Based on record review and interview, the facility failed to ensure elopement prevention interventions were implemented on the care plan for 1 (#1) of 3 sampled residents reviewed for elopement.A wandering and elopement risk assessment for Resident #1, dated 05/28/25, showed the resident was at risk for wandering and elopement.An incident report form, dated 11/06/25, showed Resident #1's family member informed the facility the resident had walked to their home. The report showed the resident had a small abrasion to their forehead.Resident #1's care plan did not show wandering and elopement incidents/interventions prior to 11/06/25.The administrator identified 21 residents in the facility at risk for elopement.On 05/13/26, an Immediate Jeopardy (IJ) situation was determined to exist related… …
F656 citations in Oklahoma
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oklahoma cites F656 more often than its own record predicts
1.10 times the share F656 takes of citations nationally.
Of every deficiency written in Oklahoma in 2025, this is the portion that was F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oklahoma surveyors wrote
F656 findings written in Oklahoma, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and interview, the facility failed to develop a care plan:a. for a resident who had a diagnosis of diabetes mellitus type 2 and acute kidney injury for 1 (#6) of 3 sampled residents reviewed for care plans. Resident #1 had no care plan for glucose levels and showed the resident's cause of death was protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure. The Certificate of Death showed a significant condition contributing to Resident #6's death was diabetes mellitus.b.to include interventions for weight loss for 1 (#1) of 3 sampled residents reviewed for weight loss.The MDS coordinator identified 105 residents resided in the facility.Findings: 1. …
Based on record review and interview, the facility failed to develop and/or implement comprehensive care plans for 2 (#1 and #3) of 3 sampled residents reviewed for care plans.The administrator identified 34 residents resided in the facility.Findings:A policy titled Care Plans - Comprehensive, dated 10/2010, read in part, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.1. A skin check document for Resident #3, dated 07/10/26, showed the resident's skin was warm and dry to the touch with redness noted to the right heel, MASD early pressure areas to the right upper buttock with measurements to the top area 1.5 x 1 and the bottom area 1 x 1.2. …
The short window
Recent years
| Year | Share of Oklahoma citations | vs expected |
|---|---|---|
| 2023 | 3.44% | 0.96× |
| 2024 | 3.10% | 0.91× |
| 2025 | 3.78% | 1.10× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oklahoma surveyors cite →
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