24th Place

In the surveyor’s words

From the most serious findings on record at 24th Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Oct 2, 2025

  On [DATE], an IJ situation was determined to exist related to the facility's failure to provide oxygen as ordered by the physician. Resident #77 was found unresponsive and without oxygen on [DATE]. The resident expired in the facility. Resident #77 had a physician order for continuous oxygen at 2 liters per minute per nasal cannula. On [DATE] at 3:01 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 3:12 p.m., the administrator was notified of the IJ and provided the IJ template. On [DATE] at 12:33 p.m., an amended plan of removal was approved by the Oklahoma State Department of Health. […]

• Actual harm, isolatedF693Dec 2, 2025

  Based on record review and interview, the facility failed to ensure physician's orders were followed for enteral feeding for 1 (#1) of 1 resident sampled for enteral feeding.The administrator identified 72 residents resided in the facility. Findings:On 12/01/25 at 10:30 a.m., Resident #1 was observed resting in bed with their eyes open.A facility policy titled Enteral Tube Feeding via Syringe (Bolus), dated November 2018, read in part, Verify that there is a physician's order for this procedure. […]

• Actual harm, isolatedF726Dec 2, 2025

  Based on record review and interview, the facility failed to ensure an RN was competent and possessed the necessary skills to provide care for 1 (#1) of 1 resident sampled for peg tubes.The DON identified one resident with a peg tube. Findings:A facility policy titled Enteral Tube Feeding via Syringe (Bolus), dated November 2018, read in part, Verify that there is a physician's order for this procedure.An undated medical diagnoses list showed Resident #1 had diagnoses which included esophagitis, dysphagia, and traumatic hemorrhage of cerebrum.An untitled document showed RN #1 completed their training on tube feeding on 07/10/25.Resident #1's treatment administration record, dated 10/01/25 to 10/31/25, showed Resident #1 had an order for Osomolite 1.5 cal oral liquid (nutritional… […]

• Actual harm, isolatedF689Oct 2, 2025

  Based on record review and interview, the facility failed to ensure fall interventions were initiated to prevent reoccurring falls for 1 (#10) of 2 sampled residents reviewed for falls.The administrator identified 74 residents resided in the facility. Findings: A review of March 2025 incidents showed Resident #10 had a non-injury fall on 03/07/25 and 03/17/25.Resident #10's fall risk assessment, dated 03/17/25, showed the resident had moderate risk for falls with a score of 9.An incident report, dated 03/19/25 at 9:00 p.m., read in part, Notified by staff that resident had a fall. Nursing assessment completed and observed with 5cmx5cm scalp hematoma. Neurological checks initiated and resident was assisted to bed. […]

• No harm, potential for more than minimal, widespreadF574Oct 2, 2025

  Based on observation and interview, the facility failed to ensure contact information for filing a complaint with the State agency was available to the residents.The administrator identified 74 residents resided in the facility. Findings:On 09/26/25 at 4:08 p.m., the administrator and surveyor observed the information board. On 09/26/25 at 2:38 p.m., the resident council group stated the contact information for filing a complaint with the State agency was covered and not visible. They stated they wanted to contact the State agency a month ago, but could not. On 09/26/25 at 4:06 p.m., the administrator stated the information for filing a complaint with the State agency was posted at the information board by the facility entrance. […]