Pauls Valley Care Center

In the surveyor’s words

From the most serious findings on record at Pauls Valley Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Jun 16, 2021

  On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent the development and worsening of pressure ulcers (PU's), to consistently and thoroughly assess the resident's skin, and to notify the physician and intervene in a timely manner for the PU's. The resident did not have weekly skin assessments conducted and developed a stage II pressure ulcer to the left inner buttock. The resident later developed a pressure ulcer to the right upper buttock that progressed to a Stage IV. Both wounds joined each other creating an unstageable pressure ulcer due to necrosis, to the sacrum. An infection was identified in the wound. […]

• Immediate jeopardy, patternF692Jun 16, 2021

  On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess and intervene in a timely manner to prevent severe weight loss for three residents who had severe weight loss. Resident #10 developed three pressure ulcers. One progressed to a Stage IV, merged with another pressure ulcer and was unstageable due to necrotic tissue. The wound became infected. On [DATE] the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 2:30 p.m., the administrator was notified of the IJ situation. At 5:16 p.m., an acceptable plan of removal was provided. The plan of removal was updated on [DATE]. […]

• Actual harm, isolatedF689Dec 18, 2025

  Based on record review and interview, the facility failed to ensure residents were free from injuries resulting in a fracture for 1 (#3) of 4 sampled residents reviewed for accidents.The DON identified 36 residents resided in the facility.Findings:An undated diagnoses report for Resident #3's showed Resident #3 was admitted on [DATE] with a diagnosis of morbid obesity (severe) due to excessive calories.A comprehensive assessment for Resident #3, dated 04/12/25, showed the resident was dependent upon staff for all transfers.A care plan for Resident #3's, revised on 10/04/25, showed Resident #3 required a mechanical lift with two staff assistance for transfers.A Combined Initial and Final incident report, dated 06/04/25, read in part, 06/04/25 1330 [1:30 p.m.], staff was transferring… […]

• No harm, potential for more than minimal, widespreadF919Oct 11, 2021

  Based on observation, interview, and record review, the facility failed to provide a functioning call light system for 29 of 29 residents who were reviewed for an adequate call system. The administrator identified 29 residents resided in the facility. Findings: On 10/07/21 at 12:50 p.m., call lights were checked in every room and neither lit up or sounded. Call lights in the bathrooms/shower rooms did not work. On 10/07/21 at 12:52 p.m., resident #6 reported the call lights had not worked for about a month. The resident reported the staff did not do room checks very often. On 10/07/21 at 1:05 p.m., resident #7 squeaked a toy and reported she also had a bell to call for assistance. […]

• No harm, potential for more than minimal, patternF638Apr 18, 2024

  Based on record review and interview, the facility failed to complete and submit quarterly reviews of the minimum data set in the required timeframe's for eight (#3, 7, 11, 12, 14,16, 17, and #23) of 10 residents whose clinical records were reviewed for completion/submission of the resident assessments. The administrator identified 34 residents. Census: 34 Findings: The facility's MDS Completion and Submission Timeframe's policy, dated 10/01/10, read in part our facility will conduct and submit resident assessments in accordance with federal and state submission timeframe's . […]