WOODLANDS SKILLED NURSING AND THERAPY

1701 EAST 6TH STREET, OKMULGEE, OK 74447 (918) 756-1967
For profit - Partnership 114 Beds BRIDGES HEALTH Data: November 2025
Trust Grade
60/100
#144 of 282 in OK
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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Woodlands Skilled Nursing and Therapy has a Trust Grade of C+, indicating a decent, slightly above-average rating among nursing homes. They rank #144 out of 282 facilities in Oklahoma, placing them in the bottom half, but they are #2 out of 4 in Okmulgee County, suggesting only one local option is better. The facility is improving, with issues decreasing from 12 in 2024 to just 2 in 2025. Staffing is a strength, rated at 4 out of 5 stars with a low turnover rate of 32%, significantly better than the state average. While there are no fines on record, which is a positive sign, there have been some concerns noted; for example, food safety practices were overlooked, and a resident was not treated with dignity during personal care. Additionally, grievances from residents about laundry and meal options have not been adequately addressed, indicating some areas for improvement.

Trust Score
C+
60/100
In Oklahoma
#144/282
Bottom 49%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
12 → 2 violations
Staff Stability
○ Average
32% turnover. Near Oklahoma's 48% average. Typical for the industry.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Oklahoma facilities.
Skilled Nurses
⚠ Watch
Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Oklahoma. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
28 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 2 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (32%)

    16 points below Oklahoma average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

3-Star Overall Rating

Near Oklahoma average (2.6)

Meets federal standards, typical of most facilities

Staff Turnover: 32%

13pts below Oklahoma avg (46%)

Typical for the industry

Chain: BRIDGES HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 28 deficiencies on record

May 2025 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure the care plan was revised for 1 (#32) of 12 residents reviewed for care plans. The administrator reported 45 residents resided in th...

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Based on record review and interview, the facility failed to ensure the care plan was revised for 1 (#32) of 12 residents reviewed for care plans. The administrator reported 45 residents resided in the facility. Findings: Resident #32's undated medical diagnoses list showed diagnosis of Parkinsonism. A facility incident report, dated 05/08/25, showed Resident #32 had a fall on 05/08/25. A fall risk assessment, dated 05/08/25, showed Resident #32 was high risk for falls. There was no documentation in Resident #32's care plan to reflect the fall on 05/08/25. On 05/22/25 at 11:46 a.m., registered nurse #1 stated the fall on 05/08/25 should have been care planned with an intervention put in place.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to ensure a resident was treated in a dignified manner during ADL care for 1 (#35) of 1 sampled resident reviewed for dignity. The administrat...

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Based on record review and interview, the facility failed to ensure a resident was treated in a dignified manner during ADL care for 1 (#35) of 1 sampled resident reviewed for dignity. The administrator identified 45 resident resided in the facility. Findings: An undated transfer/discharge report showed Resident #35 had diagnoses which included mononeuropathy, anxiety disorder, and major depressive disorder. An annual assessment, dated 04/23/25, showed Resident #35 was cognitively intact and had a brief interview for mental status score of 15. The assessment showed the resident was independent with ADLs including showers. The care plan, revised 04/24/25, showed Resident #35 had an ADL self care performance deficit related to musculoskeletal impairment. The care plan showed the resident was able to bathe self, feed self independently, ambulate independently, and toilet self. The resident council minutes for the meeting held 05/19/25 was reviewed. The minutes showed on a resident response form a concern from resident council regarding the nursing department. The form showed the aides were coming into the shower room when someone was showering without knocking. On 05/21/25 at 8:54 a.m., Resident #35 stated Monday they were taking a shower and CNA #2 opened the door when they were undressed. Resident #35 stated it had happened about three times before. Resident #35 stated the in use sign was displayed and the CNA did not even knock. Resident #35 stated CNA #2 said they had to get the shower chair from the room to give another resident a shower. Resident #35 stated they told CNA #1 who was also working on the hall about the incident. On 05/21/25 at 11:27 a.m., CNA #1 stated they were aware of the incident regarding CNA #2 opening the door while the resident was showering. CNA #1 stated this was not the first time CNA #2 had opened the door to the shower room while Resident #35 was showering. CNA #1 stated they did not tell the nurse and should have reported the incident to the nurse. On 05/22/25 at 9:13 a.m., the administrator stated there was no facility policy regarding dignity. The administrator stated they followed resident rights. On 05/22/25 at 9:43 a.m., CNA #2 was interviewed regarding opening the door when Resident #35 was showering. CNA #2 stated there was an incident Monday regarding Resident #35. CNA #2 stated they walked in on Resident #35 while they were taking a shower. CNA #2 stated they did not notice the sign on the door the shower room was in use and they did not knock. CNA #2 stated it had happen once before and the resident was not upset. CNA #2 stated the resident was upset about the incident occurring on Monday.
May 2024 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to maintain a homelike environment for two (#3 and #4) of three sampled residents reviewed for home like environment. The administrator identifi...

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Based on observation and interview, the facility failed to maintain a homelike environment for two (#3 and #4) of three sampled residents reviewed for home like environment. The administrator identified 54 residents resided in the facility. Findings: On 05/07/24 at 3:10 p.m., two children were observed running through the dining area and common area. On 05/07/24 at 3:12 p.m., food wrappers and chewed gum was observed on the floor of the activity room. On 05/07/24 at 3:15 p.m., two children were observed running down the 200 hall. On 05/08/24 at 10:12 a.m., Resident #4 stated the staff bring their children to work with them and it keeps them from getting their rest because they run up and down the hallways and are loud. On 05/08/24 at 11:00 a.m., Resident #3 stated having children running up and down the hallway bothers them. They have caught children in their room and observed them coming out of other residents' rooms. It upsets them because the children tear up the yard ornaments in the courtyard, especially the bird feeders. They have reported this to the DON but the children still run up and down the halls. On 05/08/24 at 12:48 p.m., the houskeeping supervisor stated it is the responsibility of the parent to clean up after their children, but they don't and it makes their job harder. They have brought this to the attention of the administrator but it has not been addressed. 05/08/24 at 3:12 p.m., the DON stated it is the parent's job to supervise and clean up after their children. They stated they need to have people come to work so they bring their children. 05/08/24 at 3:15 p.m., the administrator stated they do not have a policy regarding employees bringing their children to work.
Feb 2024 11 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to honor resident's choice of entertainment for one (#11) of two sampled residents who was reviewed for choices. The DON identified 58 resident...

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Based on observation and interview, the facility failed to honor resident's choice of entertainment for one (#11) of two sampled residents who was reviewed for choices. The DON identified 58 residents resided in the facility. Finding: Res #11 had diagnoses which included recurrent depressive disorders and diabetes mellitus with diabetic polyneuropathy. A significant change assessment, dated 12/27/23, documented the resident was moderately impaired with cognition and required assistance with most ADLs. On 02/12/24 at 10:37 a.m., an observation was made of Res #11 having a television mounted on the wall approximately four foot from another television mounted on the wall for the other resident which resided in the same room. The resident stated the remote control operates both televisions in the room. They stated every time the other resident utilizes their remote control for their television it operates both televisions. Res #11 stated they could not watch what they wanted related to their television being controlled by the other resident's remote. On 02/14/24 at 3:42 p.m., an interview was conducted with the maintenance man and they stated the televisions were too close together and the remote operated both televisions in the room. On 02/14/24 at 3:45 p.m., an interview was conducted with the DON and they stated there was a problem with a remote controlling the sound on two televisions but they bought some headphones for the one resident which fixed the problem. They also stated they did not know about any other problems with the televisions in other rooms.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined the facility failed to ensure the code status was identifi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined the facility failed to ensure the code status was identified and correct for one (#44) of 24 residents whose code status was reviewed. The administer identified 55 residents who resided in the facility. Findings: Res #44 had diagnoses which included diabetes mellitus, dependence on renal dialysis, chronic kidney disease, and congestive heart failure. An advanced directive acknowledgment form, dated [DATE], documented the resident did not have a DNR. An admission assessment, dated [DATE], documented the resident was intact with cognition and required substantial to maximal assistance with most ADLs. A care plan, dated [DATE], documented the resident had full code status. On [DATE] at 11:29 a.m., a red name tag was observed on the outside of the resident room. A review of the EHR, documented the resident's code status was full code. A DNR was not found in the resident's hard chart. On [DATE] at 3:29 p.m., LPN # 3 stated when a resident had a red name tag on the door they are a DNR code status. On [DATE] at 3:29 p.m., LPN #4 stated red on the door is for DNR. LPN #4 stated we would not have performed CPR if it had been needed because the resident had a red name plate.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure a resident received the necessary services to maintain their scheduled baths for one (#42) of one sampled resident for assistance wi...

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Based on record review and interview, the facility failed to ensure a resident received the necessary services to maintain their scheduled baths for one (#42) of one sampled resident for assistance with bathing. The administrator identified 55 residents who resided in the facility. Findings: Res #42 had diagnoses which included history of falling, reduced mobility, and osteoarthritis. A quarterly assessment, dated 12/21/23, documented the resident was intact with cognition and required partial to moderate assistance with bathing. A care plan, revised 12/28/23, documented the resident has a self care deficit related to impaired balance and pain. The care plan documented the resident required limited physical help from staff participation with bathing. The residents bathing schedule was bath on Monday and Thursday on the 7 to 3 shift. The resident should have received baths on 01/15, 01/18, 01/22, 01/25, 01/29, 02/01, 02/05, 02/08, and 02/12. A review of the bathing sheet for 30 days documented the resident had a bath on 01/23, refused on 01/24, refused on 01/29, was bathed on 02/01, 02/05, 02/08, and 02/12. The resident missed a baths on 01/15 and 01/18/24. On 02/13/24 at 10:22 a.m., Res #42 stated most times it takes the staff an hour or so for them to get down here to get them up in the morning and some times it was 9 or 10 at night before they will assist them to bed. Res #42 stated they knew the staff are busy. Res #42 stated they were supposed to get a two showers a week on Monday and Thursday. The resident stated some weeks they did not get bathed. Res #42 stated they did not get a bath yesterday. Res #42 stated most the time the students who come into the facilty help with their bath, if they did not, they would not get bathed. On 02/14/24 at 4:00 p.m., CNA #1 stated when they give a shower they document the bath in PCC, under the tasks. CNA #1 stated most of the residents are scheduled for two showers a week and if a a resident refused they document refused. On 02/14/24 at 4:10 p.m., CNA #2 stated they believed the residents are scheduled for three baths a week. CNA #2 stated they felt at this time they were able to get showers completed but they had missed giving residents their baths in the past due to staffing issues. On 02/15/24 at 10:14 a.m., the DON stated the baths are only documented in the EHR. The DON stated the missed baths may have not been documented, could have been a documentation error.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on record review, and interview, the facility failed to ensure wound care treatments were completed as ordered for one (#17) of three sampled resident reviewed for pressure ulcers. The DON ident...

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Based on record review, and interview, the facility failed to ensure wound care treatments were completed as ordered for one (#17) of three sampled resident reviewed for pressure ulcers. The DON identified 55 residents resided in the facility. Res #17 had diagnoses which included dementia without behavioral disturbances, atrial fibrillation, arthropathy, chronic pain, and stage II pressure ulcer. Weekly skin assessment, dated 10/27/23, documented there was no skin problems with res #17. Weekly skin assessment, dated 11/10/23, documented there was no skin problems with res #17. A physician order, dated 11/16/23, documented apply skin prep to spine every day and evening shift for wound management/prevention. A skin assessment summary documented on 11/22/23, the resident had a pressure ulcer. There was also documentation of a wound consultant visit on this day. A physician order, dated 11/22/23 documented cleanse mid back with normal saline, pat dry, apply medihoney, cover with calcium alginate, and secure with bordered foam every day shift, Monday, Wednesday, Friday, related to pressure ulcer, unstageable and as needed for soiled or dislodgment. This order was not implemented until 11/27/23 according to treatment record. A physician order, dated 01/04/24, documented cleanse mid back with NS, pat dry, apply Dakin's soaked gauze and secure with bordered foam every day shift related to pressure ulcer, unstageable and as needed for soiled or dislodgment. A care plan, dated 01/23/24, documented to cleanse mid back with normal saline, pat dry, apply Santyl, cover with calcium alginate and secure with bordered foam as per orders related to pressure ulcer, unstageable. On 02/15/24 at 11:51 a.m., the wound care nurse stated they did not know anything about the wound on the resident's back until the pressure ulcer was unstageable.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week. The administrator identified 55 residents re...

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Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week. The administrator identified 55 residents resided in the facility. Findings: A document titled Time & Attendance Detail, date range: 11/01/23 through 01/31/23, documented an RN was not in the facility for eight hours on 12/16/23. On 02/15/24 at 3:07 p.m., the corporate nurse stated on 12/16/23 there was only 6.50 hours for RN coverage.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure nursing staff completed required competency demonstrations annually for one (CMA #2) of five staff reviewed for annual competency. T...

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Based on record review and interview, the facility failed to ensure nursing staff completed required competency demonstrations annually for one (CMA #2) of five staff reviewed for annual competency. The administrator identified 55 residents resided in the facility. Findings: On 02/15/24 at 11:42 a.m., competency documentation was requested. On 02/15/24 at 1:43 p.m., HR stated they did not have an annual competency for CMA #2. On 02/15/24 at 2:54 p.m., the DON stated CMAs competencies were to be completed annually.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to act upon grievances presented during resident council ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The administrator identified 55 residents resided in the facility. Findings: The resident council reports dated 08/24/23 documented several concerns related to laundry, employees on cell phones too much, and different food request made by the residents. The resident council reports, dated 09/13/23, documented the residents were getting tired of jello and pudding for snacks and nothing else offered. There was also concerns about items missing from laundry. The resident council reports, dated 01/17/24, documented items being missed from laundry. On 02/12/24 at 9:00 a.m., an observation was made of four children being on hallway 200 with staff member. The children were observed to be standing in the doorways of the resident rooms while aides were assisting residents and passing medications. On 02/12/24 at 10:46 a.m., Res #19 stated items were always missing from laundry, the only foods food alternative meals were soups, snack consist of oatmeal pies and fudge rounds. They also stated the facility never offers fresh fruit or ice cream. Res #19 stated all the foods are locked up in the evening and there will only be peanut butter and jelly sandwiches available in the evenings. They also stated there were several residents that would like to have ham and cheese or turkey with cheese sandwiches but we only get peanut butter and jelly and we never get chips of any kind, only Fritos are offered. On 02/12/24 at 2:55 p.m., LPN #2 stated there was many times staff members would bring their children up to the facility related to staff members not having a babysitter and at times the children were in the facility for long periods of time. The children would sit in the common area watching the residents' television and laying on the couch preventing residents from sitting there to watch television. LPN #2 stated the children would be disruptive to staff members and the resident by running up and down the hallways of the facility. On 02/14/24 at 1:05 p.m., a council meeting was conducted with 12 residents. The residents voiced complaints related to their grievances about the kitchen and food were never addressed. They voiced complaints they always had the same food and whenever they asked for something different they were ignored. They stated they have asked for cottage cheese and fruit, roast with carrots and potatoes, Indian tacos with fry bread, peanut butter and snickerdoodle cookies, fried fish, tater tots, and porkloin. They complained about the sauce for chili, tacos, and spaghetti was the same every time and watered down. The council also complained about never getting extra food and the staff telling the residents there was not enough food for extra. They want different kind of beans and want the cornbread cooked thoroughly related to the cornbread always being rare in the middle. The council did complain about children being in the facility running up and down the hallways and going in and out of resident rooms without permission. They stated the children play with puzzles and games in room [ROOM NUMBER] and leave it in a mess for housekeeping to clean up. They also complained about no RN coverage on weekends. The council wanted to have bible study again and some different activities to participate in. They stated they rarely turned in any grievance anymore related to the facility not addressing the problems. On 02/14/24 at 3:00 p.m., observation was made of an activity station for toddlers to play on in room [ROOM NUMBER]. There was also observation of toddler toys stacked up on a shelf in room [ROOM NUMBER]. On 02/15/24 at 9:47 a.m., the laundry supervisor stated they did not know Res #26 was missing a certain blanket. On 02/15/24 at 9:52 a.m., Res #26 stated there was a grievance filed shortly after being admitted into the facility but their blanket was never found. On 02/15/24 at 1:00 p.m., the social service director stated they did not do anything with the council meeting complaints because they did not know they were supposed to take the complaints to administration. On 02/15/24 at 2:34 p.m., the administrator stated they have not seen the council meeting minutes and the complaints as social services always kept those meetings. They also stated they did not know they were suppose to address each complaint that the council members brought up in the meetings. The administrator then stated they would begin addressing the problems the council brought to the meetings. On 02/15/24 at 3:43 p.m., Res #19 stated they did order a chef salad for lunch but did not receive a chef salad.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

Based on observation and interview, the facility failed to document required daily staffing information. The administrator identified 55 residents resided in the facility. Findings: On 02/12/24 at 9:3...

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Based on observation and interview, the facility failed to document required daily staffing information. The administrator identified 55 residents resided in the facility. Findings: On 02/12/24 at 9:30 a.m., and throughout the survey the staffing board was observed to have no documentation of the facility name, date, census, staff names, hours of nursing staff, or titles. On 02/15/24 at 3:36 p.m., the administrator and the DON stated they were not aware of the requirements regarding posted staff information.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview, the facility failed to ensure menus were followed for one of one meal service observed. The administrator identified 55 resident who resided in the...

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Based on observation, record review, and interview, the facility failed to ensure menus were followed for one of one meal service observed. The administrator identified 55 resident who resided in the facility. Findings: On 2/14/24 at 10:39 p.m., the menu for lunch this day documented beef tacos, refried beans, Mexican rice, and desert of the day. On 02/14/24 at 12:15 p.m., the lunch service was observed and the resident were served white rice for the noon meal. On 02/14/24 at 12:27 p.m., a test tray was sampled and the white rice was very sticky and bland to the taste. On 02/15/24 at 1:23 p.m., the DM stated they did not make the Mexican rice because they did not have all the ingredients to make it.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

Based on observation, and interview, the facility failed to ensure food was served at an appetizing temperature. The administrator identified 55 residents who resided in the facility. Findings: On 0...

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Based on observation, and interview, the facility failed to ensure food was served at an appetizing temperature. The administrator identified 55 residents who resided in the facility. Findings: On 02/14/24 at 11:11 a.m., the yogurt was taken out of the refrigerator and sat on the counter. At 11:17 a.m., it was place on some of the trays for the hall meals. On 02/17/24 at 12: 20 p.m., the DM was plating meals for hall 300. The yogurt remained on the hall trays. At 12:22 p.m., the cooperate dietary manager obtained the temperature of the yogurt and it was 59.2 degrees Fahrenheit. On 02/15/24 at 1:23 p.m., the DM stated the temperature on cold food should be no higher than 41 degrees when serving.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation and interview the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The administrator identified 55 resident re...

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Based on observation and interview the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The administrator identified 55 resident residing in the facility. Findings: 1. On 02/12/24 at 9:02 a.m., an initial tour of the kitchen was conducted. The following observations were made. The large round trash can by the deep fryer was not covered. The stand up freezer which held the house shakes was observed to have ice build up. On 02/12/24 at 9:04 a.m., the refrigerator was observed to have a large mixing bowl with what looked like chocolate pudding in the bowl the plastic wrap was not covering the bowel and was in the pudding. There were 13 individual cups of pudding not labeled in the refrigerator. A bowl of what looked like tomato soup was cover with plastic wrap but not labeled or dated. A donut on a plate cover with plastic wrap not labeled or dated. A plate with cake and a dessert cup on the plate covered with plastic wrap that was coming unsecured from the plate was observed in the refrigerator not labeled or dated. [NAME] #1 stated the pudding was made for today's lunch. The bowl had tomato soup in it and the cake was an employees. [NAME] #1 stated the items should have been labeled and dated. On 02/12/24 at 9:08 a.m., the storage room was observed to have large areas of missing tile. On 2/12/24 at 9:10 a.m., DA #1 was observed entering he kitchen and did not wash their hands. On 2/12/24 at 9:18 a.m., DA #1 returned to the kitchen, hand washing was not performed by the staff member. On 02/12/24 at 9:24 a.m., debris was observed on the shelving under the prep table where the steam table lids were contained. The prep area was observed to have bread crumbs and multiple items on the counter with debris around them. On 02/12/24 at 11:28 a.m., during dining observation the DM was observed going in and out of the kitchen not washing her hands when entering the kitchen. On 02/14/24 at 10:44 a.m., The DM stated the trash should be covered. The DM stated the prep tables and shelving should be cleaned. The DM stated when staff enter the kitchen they should put on a hair net and wash their hands. The DM stated they try and defrost the freezer once a month but the one with the shakes in it was the oldest and it frosts over quicker than the other freezers. On 02/14/24 at 10:56 a.m., the DM was observed to touch the trash can lid and them move the cooked meat to puree to the prep table and then washed their hands. On 02/14/24 at 10:56 a.m., a housekeeping staff member entered the kitchen to replace the soap in the dispenser. The housekeeper did not have on a hair net. On 02/14/24 at 11:23 a.m. the DM was observed to go into the kitchen and did not wash their hands. On 02/14/24 at 11:33 a.m., DA #2 was observed to deliver a meal on a tray to a resident . DA #2 sat the tray on the table gave the meal to the resident and returned to the steam table, placed the tray back on the top of the steam table and another meal was place on the tray to deliver to another resident. On 02/14/24 at 12:02 p.m., the DM stated the staff should not be sitting the trays on the tables and then reusing them they should just hold the tray to serve the meal.
Jan 2023 14 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the OHCA of a resident with a new serious mental illness for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the OHCA of a resident with a new serious mental illness for one (#33) of two sampled residents reviewed for PASRR evaluations. The Resident Census and Conditions of Residents report, documented six residents who received antipsychotic medications. Findings: Res #33 was admitted to the facility on [DATE]. A PASRR level I was completed on 03/21/22 and documented the resident did not have a serious mental illness. On 05/04/22, Res #33 received a new diagnosis of delusional disorders. A significant change assessment, dated 11/09/22, documented the resident was severely impaired with cognition and required extensive to total assist with activities of daily living. The assessment documented the resident had no behaviors and received an antipsychotic medication. On 01/06/23 at 9:07 a.m., the business office person stated she had been doing the PASRR I for the past three weeks. She stated she had not been fully trained and educated on what to do if a resident received a new mental health diagnosis. She stated she thought that would require someone to be contacted.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, it was determined the facility failed to revise care plans to meet the needs...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, it was determined the facility failed to revise care plans to meet the needs of one (#21) of 18 residents whose care plans were reviewed. The director of nursing (DON) identified 56 residents who resided in the facility. Findings: 1. Resident #21 was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, intrinsic eczema, and hypertension. An annual assessment, dated 03/04/22, documented the resident's cognition was intact and was total assist with transfers, dressing, toilet use, and did not walk. The care plan, last revised on 03/21/22 documented the resident required interventions to minimize skin breakdown in general. A quarterly assessment, dated 10/21/22, documented the resident's cognition was intact and was a total assist with transfers, dressing, toilet use, and did not walk. A nurse note, dated 05/11/22 at 2:51 p.m., documented a CNA alerted the nurse of an open area to the resident's right great toe. The note documented a new treatment order was initiated at that time to cleanse anterior right great toe with normal saline, pat dry, apply Betadine, and leave open to air. The resident's medical record did not have any assessments of the wound after June 2022. A nurse note, dated 07/19/22, the same treatment order was put back in place which documented to cleanse anterior right great toe with normal saline, pat dry, apply Betadine, and leave open to air. A nurse note, dated 12/02/22, the same treatment order was put back in place which documented to cleanse anterior right great toe with normal saline, pat dry, apply Betadine, and leave open to air. On 01/06/23 at 3:00 p.m., the resident's right great toe was observed to have an open area approximately 0.25 x 0.3 cm. On 01/07/23 at 8:48 a.m., MDS coordinator #1 was asked if the resident's care plan had been updated and she stated she had not had the time to update the care plan.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on record review, observation, and interview, the facility failed to perform appropriate hand hygiene during wound care for one (#16) of two residents sampled for pressure ulcers. The Resident ...

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Based on record review, observation, and interview, the facility failed to perform appropriate hand hygiene during wound care for one (#16) of two residents sampled for pressure ulcers. The Resident Census and Conditions of Residents report, documented one resident who had a pressure ulcer. Findings: Res #16 had diagnoses which included COPD, diabetes mellitus, hemiplegia and hemiparesis. A physician order, dated 10/30/22, documented to cleanse buttocks, pat dry, apply hydrophilic, and leave open to air every day and evening shift. A quarterly assessment, dated 12/07/22, documented the resident was severely impaired with cognition, required extensive to total assistance with ADLs, and did not have a pressure ulcer. A care plan, last reviewed 12/23/22, documented to cleanse buttocks, pat dry, apply hydrophilic leave open to air. The care plan documented daily during daily ADL care, to observe the residents skin for redness, open areas, scratches, cuts or bruises, and report changes to the nurse. A weekly skin assessment, dated 01/03/23, documented the resident had no new skin issues. On 01/04/22 at 11:43 a.m., the resident family stated the facility was treating the resident's bottom for something but was not sure if it was an open wound. On 01/06/23 at 2:18 p.m., LPN #1 was observed performing wound care for the resident. The supplies were placed on the residents overbed table without cleaning or placing a barrier on table. LPN #1 was observed to wear gloves and clean the resident's buttock and small open area on the resident's left gluteal fold with normal saline. The LPN then applied the treatment to the resident buttock and the ulcer wearing the same gloves. The unstageable pressure ulcer to the left gluteal fold was approximately 0.25 x 0.25 cm. On 01/06/23 at 3:04 p.m., the wound nurse LPN #2 stated the resident did not have an open area on Monday when she did the skin assessment. On 01/09/23 at 11:26 a.m., the ADON stated after cleaning the area, gloves should be changed and new gloves donned. She stated hand hygiene should be used between dirty and clean when performing wound care.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on record review, observation and interview, the facility failed to provide physician ordered monthly weights for one (#16) of one resident reviewed for nutrition. The Resident Census and Condit...

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Based on record review, observation and interview, the facility failed to provide physician ordered monthly weights for one (#16) of one resident reviewed for nutrition. The Resident Census and Conditions of Residents report, documented 50 resident who resided in the facility. Findings: Res #16 had diagnoses which included COPD, diabetes mellitus, hemiplegia and hemiparesis. A physician order, dated 01/16/22, documented to weigh the resident on day shift the 16th of every month. The weight record, dated 10/16/22, documented the resident's weight as 250 pounds. This was the last weight documented in the resident's EHR. A quarterly assessment, dated 12/07/22, documented the resident was severely impaired with cognition and required extensive to total care for ADLs except eating which he was independent. The assessment documented the resident's weight was 250 pounds. A care plan, last reviewed 12/23/22, documented Res #16 had potential nutritional/weight problem related to dysphagia and impaired mobility. On 01/03/23 at 2:32 p.m., Res #16 was observed in his room in the bed and his food from lunch was still covered and not touched. There was smoked sausage, rice and vegetables and whole kernel corn. Res #16 was pointing at the corn on his overbed table. On 01/04/23 at 11:43 a.m., the resident's family member stated the resident had gained some weight. She stated Res #16 liked her to assist with his meals and will have his lunch and dinner at times in his room when she gets to the facility in the afternoon. The family member stated Res #16 liked to sleep late and did not eat breakfast most of the time. She stated the resident loved corn but could not eat the whole corn. She stated she didn't know if the kitchen could puree it or serve cream style corn for the resident. On 01/05/23 at 4:30 p.m., the MDS coordinator stated she just weighed the resident and his current weight was 232.2 pounds. On 01/05/23 at :00 p.m., the dietitian stated the resident had a 7.2% loss in three months. On 01/06/23 at 9:56 a.m., the DON stated the resident should have been weighed monthly as ordered.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on record review, observation and interview, the facility failed to ensure the physician responded to a pharmacist recommendation for one (#14) of five sampled residents who were reviewed for un...

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Based on record review, observation and interview, the facility failed to ensure the physician responded to a pharmacist recommendation for one (#14) of five sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents report documented 50 residents resided in the facility. Findings: Res #14 had diagnoses which included brief psychotic disorder, anxiety disorder, major depressive disorder, and dementia without behavioral disturbance. A MRR, dated 05/11/22, documented a request to attempt a reduction in the following medications: Zoloft 50mg every day, valproic acid 250mg three times a day, Seroquel 50mg twice a day, and Buspar 7.5mg three times a day. The physician response for May's MRR was not documented in the resident record. On 01/09/23 at 10:51 a.m., the pharmacist stated the facility could not find the physician response for May's MRR. She stated the medication had not been changed at that time. She stated she should have followed up better after the MRR was sent.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on record review, observation, and interview, the facility failed to ensure residents were free from unnecessary psychotropic medications for one (#33) of five residents reviewed for unnecessary...

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Based on record review, observation, and interview, the facility failed to ensure residents were free from unnecessary psychotropic medications for one (#33) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented six residents in the facility who are receiving antipsychotic medications. Findings: Res #33 had diagnoses which included dementia, senile degeneration of the brain, and delusional disorders. A MRR, dated 03/18/22, documented Res #33 was admitted on Seroquel 12.5mg at bedtime for insomnia. The MRR documented the antipsychotic had a black box warning for increased risk of death in elderly patients with dementia. The MRR documented if insomnia was the intended diagnosis the recommendation would be to taper off the medication. The provider documented an agreement to the recommendation on 03/24/22. The MARs for March and April 2022 were reviewed. Res #33 continued to receive the Seroquel at 12.5mg until 04/24/22. A significant change assessment, dated 11/09/22, documented the resident was severely impaired with cognition, had no behaviors, and received an antipsychotic medication. On 01/06/23 at 1:35 p.m., the DON stated the nurse would normally look at the recommendations and note them and then put in an order if the physician agreed to a recommendation. She stated this review was not noted and it must have slipped through. She stated after the nurse the reviews the MRRs, they then go to her.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Based on observation and interview, the facility failed to ensure staff did not stand while feeding residents for two (#14 and #206) of 24 sampled residents. The Resident Census and Conditions of Res...

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Based on observation and interview, the facility failed to ensure staff did not stand while feeding residents for two (#14 and #206) of 24 sampled residents. The Resident Census and Conditions of Residents report documented 50 residents who resided in the facility. Findings: On 01/04/23 at 8:26 a.m., LPN #1 was observed standing at the bedside while feeding Res #206. On 01/04/23 at 8:30 a.m., CNA #1 was observed standing at bedside while feeding Res #14. On 01/04/23 at 5:12 p.m., a staff member was observed standing at bedside while feeding Res #14. On 01/09/23 at 10:16 a.m., the DON stated that the staff should be eye level with the resident or seated while assisting them to eat.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Resident Censu...

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Based on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Resident Census and Conditions of Residents report documented 50 residents resided in the facility. Findings: The resident council minutes were reviewed for 02/11/22, 03/23/22, 04/27/22, 05/23/22 and 09/30/22, which were all of the meeting minutes provided for review for the last 12 months. There was no documentation the residents' grievances had been acted upon. On 01/05/23 at 1:33 p.m., a resident group meeting was conducted with nine residents attending. During the meeting, residents stated that they were not sure who the grievance official was, but they thought it was the administrator. They stated none of the staff, including the administrator, ever responded to their concerns or gave a reason as to why the concerns were not addressed. On 01/05/23 at 3:40 p.m., the president of the council was asked if he was allowed to have council meetings without a staff member present. He stated several meetings had been cancelled by social services because there there was no staff member available to attend the meeting. He stated he did not know the council could meet without a staff member present. He stated he would have been having council meetings if he had known there did not have to be staff members present. On 01/05/23 at 4:03 p.m., the social service director was asked why the council had not been having meetings on a regular basis and why their concerns had not been addressed. She stated she would schedule a council meeting but if she was not available, then she would cancel the meeting. She also said she would speak to the department head about any concerns that the council had but did not have any documentation related to the responses.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0576 (Tag F0576)

Could have caused harm · This affected multiple residents

Based on observation and interviews, the facility failed to provide mail delivery to residents on Saturdays. The Resident Census and Conditions of Residents identified 56 residents who resided in the...

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Based on observation and interviews, the facility failed to provide mail delivery to residents on Saturdays. The Resident Census and Conditions of Residents identified 56 residents who resided in the facility. Findings: On 01/05/23 at 1:33 p.m., a group meeting was held with nine alert and oriented residents. They all agreed the mail came to the facility but did not get distributed every day and especially not on Saturdays. They stated the mail is distributed by social services. On 01/05/23 at 2:48 p.m., social services was observed delivering the mail to residents. On 01/05/23 at 4:03 p.m., the social services director stated the mail usually came to the facility and they would put it in her mail slot. She stated she then would separate the mail by resident and deliver the mail to the residents on the days she is schedule to work, when she had time.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

2. Res #12 had a physician order, dated 06/21/22, for clopidogrel bisulfate (an antiplatelet medication) 75 mg daily related to atherosclerosis of arteries of left leg with ulceration of calf. A quar...

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2. Res #12 had a physician order, dated 06/21/22, for clopidogrel bisulfate (an antiplatelet medication) 75 mg daily related to atherosclerosis of arteries of left leg with ulceration of calf. A quarterly MDS assessment, dated 10/14/22, documented the resident received an anticoagulant medication. On 01/07/23 at 10:28 a.m., the MDS coordinator #1 stated she thought that Plavix (clopidogrel bisulfate) and was on the list to code as anticoagulants. Based on record review and interview, the facility failed to ensure MDS assessments accurately reflected the residents' status for 2 (#12 and #33) of 18 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: 1. Res #33 had diagnoses which included dementia and delusional disorder. A significant change assessment, dated 11/09/22, documented the resident was severely impaired with cognition and required extensive to total assist with activities of daily living. The assessment documented the resident had no behaviors and received an antipsychotic medication. The assessment documented the resident had a physician documented contraindicated GDR on 10/26/22. The resident's medical record did not document a contraindication for a reduction of the antipsychotic medication on 10/26/22. On 01/06/23 at 1:37 p.m., MDS coordinator #1 stated she got the date in October from a mental health progress note which documented to continue current medication.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observation and interview the facility failed to ensure one of three medication carts were locked when unattended. The Resident Census and Conditions of Residents report documented 50 reside...

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Based on observation and interview the facility failed to ensure one of three medication carts were locked when unattended. The Resident Census and Conditions of Residents report documented 50 residents who resided in the facility. Findings: On 01/03/23 at 1:23 p.m., an observation was made of an unlocked medication cart on hall 200. The staff member was in a room administering medication to a resident. The cart was between rooms and the drawers were facing the hall way. A resident in a wheel chair was in the hall by the medication cart. The CMA came out of the room and closed the drawer and locked the cart. 01/03/23 at 1:25 p.m., CMA #1 stated she thought she had locked the medication cart. On 01/09/23 at 3:30 p.m., the DON stated all medication carts should be locked at all times when not occupied by staff.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Findings: On 01/03/23 at 04:00 p.m., res. #36 stated they needed more choice for the alternative and the food they serv...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Findings: On 01/03/23 at 04:00 p.m., res. #36 stated they needed more choice for the alternative and the food they serve need a little bit of flavoring. 01/04/23 at 01:51 p.m., res. #12 stated sandwiches are offered, for a alternative, but if you did not like sandwiches, you did without. She also stated that she would like to eat other types of meat like bone in chicken, instead of hamburger every day. On 01/05/23 at 01:33 p.m., a council meeting was conducted with nine (#10, 13, 17, 22, 23, 24, 31, 32, and #42) residents. All resident stated that their preference to foods were being ignored. All residents complained of being served to much packaged meats. They all stated they would like to have some bone in chicken, roast, ham and beans, salads, biscuits, baked cakes instead of packaged snack foods, and fresh fruit. They stated that the biscuits were so hard that no one could eat them. On 01/05/23 at 01:55 p.m. an observation of a picture was shown at the council meeting by res. #42, stating this is what we had for dinner last night, beef stroganoff. The picture was ground hamburger meat with brown gravy added to it, no noodle. He stated this was no beef stroganoff that he had ever seen. Based on record review, observation and interview, the facility failed to serve appealing options for alternative food items for residents who choose not to eat food that is initially served or who request a different meal choice. The Resident Census and Conditions of Residents report, documented 50 residents who resided in the facility. Findings: 1. On 01/03/23 at 4:40 p.m., the evening meal was observed. On the steam table the dietary staff were serving 6 oz of chicken spaghetti, 4 oz of mixed vegetables and 4 oz of broccoli, a slice of white bread and a pre packaged oatmeal cream cookie . On 01/03/23 at 4:54 p.m., the DM stated the kitchen staff came out and talked to the residents to see what they wanted to eat. She stated they always have a soup and sandwich of some kind. The DM stated if a resident is not feeling well and they and want chicken noodle we will fix that for them. On 01/03/23 at 5:10 p.m., the dinner meal was observed written on the board outside the kitchen door. The menu documented the following: Chicken spaghetti, broccoli, mixed vegetables, cookie Alternate - tomato soup with crackers or ham and cheese sandwich and chips. 2. Res #20's quarterly assessment, dated 02/17/22, documented the resident was intact with cognition. On 01/04/23 at 10:37 a.m., Res #20 stated the facility served a lot of hamburger. She stated she would like a roast once and awhile. Res #20 stated if they ask for something different it was always soup and a sandwich. Res #20 stated chicken nuggets or cabbage rolls with that sauce to dip it in would be nice once in a while. 3. Res #42's quarterly assessment, dated 12/11/22, documented the resident was intact with cognition. On 01/03/22 at 3:17 p.m., Res #42 stated, The food here food sucks. Res #42 stated we only get a sandwich for the alternate meal. Res #42 stated, We have ravioli soup all the time. Have you ever heard of ravioli soup? On 01/06/22 at 11:51 p.m. Res #22 [NAME] room [ROOM NUMBER] stated he ate his vegetables but he pork was so hard he could not cut it with a knife. The pork patty was observed on the tray and not on the resident plate. At this time he tried to stab it with a fork and said see how hard it is like a hockey puck. 01/09/23 at 11:48 p.m., The DM stated she had been talking to upper management about having an alternate menu for the residents. She stated she could talk to the dietitian about changing up the menu they rotate every three months. The DM stated she makes egg salad for the residents and every Friday they have chefs choice. The DM stated the kitchen usually had a left over from the previous day for an alternate meal.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

2. On 01/03/23 at 4:45 p.m., an observation was made of the evening meal on hall 200. CMA #2 and #3 were observed delivering plates from the hall cart with gloves on, turning on the lights in resident...

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2. On 01/03/23 at 4:45 p.m., an observation was made of the evening meal on hall 200. CMA #2 and #3 were observed delivering plates from the hall cart with gloves on, turning on the lights in residents' rooms, placing the meal in front of the residents, removing the cover from the food, then exiting the rooms. Both CMAs would come out of a resident's room, grab another meal tray and proceed to another resident's room. At no time did either of the CMAs change their gloves or do hand hygiene. On 01/03/23 at 5:15 p.m., an interview with CMA #2 was conducted on infection control. She admitted she had not been changing her gloves or using hand sanitizer. She stated that she should have been changing her gloves and using hand sanitizer in between residents. Based on observation and interview, the facility failed to ensure food was stored and served in a sanitary manner. The Resident Census and Conditions of Residents report documented 50 residents who resided in the facility. Findings: 1. On 01/03/23 at 1:28 p.m., an initial tour of the kitchen was conducted and the following was observed: Two plates of food covered with plastic wrap and three drinks on the counter by the hand washing sink with two open with no lid covering, Four sandwiches and gelatin were observed in the refrigerator not dated, A cut onion in a bag tied in a knot in the refrigerator was not labeled or dated, A bowel of tamales were not labeled or dated, A plate of food in a plastic bag not labeled or dated. Five 20 pound rolls of hamburger meat were observed thawing in the refrigerator with a bag of fajita chicken laying on top of the thawing meat, On 01/03/23 at 1:36 p.m., cook #1 stated she was the evening cook and did not know when the tamales were cooked or the onion cut up and placed in the refrigerator. [NAME] #1 stated they should be labeled and dated before placing in the refrigerator. On 01/03/23 at 1:38 p.m., the DM stated the chicken should not be on the top of the thawing hamburger meat and she moved it. On 01/09/23 at 11:46 a.m., the DM stated she was told the kitchen staff could use the end end of the counter by the hand washing sink for staff to put drinks and food on. She stated she told the staff the drinks should be covered and she was going to designate over by her desk area for food and drinks for the kitchen staff. She stated the food in the refrigerator should be labeled and dated.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0886 (Tag F0886)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct COVID-19 testing at a frequency which was consistent with c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct COVID-19 testing at a frequency which was consistent with current CDC guidance/standard of practice for conducting testing during an outbreak. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: The CDC website, read in parts, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Updated Sept. 23, 2022 .3. SETTING-SPECIFIC CONSIDERATIONS .NURSING HOMES .Responding to a newly identified SARS-CoV-2-infected HCP or resident .Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 .If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days . The facility's COVID Testing Guidelines policy revised 10/02/22, read in part, .Outbreak testing: Test all staff and residents in response to an outbreak (defined any single new infection in staff or any nursing home onset infection in a resident). If no additional cases are identified during the initial round of broad-based outbreak testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued. If additional cases are identified, testing should continue facility-wide every 3-7 days until there are no new cases for 14 days . The facility's testing records, for November 2022, documented a staff member tested positive for COVID-19 on 11/07/22. The records documented the facility used the broad based approach and tested residents and staff on 11/07/22. The records documented a second staff member tested positive on 11/09. The testing records documented all staff and residents were tested on [DATE]. The testing did not continue until no new cases for 14 days. On 01/09/23 at 12:07 p.m., the IP was interviewed related to the facility's testing policy. She stated their policy was to test everyone one time and if no additional positives, then testing would end the outbreak testing. She stated the second staff member was exposed to the first staff member who had tested positive two days prior. She stated the facility tested everyone on 11/09/22 because of the staff member testing positive on 11/09/22. She stated there were no additional positives on 11/09/22 so the testing stopped.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Oklahoma facilities.
  • • 32% turnover. Below Oklahoma's 48% average. Good staff retention means consistent care.
Concerns
  • • 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.

About This Facility

What is Woodlands Skilled Nursing And Therapy's CMS Rating?

CMS assigns WOODLANDS SKILLED NURSING AND THERAPY an overall rating of 3 out of 5 stars, which is considered average nationally. Within Oklahoma, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Woodlands Skilled Nursing And Therapy Staffed?

CMS rates WOODLANDS SKILLED NURSING AND THERAPY's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 32%, compared to the Oklahoma average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Woodlands Skilled Nursing And Therapy?

State health inspectors documented 28 deficiencies at WOODLANDS SKILLED NURSING AND THERAPY during 2023 to 2025. These included: 28 with potential for harm.

Who Owns and Operates Woodlands Skilled Nursing And Therapy?

WOODLANDS SKILLED NURSING AND THERAPY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BRIDGES HEALTH, a chain that manages multiple nursing homes. With 114 certified beds and approximately 45 residents (about 39% occupancy), it is a mid-sized facility located in OKMULGEE, Oklahoma.

How Does Woodlands Skilled Nursing And Therapy Compare to Other Oklahoma Nursing Homes?

Compared to the 100 nursing homes in Oklahoma, WOODLANDS SKILLED NURSING AND THERAPY's overall rating (3 stars) is above the state average of 2.6, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Woodlands Skilled Nursing And Therapy?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Woodlands Skilled Nursing And Therapy Safe?

Based on CMS inspection data, WOODLANDS SKILLED NURSING AND THERAPY has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Oklahoma. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Woodlands Skilled Nursing And Therapy Stick Around?

WOODLANDS SKILLED NURSING AND THERAPY has a staff turnover rate of 32%, which is about average for Oklahoma nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Woodlands Skilled Nursing And Therapy Ever Fined?

WOODLANDS SKILLED NURSING AND THERAPY has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Woodlands Skilled Nursing And Therapy on Any Federal Watch List?

WOODLANDS SKILLED NURSING AND THERAPY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

WOODLANDS SKILLED NURSING AND THERAPY

1701 EAST 6TH STREET, OKMULGEE, OK 74447 | (918) 756-1967

C+
Trust Grade (60/100)
3.0
CMS Rating
28
Deficiencies

Strengths

  • 4-star staffing
  • 4-star quality

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025