Based on interview, record review, and facility document and policy review, the facility failed to ensure only licensed qualified staff replaced a resident's indwelling urinary catheter for 1 (Resident #26) of 1 resident reviewed for urinary catheters. Specifically, Certified Medication Aide (CMA) #2, under the direct supervision of Registered Nurse (RN) #1, attempted to replace Resident #26's indwelling urinary catheter. As a result, Resident #26 experienced pain, bleeding from the insertion site, and bloody urine with clots.Findings included: A facility policy titled, Catheter Care, with a copyright date of 2024, indicated, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy… …
F659 citations in Oklahoma
Resident Assessment and Care Planning Deficiencies
Provide care by qualified persons according to each resident's written plan of care.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oklahoma cites F659 more often than its own record predicts
2.07 times the share F659 takes of citations nationally.
Of every deficiency written in Oklahoma in 2025, this is the portion that was F659.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oklahoma surveyors wrote
F659 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, facility staff failed to follow the plan of care for 1 (#4) of 6 residents whose clinical records were reviewed. The facility alphabetical room roster showed there were 100 residents. Findings: An undated Closet Care Plan, for resident #4 showed the resident was confused at times, had left side weakness, and transferred with a mechanical lift/sling and two person assistance. The history and physical, dated 05/02/25, showed the resident was recently hospitalized for a stroke as well as a history of stroke with subsequent left side weakness and numbness. The history and physical showed the resident also had a history of dementia and chronic right should pain. …
The short window
Recent years
| Year | Share of Oklahoma citations | vs expected |
|---|---|---|
| 2024 | 0.05% | 1.66× |
| 2025 | 0.08% | 2.07× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oklahoma surveyors cite →
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