Wewoka Healthcare Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on record review and interview, the facility failed to notify a physician when a resident verbalized

they would harm themself and others for 1 (#17) of 5 sampled residents reviewed for abuse and neglect.The DON identified 71 residents resided in the facility.Findings:An undated admission Record showed Resident #17 had diagnoses which included schizoaffective disorder bipolar type, other hallucinations, unspecified psychosis not due to a substance or known physiological condition, and unspecified depression.Resident #17's admission resident assessment, dated 08/19/25, showed the resident's cognition was intact with a BIMS of 14. The assessment showed the resident had hallucinations, delusions, and verbal behavioral symptoms directed towards others.A nursing note, dated 08/17/25 at 5:05 a.m., showed Resident #17 was at the nurses' station screaming and cussing, threatening to kill themself and others. The note showed the resident stated they were hearing voices and evil spirits and was very aggressive to staff. The note showed Resident #17 was put on one-on-one monitoring and 911 was called.There was no documentation the physician was notified.On 09/09/25 at 11:31 a.m., LPN #1 stated if

a resident threatened to kill themself or others, they were to notify the psychiatric doctor, fill out an emergency order of detention form, initiate one-on-one monitoring, and send them to the emergency room.On 09/09/25 at 12:17 p.m., the ADON stated they were to notify the psychiatric provider if a resident threatened to kill themself or others.On 09/09/25 at 1:43 p.m., the ADON stated it did not appear the provider was notified about the incident on 08/17/25.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wewoka Healthcare Center

1400 West First Street 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

staff. A psychiatric exam report, dated 08/15/25, showed a psychiatric visit was completed for Resident #1 by the nurse practitioner. The report showed the visit was prompted by prior allegations made regarding a male peer entering their room. The report showed Resident #1 stated they and the peer of the opposite sex were friends. The report showed Resident #1 stated they did not feel threatened and enjoyed the attention

the peer of the opposite sex gave them and valued their conversations.A facility in-service education report, dated 08/16/25, showed the facility staff were educated on Recognizing Indicators of Sexual Misconduct by

a Resident.The administrator provided an untitled document, dated 08/20/25, that showed a referral was submitted to the abuse and neglect hotline regarding Resident #1's allegation of abuse by Resident #2.On 08/26/25 at 11:25 a.m., Resident #1 stated sometime in July, Resident #2 invited them to their room to play video games. Resident #1 stated Resident #2 pushed them down on the bed, positioned on top of them, and tried to kiss them. Resident #1 stated they told Resident #2 no. Resident #1 stated after a few minutes, Resident #2 moved and they exited the room. Resident #1 stated someone told the staff what happened, and the administrator asked them about the incident. Resident #1 stated they told the administrator Resident #2 tried to kiss them and they did not like it. Resident #1 stated for two weeks following the incident Resident #2 would try and approach them in common areas. Resident #1 stated Resident #2 was

a big person and they were afraid of Resident #2, so they just stayed in their room. A care plan, dated 08/26/25, showed Resident #1 had the potential to be at risk for sexual assault related to decreased awareness of personal boundaries or vulnerability.On 09/02/25 staff were interviewed and stated in August 2025 an in-service was completed regarding resident sexual abuse.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wewoka Healthcare Center

1400 West First Street 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

code status, and begin CPR.On [DATE REDACTED] at 11:46 a.m., the ADON stated staff were to notify EMS immediately.On [DATE REDACTED] at 11:49 a.m., the ADON stated according to the nursing note on [DATE REDACTED], the staff had performed CPR and notified EMS when the resident was found unresponsive. They stated anyone certified in CPR could perform CPR.On [DATE REDACTED] at 11:51 a.m., the ADON stated they were not sure how Resident #11's code status was determined on [DATE REDACTED].On [DATE REDACTED] at 11:53 a.m., the ADON stated Resident #11's code status was not listed under their name in the electronic health record.On [DATE REDACTED] at 3:38 p.m., CNA #3 stated a resident's code status would be located on their electronic health record. They stated they worked on [DATE REDACTED] when Resident #11 was found unresponsive. CNA #3 stated they worked on a different hall and the agency nurse had instructed them to continue their rounds because CNA #2 and LPN #3 were with the resident.On [DATE REDACTED] at 5:37 p.m., CNA #2 stated LPN #3 notified them they thought Resident #11 had passed and they were not sure what the resident's code status was because it was not listed under the resident's name in the electronic health record. CNA #2 stated they reviewed Resident #11's Kardex and informed LPN #3 the resident was a full code. CNA #2 stated they both went to the resident and put them

on the floor and started CPR.On [DATE REDACTED] at 5:40 p.m., CNA #2 stated LPN #3 had notified them of the incident around 5:00 a.m. because it was around the time they had started doing morning rounds. They stated EMS was called shortly after that, but not sure exactly what time.On [DATE REDACTED] at 5:41 p.m., CNA #2 stated they may have started the CPR around 5:12 a.m. to 5:15 a.m., but it was just around the time EMS came to the room.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wewoka Healthcare Center

1400 West First Street 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

hallucinations, delusions, and verbal behavioral symptoms directed towards others. The assessment showed the resident received antipsychotic, antianxiety, and antidepressant medications.A nursing note, dated 08/26/25 at 4:01 p.m., showed Resident #17 had conversations with themself. The note showed the resident stated their medications made them crazy. The nursing note showed the physician was notified.There was no documentation the resident was evaluated by a psych provider or had a medication reconciliation after the incident.A nursing note, dated 09/06/25 at 4:17 a.m., showed Resident #17 was cussing, being loud and aggressive. The note showed a nurse attempted to calm the Resident #17 and the resident shoved the nurse into the wall and was holding them against the wall. Resident #9 came to intervene and was held by the arm and neck and pushed onto the sofa by Resident #17. The note showed staff separated the residents. A nursing note, dated 09/06/25 at 6:50 a.m., read in part, Resident #17 received an immediate discharge from the facility due to violently attacking the staff and choking another resident.An Initial State Reportable Incident form, dated 09/06/25, showed suspected criminal act. It showed Resident #17 attacked a night shift nurse by violently shoving them against the wall and pinning them. The form showed Resident #17 choked Resident #9.On 09/09/25 at 10:29 a.m., CNA #1 stated Resident #17 paced the halls and talked to themself.On 09/09/25 at 10:31 a.m., CNA #1 stated Resident #17 was not on any behavior monitoring.On 09/09/25 at 11:27 a.m., LPN #1 stated Resident #17 had threatened to kill themself on 08/03/25. They stated the resident was sent to a psychiatric facility on emergency order of detention. LPN #1 stated Resident #17 re-admitted to the facility on [DATE REDACTED]. On 09/09/25 at 11:31 a.m., LPN #1 stated if a resident threatened to kill themself or others, they were to notify

the psych doctor, fill out an emergency order of detention form, initiate one-on-one monitoring, and send them to the emergency room.On 09/09/25 at 11:40 a.m., LPN #1 stated other preventive measures for residents with behavior issues would be to notify the psychiatric doctor for medication evaluation, find the root cause of the behavior, and put them on one-on-one monitoring.On 09/09/25 at 11:40 a.m., LPN #1 stated Resident #17 should have been sent to a psychiatric hospital on [DATE REDACTED]. LPN #1 stated they did not believe the facility environment was safe for a resident who threatened to kill themself and others.On 09/09/25 at 12:00 p.m., the ADON stated Resident #17 was aggressive towards a nurse and Resident #9

on 09/06/25. They stated police and EMS were notified, and the resident was discharged from the facility for resident safety.On 09/09/25 at 12:03 p.m., the ADON stated the resident had a history of hollering and saying things that may not be appropriate or make sense.On 09/09/25 at 12:05 p.m., the ADON stated Resident #17 was not on any special monitoring since their re-admission on [DATE REDACTED]. On 09/09/25 at 12:10 p.m., the ADON stated they were not aware if the resident had any interventions in place for self-harm, or physical and verbal abuse since their return to the facility. On 09/09/25 at 12:25 p.m., the ADON stated Resident #17 should have received higher level of care for threats of killing themself and others. On 09/09/25 at 12:30 p.m., the ADON stated Resident #17 did not receive a psychiatric evaluation after the incident on 08/17/25. They stated the resident had a medication order for Tylenol (an analgesic) and no other medication adjustments were completed. On 09/09/25 at 12:30 p.m., the ADON stated the facility's environment was not equipped with safety measures for a resident who verbalized threats of killing themself and others.

Event ID:

Facility ID:

If continuation sheet