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 Willow Park Health Care Center during CMS and state inspections, most recent first.
A resident with severely impaired cognition, dementia, anxiety, and documented wandering was repeatedly assessed as high risk for elopement, yet the facility failed to revise and implement a comprehensive care plan to address ongoing exit-seeking and multiple elopements. The care plan initially included general diversion and structured activity interventions, but it was not updated with enhanced measures after repeated incidents in which the resident exited or attempted to exit the building, including being found in the parking lot near a busy road. Facility records show the resident was repeatedly placed on 1:1 supervision for extended periods following these events, but this intervention was never added to the care plan. A later revised care plan referenced door-pulling and following visitors out but still omitted prior elopements and the 1:1 supervision intervention. CNAs and nursing staff reported relying on the care plan and word of mouth to identify elopement risk, with some uncertainty about what to do after multiple attempts, and leadership acknowledged a system failure in documenting exit-seeking and 1:1 supervision in the care plan, leading to an Immediate Jeopardy finding.
A resident with dementia, severe cognitive impairment, and independently ambulatory status was repeatedly assessed as high risk for elopement yet experienced multiple episodes of exit seeking and elopement by following visitors, delivery drivers, and other residents through the front door. Staff often became aware of these events only after others alerted them, including one incident where the resident was found outside near a busy street and was agitated and difficult to redirect. Although one-on-one supervision was intermittently ordered, documentation of that supervision was incomplete and the intervention was not incorporated into the care plan, which contained only general wandering and cueing strategies and was not updated to reflect increased supervision needs after repeated incidents. Direct care staff reported inconsistent awareness of the resident’s elopement risk, reliance on word of mouth or the care plan, and uncertainty about how to respond to multiple elopement attempts, and leadership acknowledged system failures in documentation and care plan updates related to supervision after these events.
A resident with significant physical and cognitive impairments was transferred using a portable lift by a single CNA, contrary to facility policy requiring two staff members for such transfers. The CNA proceeded alone because the resident was in a hurry, resulting in the lift tilting and the resident being lowered to the floor without injury. Staff interviews confirmed the policy violation and that sufficient staff were available at the time.
A resident assessed to require supervision and a smoking apron was observed smoking unsupervised, leading to an incident where their beard caught fire. Despite documented needs, staff were unaware of the resident's requirements, resulting in inadequate supervision and safety measures. This deficiency led to an Immediate Jeopardy situation.
The facility failed to complete advance directive acknowledgement forms for two residents, despite having physician orders indicating full code status. The facility's policy requires inquiry about advance directives upon admission, but the forms were not completed as part of the admission process.
The facility failed to refer residents with newly diagnosed mental illnesses for a Level II PASARR evaluation. A resident was diagnosed with bipolar disorder, major depressive disorder, and schizophrenia, another with major depressive disorder and mood disorder, and a third with schizoaffective disorder and mood disorder. The MDS coordinator was unaware of the requirement to report these diagnoses, leading to the deficiency.
The facility failed to implement enhanced barrier precautions for two residents during wound care and one during Foley catheter care, and contact precautions for a resident with a MRSA infection. Observations revealed a lack of PPE use and signage, despite care plans indicating the need for such measures. The ADON was unaware of the MRSA infection and the necessary precautions, highlighting a systemic issue in staff awareness and adherence to infection prevention protocols.
A facility failed to report an allegation of neglect involving a resident with hemiplegia and impaired cognition to the State Agency. An incident report was created, but there was no proof of fax transmission to the OSDH. The OSDH confirmed no incident reports had been received since June, and an email confirmation provided by the administrator did not confirm receipt of the fax.
The facility did not complete discharge summaries for two residents as required by their policy. One resident, who was cognitively intact, was discharged home with medications and instructions, while another, who was cognitively impaired and monitored for wandering, was transferred to another LTC facility. The DON confirmed the absence of these summaries.
A resident with cognitive impairment and wandering behaviors eloped from the facility, reaching near the street before being escorted back by staff. Despite being identified as an elopement risk, there was no incident report or documentation of the event. The facility's supervision and elopement prevention measures were inadequate, as staff were unaware of the incident, and the DON did not report it, believing the resident was never out of sight.
Failure to Revise and Implement Comprehensive Elopement Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with measurable objectives and time frames to address a resident’s high elopement risk and repeated exit-seeking behaviors. The resident had severely impaired cognition with a BIMS score of 2 and diagnoses including dementia and anxiety. An admission assessment documented wandering behaviors and independent ambulation and transfers. Multiple Elopement Risk Assessments consistently identified the resident as high risk for elopement with scores of 10. Despite this, the care plan initiated for elopement did not show that interventions were revised or expanded after multiple elopement events and exit-seeking incidents. The resident’s care plan, initiated in early May, included interventions such as distraction with food and activities, identifying patterns of wandering, and providing structured activities like signs, memory boxes, and walking inside and outside. These interventions were later cancelled in early August, and the care plan did not reflect additional or modified interventions after an elopement on mid-July. Incident reports documented that the resident eloped or attempted to elope on multiple occasions, including exiting with visitors, attempting to exit when a visitor or delivery driver held the door, and being found walking in the parking lot near a busy street and a storage facility. Each incident report stated that the resident was redirected inside, assessed, and that the care plan was updated to reflect current status, but the care plan did not show the addition of one-on-one supervision or other enhanced interventions corresponding to these events. Facility documents titled "Resident One on One" showed that after each elopement or exit-seeking incident on multiple dates in July, August, and September, the resident was placed on one-on-one supervision for extended periods, ranging from several hours to most of a shift. However, one-on-one supervision was never added as an intervention in the resident’s care plan. A revised care plan in mid-October again focused on elopement and referenced the resident pulling on locked doors and walking out of the facility following visitors, but it only listed interventions such as distraction with pleasant diversions, observing for fatigue and weight loss, observing location in the community, and providing directional cues. It did not include prior elopements or the repeated use of one-on-one supervision as an intervention, nor did it show that interventions were revised after the multiple documented elopements and exit-seeking behaviors. Staff interviews further illustrated the deficiency in implementing and communicating a comprehensive care plan. A CNA stated that interventions for elopement risk should be found in the care plan and reported being unsure what to do when a resident had multiple elopement attempts, indicating reliance on the RN for direction. Another CNA reported identifying residents at risk for elopement by word of mouth or the care plan and mentioned an elopement book but was unsure who checked it, also noting the difficulty of monitoring exits without constant presence at the door. The ADON stated that residents with an elopement risk score of 10 or higher were considered high risk and acknowledged that the resident’s care plan was revised after an early elopement attempt, but subsequent incidents still occurred. The DON stated that the resident eloped and was found in the parking lot near a very busy street and identified a system failure related to one-on-one forms and the lack of documentation in the care plan for the resident’s exit-seeking and elopements. A resident representative reported they were never informed that the resident was placed on one-on-one supervision and that the resident was later moved to another facility with memory care because the resident was not safe due to exit-seeking behaviors. An Immediate Jeopardy situation was determined to exist related to the facility’s failure to ensure a comprehensive care plan was developed and implemented for this resident to prevent elopement. The facility’s own policy on comprehensive care plans required measurable objectives and time frames to meet resident needs identified in the assessment, with alternative interventions documented as needed. Despite repeated high-risk assessments, multiple elopements and exit-seeking incidents, and the repeated use of one-on-one supervision in practice, the resident’s care plan did not reflect these interventions or show appropriate revision after each incident. This failure to integrate actual interventions and incident history into the written care plan, and to ensure staff understood and followed it, formed the basis of the cited deficiency.
Removal Plan
- Elopement Risk Assessments were completed on 100% of residents.
- Facility completed 100% audit of residents who were identified at risk for elopement.
- Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
- IDT received education on reviewing, revising, developing and implementing care plans from the VP of Reimbursement or designee(s).
- IDT team implemented an appropriate monitoring sheet for residents at risk for elopement.
Failure to Supervise High-Risk Resident Resulting in Multiple Elopements
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident with severe cognitive impairment and a documented high risk for elopement. The resident had dementia, anxiety, a severely impaired BIMS score of 2, and was independently ambulatory, with assessments repeatedly identifying them as high risk for elopement. Despite this, the resident experienced multiple episodes of exit seeking and elopement over several months, beginning with an incident in which the resident walked out the front door with visitors and had to be redirected back inside by staff after other residents alerted them. Subsequent nursing notes documented wandering, exit-seeking behaviors, and attempts to follow others out of the building. The facility’s documentation showed repeated incidents where the resident exited or attempted to exit the building by following visitors, delivery drivers, or other residents through the front door. On one occasion, the resident was observed outside walking toward a storage facility next door near a busy street and was described as agitated, difficult to redirect, and continuing to exit seek. Another incident documented the resident being found outside by the curb and returned to the facility by a staff member’s car after a visitor notified staff. In several of these events, staff were not initially aware the resident had left the building and only became aware after being notified by others or upon observing the resident outside. Although the facility intermittently placed the resident on one-on-one supervision following some of these incidents, the one-on-one forms were not completed with time intervals to show that the supervision was actually provided, and this increased supervision was not incorporated into the resident’s care plan. The care plan, revised later, did include a focus related to elopement and listed interventions such as distraction with activities, observing for fatigue and weight loss, observing location in the community, and providing directional cues. However, it did not show that supervision interventions were updated or increased after the resident’s repeated exit-seeking behaviors and documented elopements. Staff interviews further revealed that direct care staff were not consistently aware of the resident’s elopement risk, relied on word of mouth or the care plan to identify such residents, and expressed uncertainty about what to do when a resident had multiple elopement attempts. The DON acknowledged that the resident had eloped to the parking lot near a very busy street and identified a system failure related to incomplete one-on-one documentation and the lack of care plan updates to ensure adequate supervision after multiple elopement-related events. An Immediate Jeopardy situation was determined to exist due to this failure to ensure adequate supervision to prevent elopement for the resident. The survey findings noted that the facility’s own elopement and wandering policy required adequate supervision and care in accordance with a person-centered care plan for residents at risk of elopement. Despite multiple high-risk assessments and repeated incidents of exit seeking and elopement, the facility did not consistently implement, document, or care-plan increased supervision measures for the resident. Direct care staff reported gaps in communication and training regarding elopement risk and interventions, and the resident’s representative stated they were not informed when the resident was placed on one-on-one supervision and ultimately moved the resident to another facility with a memory care unit because the resident was not safe due to exit seeking attempts and elopements.
Removal Plan
- Elopement Risk Assessments were completed on all residents.
- Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
- An At-Risk Elopement Book with care plan was created and posted at the nurse's station, accessible only to staff, in accordance with HIPAA requirements.
- All nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
- Elopement and wandering residents' policy was reviewed.
- Facility implemented a monitoring sheet for residents at risk for elopement.
- An Elopement Response Drill schedule was implemented, with drills occurring on all shifts.
- The DON or designee will perform a daily audit of clinical data to ensure adequate supervision is in place for residents with active wandering and elopement risk.
Failure to Provide Required Two-Person Assist During Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was moderately cognitively impaired and dependent on staff for activities of daily living due to multiple sclerosis, paralytic syndrome, lack of coordination, and tremors, was transferred using a portable lift by a single certified nursing assistant (CNA) instead of the required two-person assist. Facility policy, as well as standard practice reported by multiple staff members, mandated that two staff members be present when using the lift for resident transfers. Despite this, the CNA proceeded alone because the resident was in a hurry to get up for a smoke break, resulting in the lift tilting and the resident being lowered to the floor. The incident was observed on camera, and the resident did not sustain injuries. Interviews with staff confirmed that the use of the lift by one person was a violation of both policy and standard procedure, and that adequate staffing was available at the time of the incident. The CNA involved acknowledged awareness of the policy but chose not to wait for assistance. The event was documented in a progress note, and the resident later confirmed the occurrence, stating they were not injured or afraid of the lift.
Failure to Supervise Smoking Resident Leads to Immediate Jeopardy
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified at the facility due to the failure to provide adequate supervision and safety measures for a resident who required assistance while smoking. The resident, who had been assessed to need supervision and a smoking apron, was observed smoking without these precautions. This lapse in supervision led to an incident where the resident's beard caught fire, resulting in burns to the face and under the ear. The resident had multiple assessments indicating the need for supervision and the use of a smoking apron. Despite these documented requirements, staff members were unaware of the resident's need for a smoking apron and failed to provide the necessary supervision. Observations showed the resident smoking unsupervised, with cigarette ashes on their clothing, and dozing off while smoking, which posed a significant safety risk. Interviews with staff revealed a lack of awareness and understanding of the smoking safety requirements for the resident. Staff members were unsure about which residents required supervision and the use of smoking aprons, indicating a breakdown in communication and adherence to the facility's smoking policy. This deficiency in supervision and safety measures directly contributed to the incident and the subsequent identification of an IJ situation.
Failure to Complete Advance Directive Acknowledgement Forms
Penalty
Summary
The facility failed to ensure that advance directive acknowledgement forms were completed for two of the 18 sampled residents reviewed for advance directives. Resident #10 was admitted to the facility with a re-entry date and had a physician order indicating full code status, but there was no acknowledgement form for an advance directive in either the clinical or electronic record. Similarly, Resident #24, who was also admitted to the facility, had a physician order documenting full code status, yet lacked an acknowledgement form for an advance directive in both records. The facility's Advance Directives policy, dated December 2016, requires the Social Services Director or designee to inquire about the existence of any written advance directive prior to or upon admission of a resident. However, during the survey, the administrator acknowledged that the advance directive forms, which were part of the admission packet, were not being completed for these residents.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer residents with newly diagnosed mental illnesses to the OHCA for a Level II PASARR evaluation, affecting three residents. Resident #9 was admitted with no documented mental illness on the Level I PASARR screen. However, the resident was later diagnosed with bipolar disorder, major depressive disorder, and schizophrenia, but these diagnoses were not reported for a Level II evaluation. Similarly, Resident #38 was admitted without a mental illness diagnosis, but later diagnosed with major depressive disorder and mood disorder, which were not reported. Resident #60 was also admitted without a mental illness diagnosis, but was later diagnosed with schizoaffective disorder and mood disorder, which were not reported for further evaluation. The MDS coordinator was unaware of the requirement to report new mental illness diagnoses not documented on the Level I PASARR screening at admission. The coordinator reported that they had only been reporting new mental illnesses if a resident had an inpatient mental hospital stay. Upon reviewing the facility's PASARR policy, the MDS coordinator acknowledged that the new diagnoses for Residents #9, #38, and #60 should have been reported to the OHCA when they became evident. This lack of awareness and adherence to the PASARR policy led to the failure in referring these residents for necessary evaluations.
Failure to Implement Infection Control Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents during wound care and one resident during Foley catheter care. Resident #78, who had diagnoses including diabetes mellitus, lung cancer, and dementia, was observed during wound care without the use of gowns for enhanced barrier precautions. The resident's room lacked signage and PPE supplies, despite having a care plan indicating the need for enhanced barrier precautions due to skin integrity issues. Similarly, Resident #69, with diagnoses including malignant neoplasm and local infection, had no enhanced barrier precautions signage or PPE supply available during wound care. The ADON provided wound care wearing only gloves, and a CNA later donned a gown and gloves for Foley catheter care, indicating inconsistent application of precautions. The facility also failed to implement contact precautions for Resident #49, who had a diagnosis of diabetes mellitus and a MRSA infection in a toe wound. The resident was observed without a dressing on the wound, and the wound care nurse used only gloves during care, disposing of supplies improperly. The ADON was unaware of the MRSA infection and the need for contact precautions, which should have included signage, biohazard bags, and PPE outside the resident's door. The lack of awareness and implementation of necessary precautions by staff contributed to the deficiency. The facility's policies on enhanced barrier and contact precautions were not followed, as evidenced by the lack of appropriate PPE use and signage for residents requiring such measures. The ADON acknowledged the failure to implement contact precautions for Resident #49 and the need for enhanced barrier precautions for residents with Foley catheters and open wounds. The report highlights a systemic issue in ensuring staff awareness and adherence to infection prevention protocols.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident with hemiplegia and impaired cognition to the State Agency (OSDH). The resident was dependent on staff for activities of daily living. An incident report was created on 09/03/24, documenting notifications to the physician, family, local law enforcement, and nurse aide registry. However, there was no proof of fax transmission to the OSDH. On 10/03/24, the OSDH complaint department confirmed that no incident reports had been received from the facility since 06/18/24. The administrator later provided an email confirmation submitted to the OSDH on 09/09/24, but it did not confirm receipt of the fax transmission by OSDH.
Failure to Complete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents, which is a requirement according to their Discharging the Resident policy dated December 2016. This policy mandates that a discharge summary, including a recapitulation of the resident's stay, should be completed and communicated to the resident and receiving health care provider at the time of discharge. Resident #4, who was cognitively intact, was discharged home with medications and discharge instructions as per a physician's order, but no discharge summary was completed. Similarly, Resident #5, who was cognitively impaired with memory problems and monitored for wandering behaviors, was discharged to another long-term care facility without a completed discharge summary. The Director of Nursing confirmed that the discharge summaries for both residents could not be located but should have been completed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as an elopement risk. The resident, who had a history of hemiplegia/hemiparesis, hypertension, aphasia, dysphagia, muscle weakness, and transient ischemic attack, was documented as cognitively impaired with memory problems and was known to ambulate independently. Despite being identified as an elopement risk due to wandering behaviors, the facility did not have an incident report or documentation of an elopement incident for this resident. Staff members, including the DON and LPNs, reported being unaware of any elopement incidents, although there were reports of the resident being seen outside the facility near the street. On one occasion, an LPN received a phone call from an anonymous caller reporting that a resident was outside near the street. By the time the LPN reached the door, an unidentified staff member was already escorting the resident back inside, unharmed. The DON later stated that the resident was never out of sight and therefore did not complete an incident report. The facility had been seeking more appropriate placement for the resident due to wandering behaviors, and the resident was eventually discharged to another long-term care facility. However, the lack of documentation and reporting of the incident indicates a failure in the facility's supervision and elopement prevention measures.
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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 | 0.5 mi | ★★★★★ | 0 | 0 |
| Mcmahon-tomlinson Nursing Center | 1.4 mi | ★★★★★ | 4 | 0 |
| Lawton Post Acute & Rehab | 4.2 mi | ★★★★★ | 7 | 4 |
| Ayers Nursing Home | 27.3 mi | ★★★★★ | 0 | 0 |
| Temple Manor Nursing Home | 28.6 mi | ★★★★★ | 0 | 0 |
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