Lawton Post Acute & Rehab

In the surveyor’s words

From the most serious findings on record at Lawton Post Acute & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF656Apr 28, 2026

  Based on record review and interview, the facility failed to identify and implement interventions on care plans to prevent falls for 1 (#47) of 3 sampled residents reviewed for care plans. Resident #47 had 7 falls with 2 which resulted in fractures. The administrator identified 80 residents resided in the facility.On 04/27/26, an IJ situation was determined to exist related to the facility's failure to identify and implement interventions to prevent falls resulting in fractures for a resident who sustained seven falls in five months.On 04/27/26 at 10:44 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.On 04/27/26 at 12:48 p.m., the administrator and DON were notified of the IJ situation and provided the IJ template.On 04/27/26 at… […]

• Immediate jeopardy, patternF689Apr 28, 2026

  Based on observation, record review, and interview, the facility failed to:a. ensure adequate supervision was provided and exit doors and perimeter fences were secure to prevent an elopement for 1 (#92) of 3 sampled residents reviewed for elopement risk.The administrator identified 80 residents resided in the facility. The DON identified six residents in the facility at risk for elopement.An elopement evaluation for Resident #92, dated 02/28/26, showed the resident was at risk for elopement and wandering. The evaluation showed the resident wandered around the facility into rooms. […]

• Immediate jeopardy, isolatedF580Apr 28, 2026

  Based on record review and interview, the facility failed to ensure the physician and family were notified when a resident had a significant change of condition for 1 (#96) of 1 sampled resident reviewed for a change of condition which resulted in death. Resident #96 was on the toilet and bleeding. ACMA #2 stated they contacted LPN #1 about the residents' condition, and they had left the blood in the toilet for LPN #1 to observe. LPN #1 came to observe the resident; however, LPN #1 told them to continue to monitor the resident since they had refused to go to the ER. […]

• Immediate jeopardy, isolatedF684Apr 28, 2026

  Based on record review and interview, the facility failed to promptly assess, identify, and intervene when a resident experienced an acute new onset of profuse bleeding from an unknown source for 1 (#96) of 1 sampled resident reviewed for a change in condition when facility staff failed to notify the medical provider of a critical hemoglobin lab value of 6.3 with a normal reference range was 13.7 to 17.5, and identify the new onset of profuse bleeding from an unknown source on a resident with a recent repair of an abdominal aortic aneurysm resulting in an attempted transfer to the acute care hospital and subsequent death in the ambulance while in the facility parking lot.Specifically, the facility failed to: a. […]

• Immediate jeopardy, isolatedF726Apr 28, 2026

  Based on record review and interview, the facility failed to ensure sufficient/competent staff to assess, monitor, and intervene for a resident with profuse bleeding for 1 (#96) of 1 sampled resident reviewed for a change in condition when facility staff failed to assess, monitor, intervene for significant change in condition when a resident experienced an acute onset of profuse bleeding and failed to notify the medical provider of a critical hemoglobin lab value of 6.3 with a normal reference range of 13.7 to 17.5, and the onset of profuse bleeding on a resident with a known history of encounter for surgical aftercare following surgery on the circulatory system and the presences of an aortocoronary bypass graft resulting in the subsequent death of Resident #96.Specifically, the facility… […]