facility. The hospice provider's representative admitted to not notifying the facility of the DNR status change and was unsure of the standard procedure for such notifications. Facility staff also indicated that without direct communication or documentation from the hospice provider, they could not update the resident's code status, especially when the resident or family was unavailable for care plan meetings.
Failure to Maintain Resident Dignity in Clothing and Dining Assistance
Penalty
Summary
The facility failed to maintain the dignity of two residents, both diagnosed with dementia, by not providing clean clothing and appropriate dining assistance. One resident was observed on multiple occasions with food debris on their clothing and blanket, indicating a lack of attention to personal cleanliness after meals. Despite being severely impaired in cognition, the resident was left in the common area with food debris, and staff admitted to not knowing why the resident was not cleaned up. Another resident, also severely impaired in cognition, was assisted with their meal by a CNA who stood while feeding them, contrary to the facility's protocol. The CNA expressed a preference for standing, while the LPN and DON confirmed that staff should sit to maintain the resident's dignity during meals. This inconsistency in following proper dining assistance procedures further contributed to the failure in maintaining resident dignity.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 6.9% during the observation of medication administration. Specifically, a Certified Medication Aide (CMA) administered medications to a resident without adhering to the proper procedures. The CMA administered two puffs of albuterol sulfate inhalation aerosol to the resident without waiting the required one minute between puffs, as per the manufacturer's instructions. Additionally, the CMA administered two sprays of aller-flo fluticasone in each nostril of the resident, contrary to the physician's order, which specified one spray in each nostril twice a day. The Director of Nursing (DON) and the CMA supervisor both expressed expectations that medications be administered according to the five rights and prescriber orders. However, the CMA supervisor admitted that they had not trained CMA #1, as this staff member was hired before their tenure at the facility. The supervisor monitored medication administration from a distance to ensure compliance, but this oversight did not prevent the errors observed. These actions and inactions contributed to the facility's failure to maintain the required medication error rate.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure the security of medications on two of its medication/treatment carts, specifically on the 300 hall and 400 hall. Observations revealed that the 300 hall medication/treatment cart was left unattended and unlocked multiple times by an LPN while they entered various rooms. This occurred on several occasions within a short time frame, indicating a pattern of non-compliance with the facility's policy. The policy, dated April 2007, clearly states that the nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Additionally, the 400 hall medication/treatment cart was also found to be unlocked and unattended. Interviews with the staff, including LPNs and the DON, confirmed that the carts were expected to be locked when unattended. However, one LPN admitted to not locking the cart when moving from room to room, only securing it when finished on the hall. The DON mentioned that they randomly checked the carts to ensure compliance, but the observations suggest that these checks were not effective in preventing the deficiency.
Deficiency in Hand Hygiene and Food Covering Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed in the kitchen, as observed during a survey. Dietary aide #2 was seen entering the kitchen, touching their pants, and beginning work without washing their hands. Similarly, the dietary manager put on gloves without prior handwashing, and dietary aide #1 started preparing meal trays without washing their hands. Dietary aide #2 was also observed touching their face, donning gloves, preparing food, and removing gloves without washing hands. The facility's policy on preventing foodborne illness requires employees to wash their hands whenever entering or re-entering the kitchen, and it specifies that antimicrobial hand gel cannot replace handwashing in foodservice areas. Despite this policy, staff did not adhere to these guidelines, as confirmed by the dietary manager and dietary aide #2. Additionally, the facility did not ensure that food delivered to residents on the C hall was adequately covered. Meal trays were delivered with uncovered cake on saucers, and cook #1 confirmed that while main plates were covered, small bowls or saucers were not. The dietary manager stated that uncovered food items were protected by the cart, and staff were instructed to push the cart down the hall to each room rather than carrying uncovered food. This practice did not align with the facility's standards for food safety and hygiene, as observed during the survey.
Infection Control Deficiencies in PPE, Laundry, and Water Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by several observations and interviews. Two residents, one with diabetes and another with dementia, were not provided with appropriate PPE during care. An LPN was observed providing wound care without a gown, and CNAs did not wear gowns during catheter care. Additionally, the facility did not have EBP signage outside the residents' rooms, leading to staff being unaware of the need for PPE. Furthermore, catheter bags and tubing for two residents were observed in contact with the floor, contrary to the facility's policy. The facility also failed to maintain infection control in the transportation of clean laundry, as clothing racks were not covered during transport, exposing them to potential contamination. The laundry supervisor and administrator acknowledged the lack of covers for clothing racks. Additionally, the facility had not implemented a water management program to prevent the spread of waterborne pathogens, as the maintenance supervisor had not assessed the water system for potential growth areas of bacteria. The administrator confirmed that the Legionella Water Management Program policy had not been implemented, although some educational classes had begun.
Failure to Provide Immunization Education and Offer
Penalty
Summary
The facility failed to ensure that residents were provided education and offered influenza and pneumococcal immunizations, as evidenced by the cases of two residents. Resident #88, who was admitted with a diagnosis including coronary artery disease, did not have documentation in their clinical record indicating they had been educated or offered these immunizations. Similarly, Resident #17, admitted with a diagnosis including diabetes mellitus, also lacked documentation of being educated or offered the immunizations. The corporate nurse and infection preventionist acknowledged the absence of documentation for these residents, noting that a previous infection preventionist was responsible for this task but could not locate the necessary records.
Failure to Provide COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to ensure that residents were provided education and offered the COVID-19 vaccine, as evidenced by the lack of documentation for four residents. Resident #78, who was admitted with dementia, Resident #88 with coronary artery disease, Resident #17 with diabetes mellitus, and Resident #49, also with diabetes mellitus, were not documented as having received education or an offer for the COVID-19 immunization. The Director of Nursing identified a total of 87 residents in the facility, but the clinical records for these four residents did not show any evidence of the required education or vaccine offer. A corporate nurse and infection preventionist confirmed that the previous infection preventionist was responsible for these tasks but could not locate the necessary documentation for the affected residents.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically for Resident #35, who was observed self-administering Albuterol Sulfate HFA Aerosol Solution. Resident #35 had a diagnosis of chronic obstructive pulmonary disease and was cognitively intact for daily decision-making, as per the annual assessment. However, there was no documented assessment for self-administering an inhaler in the resident's electronic clinical record. The facility's policy, dated December 2016, requires an interdisciplinary team to determine if it is clinically appropriate and safe for residents to self-administer medications, including a specific skill assessment. The LPN and DON acknowledged that the assessment had not been completed, which was contrary to the facility's policy.
Failure to Notify Guardian of Resident's Suicidal Ideation
Penalty
Summary
The facility failed to notify a resident's guardian about a significant change in the resident's condition, specifically regarding suicidal ideations. The resident, who had diagnoses including major depressive disorder, schizophrenia, and anxiety, expressed a desire to die out of frustration. Despite the resident's statements, the facility did not document any notification to the guardian, as required by their policy. The resident was placed under one-on-one observation, and the staff attempted to manage the situation internally without involving the guardian. Multiple staff members, including LPNs and the SSD, were aware of the resident's statements and the subsequent actions taken, such as contacting emergency services and placing the resident under observation. However, there was a lack of communication and documentation regarding the notification of the guardian. The corporate nurse confirmed that the resident had a guardian who should have been informed, but no documentation of such notification was found in the clinical record.
Failure to Monitor Dialysis Port for Resident
Penalty
Summary
The facility failed to properly assess and monitor the dialysis port for a resident who required dialysis services. The resident, diagnosed with renal failure, had a care plan indicating non-adherence to scheduled dialysis treatments. Despite this, there was no documentation of pre and post-dialysis assessments in the treatment records or progress notes for December 2024, January 2025, and February 2025. The facility's Hemodialysis Access Care policy outlined specific procedures for the care of central dialysis catheters, including keeping the site clean and dry, using sterile techniques for dressing changes, and documenting the condition of the catheter and any dialysis-related observations every shift. Interviews with the resident and facility staff revealed that the facility did not perform any assessments before or after the resident's dialysis sessions. An LPN mentioned reviewing dialysis papers upon the resident's return but admitted that monitoring of the central catheter was not documented. The corporate nurse acknowledged that the assessments and notes were not completed due to oversight by prior leadership. This lack of documentation and adherence to the facility's policy contributed to the deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Obtain Physician-Ordered Labs for Resident
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered by the physician for a resident with multiple diagnoses, including diabetes, hyperlipidemia, congestive heart failure, and end-stage renal disease. The physician's order, dated June 3, 2024, required the resident to have a complete blood count, hemoglobin A1C, comprehensive metabolic panel, lipids, and liver function test every three months. Although the September 2024 medication administration record indicated that these labs were completed on September 3, 2024, and documented by an LPN, the clinical record did not contain the lab reports for that month. Upon review, the LPN acknowledged that the ordered labs for September 2024 had not been completed for the resident, despite having documented them as completed. The Director of Nursing confirmed that lab orders were supposed to be documented on the treatment record by the nurse when completed, but the discrepancy was not explained.
Inappropriate Resident Discharge Due to Electronic Monitoring
Penalty
Summary
The facility failed to comply with regulations regarding the discharge of a resident due to the use of authorized electronic monitoring in the resident's room. The facility's policy on transfer or discharge, dated March 2021, allows for discharge only under specific conditions, such as the resident's welfare, improvement in health, or failure to pay. However, the facility initiated the discharge of a resident diagnosed with Alzheimer's, dementia, cerebral infarction, stage three chronic kidney disease, depressive disorder, and hypertension, citing misuse of surveillance cameras and inability to meet the resident's needs as reasons. This action was contrary to the Nursing Home Care Act, which prohibits the removal of a resident due to authorized electronic monitoring. The Director of Nursing (DON) acknowledged that the facility could meet the resident's needs and that the family was dissatisfied with the care provided. The DON also admitted to being unaware of the requirement regarding video surveillance and the discharge of a resident. The resident's family had installed video surveillance with audio in the resident's room, and the facility expressed concerns about audio surveillance capturing conversations in the hallways. Despite these concerns, the facility's actions were not aligned with the legal requirements, leading to the inappropriate discharge of the resident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving two residents. Resident #2, who had severe cognitive impairment and diagnoses including autistic disorder and hemiplegia, was involved in an altercation with Resident #1. The incident occurred after dining services when Resident #1 followed Resident #2, yelling and eventually putting Resident #2 in a chokehold. Multiple dietary aides witnessed the event, noting that Resident #1 was agitated by the noises Resident #2 made during meal service and subsequently stalked and physically assaulted Resident #2. The facility's policies on abuse prevention and neglect were not effectively implemented, as evidenced by the lack of comprehensive staff training on de-escalation techniques and resident-to-resident behaviors. Although an in-service was conducted on the day of the incident, it did not include all staff signatures, and several staff members, including a CMA, two LPNs, and the Infection Preventionist, confirmed they had not received the necessary training. This lack of training contributed to the facility's failure to protect Resident #2 from abuse by another resident.
Failure to Provide Written Grievance Summary
Penalty
Summary
The facility failed to provide a written summary or findings of a grievance investigation for a resident's representative, despite having a policy in place that requires such documentation. The grievance policy, which is posted in the common area, states that the resident or the person filing the grievance on behalf of the resident will be informed both verbally and in writing of the findings of the investigation and any corrective actions. However, in the case of a resident whose grievances were reviewed, the facility only provided verbal communication to the resident's Power of Attorney (POA) and did not issue a written summary as required. The deficiency was identified through a review of grievance reports and interviews. Two grievance reports were completed for the resident, with resolutions documented as a phone conversation and a one-to-one discussion with the POA. Despite these interactions, the POA reported not receiving any written responses to the grievances filed. The facility administrator confirmed that no written summaries were provided, believing that verbal follow-up was sufficient, which contradicts the facility's established grievance policy.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and a certified nursing assistant (CNA) to the Oklahoma State Department of Health (OSDH). The incident was initially brought to the attention of the facility's administration in April when a CNA reported hearing a rumor about inappropriate behavior between another CNA and a resident. Despite the report, the facility administrator did not report the incident to OSDH, as they were uncertain whether the situation was a true allegation of abuse or merely a rumor. The administrator conducted an internal inquiry by questioning the involved parties and other staff but did not consider this a formal investigation. The facility's abuse policy mandates that all suspected abuse be investigated and reported to the appropriate agencies. However, the administrator's uncertainty about the nature of the incident led to a failure to comply with this policy. The Director of Nursing (DON) and other staff were aware of the rumor, but no formal report was made to the state licensing agency. This inaction resulted in a deficiency as the facility did not fulfill its obligation to report the alleged abuse, as required by their own policy and state regulations.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident and a Certified Nursing Assistant (CNA). The facility's abuse policy mandates that all suspected abuse be investigated and reported to the appropriate agencies. However, there was no documented investigation regarding the incident involving the resident and CNA #2. The incident was initially reported as a rumor by CNA #1 and CNA #3, who mentioned inappropriate behavior involving CNA #2's breasts and the resident. Despite the report, the facility did not conduct a thorough investigation or document any findings. The Director of Nursing (DON) and the administrator were informed of the situation in April, but the administrator did not report the incident to the Oklahoma State Department of Health (OSDH) because they were uncertain if it was a true allegation of abuse or merely a rumor. The administrator admitted that their attempt to determine the nature of the incident was not a true investigation. Although an in-service on the facility's abuse policy was conducted for all staff, there was no documentation of the investigation or any formal report submitted regarding the alleged inappropriate behavior.
Failure to Update Care Plan with Physician's Order
Penalty
Summary
The facility failed to update the care plan of a resident with a physician's order, which was a deficiency identified during a survey. The resident in question had diagnoses including dementia and stage 3 chronic kidney disease. A physician's progress note from a Urologic Specialist, which was faxed to the facility, included an order for the resident to drink water and avoid coke and tea. However, this order was not incorporated into the resident's care plan. On July 11, 2024, the Director of Nursing (DON) acknowledged that the care plan had not been updated with the specialist's order and was unsure why the order was overlooked.
Failure to Implement Physician's Order for Resident
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with dementia and stage 3 chronic kidney disease. A progress note from a Urologic Specialist, which was faxed to the facility, included an order for the resident to drink water and avoid coke and tea. However, this order was neither documented nor executed for the resident. The Director of Nursing (DON) confirmed that the order was overlooked and could not provide an explanation for this oversight.
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Illustrative
What surveyors actually found near you
We read the 32 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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Poteau
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heavener Nursing & Rehab | 10.4 mi | ★★★★★ | 0 | 0 |
| Spiro Nursing Home, Inc. | 13.3 mi | ★★★★★ | 0 | 0 |
| Pocola Health And Rehab | 17 mi | ★★★★★ | 1 | 0 |
| Fianna Hills Nursing And Rehabilitation Center | 21.3 mi | ★★★★★ | 1 | 0 |
| Brooken Hill Health And Rehab, Llc | 21.5 mi | ★★★★★ | 10 | 0 |
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