Federal inspectors found multiple medication errors at Choctaw Residential Center during a March inspection, documenting cases where nurses failed to follow basic safety protocols that could prevent adverse outcomes for residents.
Licensed Practical Nurse #1 administered Glipizide 10 mg to Resident #39 on March 5, despite the diabetes medication being discontinued two days earlier on March 3. The nurse also gave the resident an Albuterol inhaler at 8:15 AM, even though records showed the medication had already been administered at 6:00 AM and was scheduled every six hours.
Most troubling, the same nurse documented giving a Mometasone Furoate inhaler to the resident at 8:00 AM but later admitted she never administered it at all.
During questioning, LPN #1 confirmed all three violations. She acknowledged that her failure to verify the six basic rights of medication administration could lead to adverse resident outcomes. The facility's own policy requires nurses to check the right resident, right drug, right dosage, right route, right time, and right documentation before giving any medication.
Resident #39 has Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure, conditions that require precise medication management.
The medication errors extended beyond one nurse. Licensed Practical Nurse #4 gave Resident #90 an enteric-coated aspirin tablet instead of the prescribed chewable form. The nurse admitted during questioning that she realized the mistake after giving the medication and confirmed she had not thoroughly checked the medication requirements.
Resident #90 has End-Stage Renal Disease, a condition where medication forms and dosages require careful attention.
Inspectors observed both nurses during their medication rounds and found neither verified medications against patient records before administration, a fundamental safety step outlined in the facility's policies.
The facility also failed to provide basic personal care to residents who depended entirely on staff assistance. Resident #74 was found lying in bed with fingernails approximately one inch long on his left hand, covered with a brown substance. One nail was broken off and hanging inside his palm.
The resident's teeth and gums were covered in a thick white substance. When inspectors returned two days later, his condition was unchanged. Resident #74 told staff he had asked them to brush his teeth in the past.
Registered Nurse #1 acknowledged the resident's long nails could cause skin breakdown because his fingers were contracted and turned inward toward his palm. She described his teeth as needing brushing and confirmed that staff neglect could cause gingivitis and tooth decay.
The resident requires total assistance with personal hygiene and has been at the facility since February 2022 following a stroke that caused paralysis on his left side. Despite being cognitively intact, he depends completely on staff for basic care.
Documentation showed aides were responsible for brushing his teeth daily, but the care was not being provided.
Weekend activities presented another problem for residents. Three cognitively intact residents complained that the facility offered no organized activities on Saturdays and Sundays, leaving them with nothing to do but puzzles and coloring sheets.
Resident #6, who has been at the facility since December 2020, said she felt better recently and wanted to participate in group activities but none were available on weekends. Resident #9 participated in bingo and singing during weekdays but found weekends empty of programming.
Resident #41 expressed frustration that she enjoyed playing cards like Spades and Monopoly but had no weekend options except puzzles, which she was tired of doing. She said residents "just sit around" on weekends.
The Activity Director worked only Monday through Friday, leaving weekend coverage to charge nurses who were expected to help residents with independent activities. The administrator acknowledged the facility had failed to provide structured weekend activities and was attempting to hire weekend activity staff.
Activity calendars for February and March 2025 listed only "Independent activities of choice" for weekends. Attendance records showed no documented weekend participation for the three residents who complained.
The Activity Director, who had worked in the position for five years and completed required training, defended her approach. She counted smoking time and hallway conversations as activities for residents, claiming she had done all she could to meet their interests.
All three residents had indicated in their assessments that participating in favorite activities was "very important" to them. Two specifically said doing things with groups of people was also very important.
A certified nursing aide who worked some weekends confirmed the facility had no weekend activities, saying church members occasionally came to sing but "it's not often." A housekeeper who worked weekends stated simply, "No, they don't do anything."
The facility's policy promises an ongoing program to support residents' activity choices based on their assessments, care plans, and preferences, designed to meet each resident's interests and support their physical, mental, and psychosocial well-being.
For residents like #74, who cannot advocate for basic hygiene care despite asking for help, and residents like #6, #9, and #41, who clearly expressed their desire for weekend activities, the gap between policy and practice remained stark during the March inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Choctaw Residential Center from 2025-03-06 including all violations, facility responses, and corrective action plans.