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 Wagoner Health & Rehab during CMS and state inspections, most recent first.
The facility failed to ensure that meals were served at a palatable, appetizing temperature for multiple cognitively intact residents receiving in-room meal service. A test tray showed undercooked, lukewarm fried potatoes, lukewarm turnip greens, and cold, dry cornbread. A resident reported that food delivered to their room was always cold and did not taste good. Another resident stated that their food arrived cold, had tasted bad for a long time, and that potatoes served at a recent lunch were undercooked and crunchy. A third resident, who ate all meals in their room, reported that their food was almost always cold upon arrival, while 48 residents in total were identified as receiving meals from the kitchen.
Surveyors found that dietary staff, including a dietary aide and the Dietary Manager, repeatedly entered the kitchen and began work without performing required hand hygiene, despite a facility policy mandating handwashing upon kitchen entry. Over several closely spaced observations, the dietary aide was seen multiple times starting work without washing hands, and the Dietary Manager was also observed doing the same. The infection preventionist reported that dozens of residents received meals prepared in this kitchen during the period in question.
A resident with emphysema and heart failure had an order for oxycodone 10 mg PO every six hours. Facility policy required two staff signatures when wasting narcotic medications, but documentation on the controlled drug record showed that one oxycodone tablet was wasted with only a single staff signature. An LPN and the infection preventionist both stated that two staff members must sign when a narcotic is wasted, confirming that the documented wasting did not follow facility policy, in a setting where multiple residents were receiving medications.
A resident with a PEG tube, identified as at risk for infection and placed on Enhanced Barrier Precautions (EBP), had a care plan and door signage indicating that EBP should be used during care. The facility’s EBP policy required staff to don gown and gloves for high-contact care of residents with indwelling medical devices, including feeding tubes. An LPN was observed performing PEG tube care for this resident without wearing a gown, contrary to the posted EBP sign, the resident’s care plan, and facility policy. The LPN later acknowledged a gown should have been worn, and the infection preventionist confirmed that gowns are required when providing care to residents on EBP, noting that multiple residents in the facility were on EBP.
The facility did not update care plans with new fall prevention interventions after three residents experienced falls, despite existing policies requiring timely review and revision. One resident with heart failure and neuropathy, another with atrial fibrillation and a fall history, and a third with dementia and Alzheimer's each had falls that were not followed by care plan updates, as confirmed by the DON and facility records.
A scoop was left in a bulk flour container and the handwashing sink in the kitchen did not have hot water, contrary to facility policy and professional standards. Meals prepared under these conditions were served to 46 residents, as confirmed by the dietary manager and corporate nurse manager.
The facility did not ensure that competency and skills checks were completed upon hire and annually for several LPNs and CNAs. Employment files lacked documentation of these required assessments, and facility leadership confirmed that competencies had not been completed in over a year.
The facility did not ensure that dietary menus were reviewed and approved by the dietician as required by policy. A menu for one week lacked documentation of dietician approval, and both the dietary manager and social services director confirmed that the approval had not occurred.
Staff did not consistently use enhanced barrier precautions during wound care and urinary catheter care, including failure to wear gowns and improper glove use. In several cases, staff relied on personal knowledge or verbal communication instead of signage to identify when precautions were needed. Additionally, clean laundry was transported uncovered to resident rooms, contrary to infection control protocols.
A resident with atrial fibrillation was inaccurately coded on their admission assessment as having received an anticoagulant, despite medication records showing no such administration. The MDS coordinator confirmed the error during an interview.
Surveyors identified that two residents did not have comprehensive care plans addressing their specific needs. One resident with severe cognitive impairment used a half bed rail for mobility, which was not documented in the care plan as required by facility policy. Another resident with congestive heart failure, dependent on staff for daily activities and using supplemental oxygen, also lacked care plan documentation for both ADL assistance and oxygen use. The MDS coordinator confirmed these omissions.
A resident with severe cognitive impairment was observed using a half bed rail without documented assessment for entrapment risk or consideration of alternatives, and no informed consent was obtained. Staff confirmed that only an outdated assessment was on file, and facility policy requiring annual assessment and consent was not followed.
Surveyors found that multiple medication and treatment carts were left unlocked and unattended in several areas of the facility on repeated occasions. Staff, including LPNs, admitted to forgetting to lock the carts, and the DON confirmed that the expectation was for all carts to be secured when not in use. The facility's policy required all drug and biological storage compartments to be locked when unattended, but this was not consistently followed.
Several residents reported that meals were often served lukewarm, bland, and unappetizing, with some foods missing expected components such as icing on desserts. Test tray observations confirmed that hot foods were not consistently hot and cold foods were not cold, particularly for those eating in their rooms. The dietary manager acknowledged these issues, indicating a failure to ensure food was palatable and served at appropriate temperatures.
A resident with severe cognitive impairment and Alzheimer's disease was found with a loose half bed rail on two occasions. Although facility policy required regular inspection of beds and related equipment, maintenance staff did not routinely monitor bed rails after installation and only addressed issues when reported by staff. The administrator was unaware that regular safety inspections were not being conducted.
The facility failed to maintain a functioning call light system in a resident's room. Staff interviews confirmed that the system should illuminate a light in the hallway when activated, but this did not occur during an observation. The maintenance supervisor indicated that call lights were tested weekly, but these tests were not documented.
Failure to Provide Palatable, Proper-Temperature Meals to Residents
Penalty
Summary
The facility failed to provide meals at a palatable, appetizing temperature for three cognitively intact residents who received meals in their rooms, as well as on a test tray sampled by surveyors. During a test tray observation, fried potatoes were found to be undercooked and lukewarm, turnip greens were lukewarm, and cornbread was cold and dry. One resident with a BIMS score of 15 reported that when they ate in their room the food was always cold and did not taste good. Another resident with a BIMS score of 15 stated that their food was cold by the time it was delivered to their room and that the food had tasted bad for a long time; this resident further reported that potatoes served at a recent lunch were undercooked, crunchy, and the entire meal was cold. A third resident with a BIMS score of 15, who ate all meals in their room, stated that the food was almost always cold by the time it arrived. The infection preventionist identified that 48 residents received meals from the kitchen at the time of the survey.
Failure of Dietary Staff to Perform Required Hand Hygiene Upon Kitchen Entry
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation and employee hygiene when two dietary staff members, a dietary aide and the Dietary Manager (DM), failed to wash their hands immediately upon entering the kitchen as required by facility policy. On multiple occasions within a short time frame, the dietary aide was observed entering the kitchen and beginning work without handwashing, specifically at 11:55 a.m., 11:59 a.m., 12:04 p.m., and 12:07 p.m. on the same day. The DM was also observed entering the kitchen at 12:00 p.m. and starting work without washing their hands. An undated facility policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” required staff to wash their hands when entering the kitchen, and the DM confirmed that staff were expected to wash their hands upon entry. The infection preventionist identified that 48 residents received meals from the kitchen during this period. No additional resident-specific medical histories or conditions were described in the report beyond the number of residents receiving meals from the kitchen.
Failure to Obtain Required Dual Witness Signatures for Wasted Narcotic Medication
Penalty
Summary
The facility failed to follow its Discarding and Destroying Medications policy requiring the signatures of at least two witnesses when wasting narcotic medications. Record review showed that a resident admitted on 08/20/24, with diagnoses including emphysema and heart failure, had a physician’s order dated 12/06/25 for oxycodone 10 mg by mouth every six hours. On the Controlled Drug Receipt/Record/Disposition Form for February 2026, an entry dated 02/13/26 at 6:00 a.m. documented that one 10 mg oxycodone tablet was wasted, but the form contained only one signature instead of the required two. During interviews, an LPN stated that when a narcotic medication is wasted a nurse must witness and sign off with the other employee, and the infection preventionist confirmed that two staff members are required to sign when a narcotic is wasted, demonstrating that the documented practice for this resident did not comply with facility policy. The infection preventionist identified that 48 residents in the facility received medications, indicating that the deficient practice occurred in a setting where multiple residents were receiving pharmaceutical services, although the documented failure to obtain two signatures for narcotic wasting was specifically identified for one resident receiving oxycodone.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during PEG tube care. Resident #7 had a care plan focus initiated on 05/09/25 indicating risk of infection due to the presence of a PEG tube and specifying that EBP was to be utilized when providing care. The facility’s EBP policy dated 04/29/24 required donning gown and gloves during high-contact resident care activities for residents with indwelling medical devices, including feeding tubes, and a sign on Resident #7’s door indicated the resident was on EBP. On 02/23/26 at 9:20 a.m., LPN #1 was observed providing PEG tube care to Resident #7 without wearing a gown, contrary to the posted EBP sign, the resident’s care plan, and the facility’s EBP policy. During interview at 9:25 a.m., LPN #1 acknowledged they should have worn a gown while providing PEG tube care, and on 02/24/26 at 3:35 p.m., the infection preventionist confirmed that gowns were to be used when providing care to residents on EBP. The infection preventionist identified that 23 residents in the facility were on EBP.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise the care plans for three out of four sampled residents after each experienced a fall, as required by their own policy and regulatory standards. For one resident with congestive heart failure and multifocal motor neuropathy, the care plan documented several previous falls and interventions, but after a non-injury fall while transferring from bed without assistance, no new intervention was added to the care plan. Another resident with atrial fibrillation and a history of falls had a care plan indicating risk for falls, but after a fall resulting in a major injury while ambulating, the care plan was not updated to reflect new interventions. The resident confirmed having fallen and sustaining a shoulder injury. A third resident with dementia and Alzheimer's disease had a care plan noting multiple prior falls and interventions, but following a minor injury fall while transferring from bed, the care plan was not revised to include additional interventions. The Director of Nursing confirmed that the care plans for these residents should have been updated to reflect new fall prevention interventions after each fall event. The facility's policy requires staff and practitioners to identify possible causes and implement pertinent interventions within 24 hours of a fall, and to re-evaluate and reconsider interventions if falls continue. Despite this, the care plans for the affected residents were not revised after their most recent falls, as documented in the facility's records and confirmed through staff and resident interviews.
Improper Food Storage and Hand Hygiene Deficiency
Penalty
Summary
During an initial kitchen tour, a scoop was found left inside a bulk container of flour, and the handwashing sink was observed to lack hot water. The facility's policy on food receiving and storage requires compliance with safe food handling practices. The dietary manager confirmed that scoops should not be left in bulk containers and acknowledged the handwashing sink was not functioning properly. The corporate nurse manager reported that 46 residents received meals prepared in the kitchen during this time. These findings indicate that the facility did not adhere to professional standards for food storage and hand hygiene, as required by their own policies and regulatory guidelines.
Failure to Complete Required Staff Competency Checks
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had completed competency and skills checks both upon hire and annually, as required. Record review revealed that five employees, including two LPNs and three CNAs, did not have documentation of completed competency or skills checks in their employment files. The business office manager confirmed that there were no skills checks or competencies available for these staff members. Additionally, the Director of Nursing acknowledged that competencies should be completed upon hire and annually, but stated that they had not been completed in over a year. This deficiency was identified through review of employment files and interviews with facility staff, which confirmed the lack of required competency assessments for all reviewed employees.
Menus Not Reviewed or Approved by Dietician
Penalty
Summary
The facility failed to ensure that dietary menus were reviewed and approved by the dietician as required by policy. A review of a dietary menu for a specified week revealed no documentation of dietician approval. The dietary manager initially believed the menus had been approved by the dietician but was unable to provide documentation to support this. Additionally, the social services director confirmed that the menu had not been approved by the dietician. The facility's policy states that all menus are to be reviewed and approved by the dietician to meet residents' nutritional needs, but this process was not followed for the menu in question.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control
Penalty
Summary
The facility failed to ensure proper implementation of enhanced barrier precautions (EBP) and infection control practices during wound care and urinary catheter care, as well as during the transport of clean laundry. During wound care for a resident with a stage four pressure ulcer and severe cognitive impairment, an LPN did not wear a gown as required by the facility's EBP policy, and there was no signage indicating the need for EBP near the resident's room. The LPN believed that only gloves were necessary for wound care, and the facility did not utilize signage to indicate when EBP was required. In multiple instances of urinary catheter care, staff did not follow EBP protocols. One CNA wore multiple pairs of gloves at once and failed to change gloves during care, based on misinformation from an online video, and did not use a gown. Another LPN and two CNAs provided catheter care and flushing without wearing gowns, and the LPN failed to perform hand hygiene when changing gloves or after removing gloves. The staff relied on verbal communication or personal knowledge to determine when EBP was needed, rather than consistent signage or clear protocols. Additionally, the facility did not maintain infection control standards during the transport of clean laundry. The laundry staff was observed multiple times transporting clean clothes uncovered to resident rooms and was unaware that linens were supposed to be covered. The infection preventionist confirmed that clean clothes should be covered during transport.
Inaccurate Admission Assessment Coding
Penalty
Summary
The facility failed to ensure the accuracy of an admission assessment for one resident. The admission assessment, dated 03/07/25, indicated that the resident, who had a diagnosis of atrial fibrillation and a BIMS score of 15, had received an anticoagulant medication during the look back period. However, a review of the medication administration record and treatment administration record for March 2025 did not show that the resident had actually received an anticoagulant. During an interview, the MDS coordinator confirmed that the assessment had been coded inaccurately and acknowledged that the resident should not have been coded as having received an anticoagulant.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
Surveyors found that the facility failed to develop and implement comprehensive care plans for two of twelve sampled residents. In the first case, a resident with Alzheimer's disease and severe cognitive impairment was observed using a half bed rail for bed mobility on multiple occasions. Despite facility policy requiring the use of side rails to be addressed in the care plan, the resident's care plan did not document the use of the half side rail. The MDS coordinator confirmed that a care plan related to the use of the half bed rail had not been developed for this resident. In the second case, another resident with congestive heart failure, who was dependent on staff for several activities of daily living and used supplemental oxygen, was observed with an oxygen nasal cannula in place. The resident's care plan did not indicate the level of assistance required for activities of daily living or the use of supplemental oxygen. The MDS coordinator acknowledged that they were unaware of the resident's routine use of supplemental oxygen and had missed developing a care plan for both the oxygen use and the resident's ADL needs.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to complete required assessments and obtain informed consent for the use of bed rails for a resident. Observations on two separate occasions showed the resident in bed with a half bed rail in the up position. Documentation review revealed that the evaluation form for side rail use did not include an assessment for entrapment risk or consideration of alternatives prior to implementing the bed rail. The resident's annual assessment indicated a diagnosis of Alzheimer's disease with severe cognitive impairment, but there was no documentation of consent for the use of the bed rail. Interviews with staff confirmed that the resident used the bed rail for mobility and positioning, and that the only documentation completed was an assessment from several months prior. The DON acknowledged that no consent had been obtained and that alternatives to bed rail use had not been assessed or documented. Facility policy required both an assessment for entrapment risk and informed consent prior to bed rail use, but these steps were not followed for this resident.
Medication and Treatment Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that three of five medication and treatment carts in the facility were repeatedly left unlocked and unattended in various locations, including by the nurses station and in the front living room area. These observations occurred on multiple occasions over several days, with specific carts such as the North hall treatment cart, the [NAME] hall treatment cart, and the overflow treatment cart being found unsecured. Facility staff, including LPNs, acknowledged that the carts should have been locked when not in use but admitted to forgetting to do so. The Director of Nursing (DON) confirmed that staff were expected to keep the carts locked when unattended and recognized that surveyors had observed the carts unlocked and unattended multiple times. The facility's policy, dated 07/21/24, required that all compartments containing drugs and biologicals, including carts, be locked when not in use and not left unattended if open or accessible. Despite this policy, staff failed to consistently secure the carts, as evidenced by direct observations and staff interviews. No specific residents were identified as being directly affected in the report, and there was no mention of any adverse outcomes related to the unsecured carts.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable meals to residents, as evidenced by both direct observation and resident interviews. During test tray samplings, meals such as Dorito casserole and mixed vegetables were found to be lukewarm, bland, and not well seasoned, while banana cake was served dry and without icing. Multiple residents reported that hot foods were not served hot and cold foods were not served cold, particularly when meals were delivered to their rooms. Additionally, some residents described the food as bland and unappetizing, with one resident stating they only ate breakfast from the kitchen due to the poor quality of lunch and dinner meals. Assessments showed that the residents involved had varying levels of cognitive function, with most being independent in daily decision-making. The dietary manager acknowledged the issues, noting efforts to serve food quickly to maintain temperature and confirming that the banana cake should have included icing. These findings indicate that the facility did not consistently ensure meals were palatable, attractive, and served at safe and appetizing temperatures for the residents.
Failure to Monitor and Maintain Bed Rail Safety
Penalty
Summary
The facility failed to ensure that bed rails were properly monitored for safety for a resident who used a half bed rail. During two separate observations, the bed rail on the left side of the resident's bed was found to be loose when moved side to side and back and forth. The resident, who had a diagnosis of Alzheimer's disease and was severely impaired in cognition, confirmed that the bed rail was wiggly. The facility's policy required regular inspection of beds and related equipment by maintenance staff to identify risks, including potential entrapment hazards. Despite this policy, the maintenance supervisor stated that bed rails were not routinely monitored after installation and were only tightened if staff reported them as loose. The maintenance supervisor acknowledged the looseness of the bed rail upon observation and noted that it had been recently installed. The administrator confirmed that CNAs documented issues in the maintenance log if they noticed loose bed rails, but was unaware that maintenance staff were not conducting regular inspections for bed and bed rail safety.
Call Light System Malfunction in Resident Room
Penalty
Summary
The facility failed to ensure the call light system was functioning in one of six occupied resident rooms reviewed for call light functionality. The facility's policy, reviewed in July, stated that maintenance personnel were responsible for maintaining the nurse call system in good working order. During an observation, it was noted that when the call system in a specific room was activated, no light illuminated in the hallway or at the nurse's desk, indicating a malfunction. Interviews with staff, including an LPN and a CNA, confirmed that the call light system should illuminate a light in the hallway when activated. The maintenance supervisor stated that call lights were tested weekly, but these tests were not documented.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 83 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wagoner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fort Gibson Care & Rehab Center | 13.9 mi | ★★★★★ | 0 | 0 |
| Brentwood Extended Care & Rehab | 13.9 mi | ★★★★★ | 0 | 0 |
| Coweta Care & Rehab Center | 14.1 mi | ★★★★★ | 4 | 0 |
| The Springs Skilled Nursing And Therapy | 14.6 mi | ★★★★★ | 16 | 0 |
| Lane Nursing & Ventilator Care | 15 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wagoner Health & Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.