The Oaks Healthcare Center

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, record review, and interview, the facility failed to serve food that was palatable and at a safe and appetizing temperature for the residents.The DON identified 103 residents received meals prepared by the kitchen and two residents received nutrition via percutaneous endoscopic gastrostomy tube. Findings:On 08/21/25 at 12:44 p.m., a meal test tray was obtained. The plate had turkey pot pie, salad, and a hot roll. The plate was not on a plate warmer and was covered with a lid. The turkey pot pie temped at 140 degrees F, the salad temped at 87.2 degrees F, and the hot roll temped at 94.3 degrees F.

The salad was warm to taste, and the turkey pot pie and hot roll were not hot to taste.A resident/family council meeting document, dated 07/16/25, showed a resident stated the food was terrible and cold at mealtimes. A hot food temperature chart for August 2025 showed food temperature checks were not obtained for 08/01/25 through 08/07/25 and 08/17/25 through 08/19/25. Evening meal temperature checks were not obtained on 08/08/25 and 08/09/25. On 08/20/25 at 4:37 p.m., Resident #7 stated the food was served cold.On 08/20/25 at 3:55 p.m., Resident #1 stated they received their diet per physician order, but

the food was cold. On 08/21/25 at 9:27 a.m., Resident #3 stated the food was always cold. On 08/21//25 at 11:45 a.m., Resident #4 stated the facility served to much starch for a diabetic diet and the food was always cold. On 08/21/25 at 3:00 p.m., the DM stated the reason a plate warmer was not used for the lunch meal

on 08/21/25 was because the salad was a cold item to be served. The DM stated cold and hot food should not have been served on the same plate. The DM stated the food temperature chart had food temperatures missing and they would not know if the food was served at the correct temperature.

Residents Affected - Some

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Healthcare Center

1501 Clayton Avenue Poteau, OK 74953

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program during wound care for 2 (#2 and #3) of 3 sampled residents reviewed for enhanced barrier precautions. The DON identified 18 residents with wounds and 27 residents on enhanced barrier precautions. Findings:1.On 08/21/25 at 9:26 a.m., LPN #1 obtained supplies to perform wound care for Resident #2. LPN #1 donned a pair of gloves and a gown. LPN #1 positioned the resident for comfort and removed the current dressing. LPN #1 removed their gloves and exited the room to obtain more supplies.

LPN #1 did not remove or change their gown when exiting and reentering the room. LPN #1 continued with

the wound care. LPN #1 changed wound areas and needed more supplies. LPN #1 removed their gloves and exited the room again to obtain more supplies. Wearing the same gown, LPN #1 exited and reentered to room without changing their gown. An undated policy titled Enhanced Barrier Precautions Policy, read in part, An order for enhanced barrier precautions will be obtained for residents with any of the following: i. wounds .Make gowns and gloves available immediately near or outside of the resident's room.d. Position a trash can inside the resident room for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.An undated face sheet showed Resident #2 had diagnoses which included atherosclerosis of native arteries of the right leg with ulceration of calf, diabetes mellitus, and moderate protein-calorie malnutrition.A quarterly assessment, dated 07/31/25, showed Resident #2 had a brief interview for mental status score of 14 which indicated the resident's cognition was intact and a diabetic foot ulcer. A physician order, dated 08/19/25, showed Resident #2 was to have wound care to bilateral lower extremities every day shift every Tuesday. The order showed staff were to cleanse the wound with normal saline, pat dry, apply gentamicin (topical for skin infections), apply iodoform (antiseptic)to wound bed, and cover with a 4X4 gauze. The order showed staff was then to apply three-layers compression consisting of past gauze, rolled gauze, and self-adherent wrap. On 08/21/25 at 9:45 a.m., LPN #1 stated the process they knew was to remove and place their PPE in the barrel out in the hallway. 2.On 08/21/25 at 9:00 a.m., LPN #1 gathered supplies to compete wound care for Resident #3.

There was no signage posted at the door regarding precautions or PPE available at the door. LPN #1 obtained gloves from their cart and entered the room with the wound supplies. LPN #1 was not wearing a gown. LPN #1 positioned the resident and removed the current dressing. LPN #1 changed their gloves and used alcohol-based hand gel. LPN #1 donned gloves and completed the wound care. LPN #1 did not wear

a gown. An undated face sheet showed Resident #3 had diagnoses which included osteoarthritis, thrombocytopenia, severe protein-calorie malnutrition, and cerebral vascular disease. A physician order, dated 05/23/25, showed staff was to clean the left hip wound with normal saline or wound cleanser, pat dry, pack wound with iodoform, and cover with a bordered foam dressing daily and as needed. A significant change assessment, dated 08/10/25, showed Resident #3 was severely cognitively impaired and had one unstageable pressure ulcer. On 08/21/25 at 9:15 a.m., LPN #1 stated all residents with wounds should be

on enhanced barrier precautions. LPN #1 stated they had forgot.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet