24th Place Nursing Home: Fall Documentation Failures - OK
Inspectors visited the facility at 600 24th Avenue Southwest on October 2, 2025, following a complaint. What they found, or more precisely what they couldn't find, was a paper trail that should have existed for months.
The falls happened on March 17, March 19, and April 19, 2025. After each one, the facility was expected to conduct a structured investigation, document what interventions were put in place to prevent another fall, and complete a formal root cause analysis called a Five Why, a method that works backward through a sequence of contributing factors to identify what actually caused an event.
None of that documentation could be produced.
On the morning of October 1, at 11:13 a.m., the chief nursing officer told inspectors the facility could not locate any interventions related to the fall that occurred on March 19. Eighteen minutes later, at 11:35 a.m., the same administrator confirmed the facility also could not locate documentation showing that a Five Why had been completed after either the March 17 fall or the April 19 fall.
That is three falls. Three gaps. One after another across a two-month stretch of spring, and by October, the facility's top nursing official was standing in front of inspectors with nothing to show.
The inspection classified the violation as causing actual harm, not the potential for harm. Actual harm. The falls themselves are what the record reflects, and the missing documentation means there is no evidence the facility took any systematic steps to understand why they were happening or to stop them from happening again.
A Five Why investigation is not a formality. When a resident falls in a nursing home, the goal of the analysis is to move past the surface explanation and find the real cause. Did the call light go unanswered? Was the resident's mobility reassessment overdue? Had a new medication altered their balance? The questions matter because the answers shape whether the next resident in a similar situation gets hurt. Without the documentation, there is no way to know what, if anything, was learned.
The interventions record matters for the same reason. If staff identified that a resident needed a bed alarm, a mobility aid, or closer monitoring after a fall, that decision should appear somewhere in the chart. It is how the next shift knows what precautions are in place. It is how a nurse two weeks later knows the situation has changed. When that record doesn't exist, the protection may not exist either.
The chief nursing officer's statements during the inspection did not suggest the documents had been lost or misfiled. The word used was that they could not locate them. For a fall on March 17, that was more than six months of time during which the documentation was not produced, not found, and apparently not noticed as missing until inspectors asked.
The inspection covered a few residents, according to the report's notation on scope. The violation was not cited as widespread. But the pattern across three separate falls, each missing its own required follow-through, suggests something more than a clerical error on a single bad day.
24th Place received an actual harm finding, the agency's designation for violations where a resident suffered real injury or negative health consequences, not merely an elevated risk of them. The falls themselves are the harm the record reflects. What the missing documentation represents is the absence of any documented effort to make sure the next fall didn't happen the same way.
The residents who fell in the spring of 2025 are identified in the inspection report only by the dates of their falls. Their names are not in the public record. Whether any of them fell again, and whether anything was different the second time, is not something the documentation can answer.
Because there is no documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for 24th Place from 2025-10-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
24th Place in Norman, OK was cited for violations during a health inspection on October 2, 2025.
Inspectors visited the facility at 600 24th Avenue Southwest on October 2, 2025, following a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.