Mcmahon-Tomlinson Nursing Center

In the surveyor’s words

From the most serious findings on record at Mcmahon-Tomlinson Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 22, 2021

  On 07/21/21 at 2:48 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect a resident from sexual abuse. A licensed practical nurse/charge nurse observed the resident in bed and a facility maintenance staff member was observed to have his hand under the resident's covers, with his hand moving back and forth over the resident's genital area. The nurse did not intervene, did not separate the resident from the staff member, and left the room without protecting the resident from further abuse. On 07/21/21, the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 3:20 p.m., the administrator was notified of the IJ situation. At 5:18 p.m., an acceptable plan of removal was provided. […]

• Immediate jeopardy, isolatedF607Jul 22, 2021

  On 07/21/21 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy to prevent abuse and protect a resident from alleged sexual abuse. A licensed practical nurse/charge nurse observed the resident in bed and a facility maintenance staff member was observed to have his hand under the resident's covers, with his hand moving back and forth over the resident's genital area. The nurse did not intervene, did not separate the resident from the staff member, and left the room without protecting the resident from further potential abuse. The facility did not immediately interview other residents or staff members to identify potential concerns and further protect all residents. […]

• Immediate jeopardy, isolatedF610Jul 22, 2021

  On 07/21/21 at 2:48 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to immediately intervene to protect a resident from alleged sexual abuse. A licensed practical nurse/charge nurse observed the resident in bed and a facility maintenance staff member was observed to have his hand under the resident's covers, with his hand moving back and forth over the resident's genital area. The nurse did not intervene, did not separate the resident from the staff member, and left the room without protecting the resident from further potential abuse. […]

• Actual harm, isolatedF600Dec 16, 2025

  Based on observation, record review, and interview, the facility failed to ensure wound care was provided per physician orders for 1 (#31) of 2 sampled residents reviewed for wound care.The DON identified 123 residents resided in the facility.Findings: On 12/10/25 at 10:50 a.m., Resident #31 was observed in bed. The resident had staples to a right above knee amputation site.An Abuse & Neglect policy, dated 01/02/22, read in part, Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.A care plan for Resident #31, dated 10/02/25, showed a pressure ulcer development related to immobility and a low Braden score to the right foot, right inner… […]

• Actual harm, isolatedF686Dec 16, 2025

  Based on observation, record review, and interview, the facility failed to follow physician's orders and care plans to prevent the worsening of wounds for 1 (#31) of 2 sampled residents reviewed for wound care.The DON identified 123 residents resided in the facility.Findings: On 12/10/25 at 10:50 a.m., Resident #31 was observed in bed. The resident had staples to a right above knee amputation siteA Skin Assessment and Ongoing Skin Integrity Monitoring policy, dated 03/16/24, showed comprehensive skin assessment and ongoing monitoring were performed to identify risks, prevent skin breakdown, and ensure timely interventions in accordance with professional standards. […]