Elmwood Manor Nursing Home

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

diagnoses which included bipolar, Alzheimer's and dementia with a moderate cognitive impairment with decision making with daily events, with a BIMS of 12.#2. An undated diagnoses report showed Resident #2 diagnoses which included Alzheimer's, dementia and severe depression with a staff assessment that indicated a severe cognitive impairment for daily decision making with daily events.A behavior note, dated 01/12/24, for Resident #2 showed, Resident #2 followed Resident #3 and #4 making them uncomfortable, and Resident #2 kissed Resident #4. Resident #2's care plan, dated 02/05/25, showed a focus for inappropriate talking/asking questions to [opposite sex] residents included the following interventions for sexual behaviors directed towards staff and residents:a. Pristiq (antianxiety) 50 mg, one time daily,b.

Provera (hormone regulator) 20 mg, twice dailyThe care plan did not address any other interventions for sexual behaviors.A behavior note, dated 05/21/25, for Resident #2 showed Resident #2 was moved away from an unidentified resident, due to inappropriate language and expression of physical contact. Resident #2's quarterly assessment, dated 09/25/25, did not show any behaviors.A revised physician's order, dated 10/16/25, Provera (hormone regulation) 10 mg, oral tablet twice a day.A revised physician's order, dated 10/17/25, Pristiq(anti-anxiety) 25 mg, 1 oral tablet 24 hour extended release once a day.A behavior note, dated 09/09/24, read in part, This morning while walking down the hallway a resident [Resident #3] reported to me this resident is saying vulgar comments to them. #3. A quarterly assessment for Resident #3, dated 09/27/25, showed a BIMS of 00 and diagnoses which included modified independence for decision-making skills for daily events, schizophrenia and mild neurocognitive disorder.On 10/29/25 at 2:07 p.m., Resident #3 stated they felt violated by Resident #2 and they did not know if the facility ever investigated the incident. #4. On 10/29/25 at 2:00 p.m., Resident #4 was observed seated in a wheelchair playing bingo with Resident #3. Resident #4 was observed to show a communication deficit of slowed speech and struggled to find words.Resident #4's quarterly assessment, dated 09/25/25, showed they were unable to participate and had a BIMS score 00. The assessment showed Resident #4 had diagnoses which included cerebral infarction, other paralytic syndrome, and cerebrovascular disease affecting the left dominant side.On 10/29/25 at 2:00 p.m., Resident #4 stated they felt bad when Resident #2 kissed them.An incident report, dated 10/14/25, read in part, It was reported by the charge nurse that [Resident #2] was touching [Resident #1] inappropriately. [Resident #1] were [sic] moved away from [Resident #2] and put on 15 min monitoring and one on one when in the area that [Resident #2] is in. Staff was notified. The inappropriate touching was [Resident #2] had [Resident #1's] shirt up and was touching their breast.On 10/29/25 at 1:29 p.m., CNA #1 stated Resident #2 was always saying nasty and perverted things to residents and staff.On 10/29/25 at 1:36 p.m., the general manager stated they did not complete safe surveys regarding abuse.On 10/29/25 at 2:04 p.m., the administrator was asked for documentation for the alleged sexual abuse incident which occurred on 10/14/25. The administrator stated they had not conducted an investigation over the abuse incident on 10/14/25.

Event ID:

Facility ID:

If continuation sheet

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

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elmwood Manor Nursing Home

300 South Seminole Wewoka, OK 74884

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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, and interview, the facility failed to thoroughly investigate allegations of abuse for 1 (#1) of 8 residents sampled for abuse.The corporate nurse identified 39 residents resided in the facility.Findings: A facility policy titled, Abuse Investigations, revised October 2009, read in part, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will, as a minimum: Interview any witnesses to the incident; .Interview staff members (on all shifts) who have had contact with the resident

during the period of the alleged incident; . Interview the resident's roommate, family members, and visitors; .Review all events leading up to the alleged incident.5. Witness reports will be obtained in writing. Witness will be required to sign and date such reports.An incident report dated of 10/14/25, showed [Resident #2] was inappropriately touching [Resident #1] and had [Resident #1's] shirt up and touching their breast.On 10/29/25 at 1:35 p.m., the general manager was asked if the10/14/25 allegation abuse witness statements were completed. They stated I should have done a full investigation for 10/14/25 abuse incident.On 10/29/25 at 2:04 p.m., the administrator stated they had no witness statements from the 10/14/25 incident of abuse on Resident #1 and Resident #2.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elmwood Manor Nursing Home

300 South Seminole Wewoka, OK 74884

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

strangled' on tough meat. Resident #8's nursing note, dated [DATE REDACTED], read in part, CN [charge nurse] requested assistance with [Resident #8] c/o [complain of] of 'something in throat', upon inspection [Resident #8] had a visibly large chunk of meat in throat. Resident #8's nursing note, dated [DATE REDACTED], read in part, [Resident #8] was getting choked on meats. Resident #8's physicians order, dated [DATE REDACTED], read in part, Regular diet, Chopped Meats texture, Regular/Thin consistency. Resident #8's care plan, dated [DATE REDACTED], read in part, Eating: Assist with meal set up and feeding. Resident #8's nursing note, dated [DATE REDACTED], read in part, Called to residents [sic] room d/t [due to] resident choaking [sic]. Upon entering [CNA #3] was doing the Heimlich on resident. Resident #8's incident note, dated [DATE REDACTED], read in part, The call light was initiated, and a nurse aide entered the room. [Resident #8] pointed to [their] throat showing choaking [sic].

CNA #3's witness statement, dated [DATE REDACTED], read in part, I [CNA #3] came to answer to [Resident #8] light and when I walked into the room, they were sitting up in bed eating. Resident #8 had they arms up waving me towards them when I noticed they were choking. I ran over to Resident #8 and called for [CNA #4] to help sit them up, [CNA #4] could not get their arms around Resident #8. LPN #3's witness statement, dated [DATE REDACTED], read in part, At 5:28 p.m., I saw [CNA #3] running down the hallway and yelled '[resident name withheld] is choking.' [LPN #3] ran to the room upon entering [CNA #4] was standing next to [Resident #8] bed. EMS [emergency medical services] at 5:50 p.m. pronounced time of death. On [DATE REDACTED] at 11:27 a.m.,

the corporate nurse stated staff should have been monitoring Resident #8, but staff were passing out meal trays for dinner in the hallway. On [DATE REDACTED] at 12:44 p.m., the activities director stated they worked on [DATE REDACTED] and when Resident #8 was in bed eating and no staff was in the room when Resident #8 started choking.

On [DATE REDACTED] at 1:18 p.m. the maintenance supervisor stated LPN #3 asked them to come help with the Heimlich because they were too small to perform the maneuver on Resident #8.

Event ID:

Facility ID:

If continuation sheet

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

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elmwood Manor Nursing Home

300 South Seminole Wewoka, OK 74884

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, record review and interview, the facility failed to ensure 1 of 1 treatment cart was locked when not in use.The corporate nurse identified 39 residents resided in the facility and had one treatment cart.Findings:On 11/03/25 at 2:39 p.m., the treatment cart was observed [NAME] of the nurse's station unlocked and unsupervised with insulin pens and vials in the top drawer.On 11/03/25 at 2:40 p.m., LPN #1 was observed walking to the South end of the hallway and away from the treatment cart.On 11/06/25 at 1:29 p.m., the treatment cart was observed [NAME] of the nurse's station unlocked and unsupervised.On 11/06/25 at 1:30 p.m., LPN #2 was observed standing in dining hall out sight of the treatment cart, which was unlocked and unsupervised.A policy titled Security of Medication Cart, revised April 2007, read in part, 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 4. Medication carts must be securely locked at all times when out of the nurse's view.On 11/04/25 at 2:41 p.m. LPN #1 stated the treatment cart was unlocked and unsupervised. LPN #1 stated it was their responsibility to ensure the treatment cart was locked.On 11/04/25 2:45p.m., the corporate nurse stated the facility had two medication carts and one treatment cart that sat by the nurse's station. On 11/04/24 at 3:11 p.m., the corporate nurse was asked what items were stored in the treatment cart. They stated the treatment cart contained insulin and peg tube supplies.On 11/06/25 at 1:31 p.m., LPN #2 stated they were supposed to supervise the treatment cart and lock it.

Event ID:

Facility ID:

If continuation sheet

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

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elmwood Manor Nursing Home

300 South Seminole Wewoka, OK 74884

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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on record review and interview, the facility failed to track and monitor choking incidents for 1 (#8) of 3 sampled residents reviewed for choking incidents for quality assurance.The corporate nurse identified 39 residents resided in the facility.Findings:A policy titled Safety and Supervision of Residents, revised December 2007, read in part, QA & A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization.A nursing note for Resident #8, dated 01/18/24, read

in part, called to residents room D/T [due to] resident choaking [sic], . At 5:50 p.m. Paramedic staff pronounced time of death.The quality assurance notes, dated 02/29/24, did not show any documentation for monitoring and tracking related to Resident #8's choking incident on 01/18/24 which resulted in Resident #8's death in the facility.On 11/04/25 at 1:07 p.m., the corporate nurse stated they did not QA or document the 01/18/24 incident involving Resident #8.

Event ID:

Facility ID:

If continuation sheet