On 04/10/25 at 11:40 a.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to update Resident #1's care plan related to sexually inappropriate behaviors. Resident #1 was observed to place their hand under Resident #2's shirt and rub the resident's breast area. Resident #1 had a history of a similar incident involving another resident of the opposite sex. Resident #1 was sent to a behavioral health hospital after the first and second incident with no updated interventions to the resident's care plan to prevent recurrence. On 04/10/25 at 12:03 p.m., the administrator and DON were notified of the immediate jeopardy and provided the immediate jeopardy template. …
F657 citations in Oklahoma
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oklahoma cites F657 more often than its own record predicts
2.11 times the share F657 takes of citations nationally.
Of every deficiency written in Oklahoma in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oklahoma surveyors wrote
F657 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 ensure a resident's care plan was updated to include an intervention to prevent an identified pattern of falls for 1 (#39) of 2 sampled residents reviewed for accidents. The DON stated 54 residents at the facility had care plans. Findings: A facility policy titled Care Plans, Comprehensive Person-Centered, dated December 2016, read in part, The Interdisciplinary Team (IDT), in conjunction with the resident and/or their family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. A progress note, dated 08/12/24 at 2:30 a.m., showed Res #39 had fallen while attempting to go to their bathroom. …
Based on interview, record review, and facility policy review, the facility failed to revise the care plan for 1 (Resident #16) of 16 sampled residents. Specifically, Resident #16 requested to have a daily shower in June 2026, and the facility failed to revise and update the care plan with interventions related to the resident's choice for daily showers.Findings included: An undated facility policy titled, Comprehensive Care Plans, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive… …
The short window
Recent years
| Year | Share of Oklahoma citations | vs expected |
|---|---|---|
| 2023 | 4.00% | 1.87× |
| 2024 | 3.34% | 1.75× |
| 2025 | 3.94% | 2.11× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oklahoma surveyors cite →
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