Wagoner Health & Rehab

In the surveyor’s words

From the most serious findings on record at Wagoner Health & Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 10, 2025

  Based on observation, record review, and interview, the facility failed to ensure scoops were not left in bulk containers and the handwashing sink had hot water. The corporate nurse manager reported 46 residents received meals from the kitchen. Findings: On 04/07/25 at 7:27 a.m., an initial tour of the kitchen was conducted. A scoop was observed in a bulk container of flour and the handwashing sink did not have hot water. An undated facility policy titled Food Receiving and Storage, read in part, Foods shall be received and stored in a manner that complies with safe food handling practices. On 04/09/25 at 10:15 a.m., the dietary manager stated that scoops should not be left in bulk containers, and that the handwashing sink should be repaired.

• No harm, potential for more than minimal, patternF804Feb 25, 2026

  Based on observation and interview, the facility failed to provide meals at a palatable temperature for 3 (#4, 6, and #7) of 3 sampled residents reviewed for meal palatability.The infection preventionist identified 48 residents received meals from the kitchen. Findings:On 02/23/26 at 12:50 p.m., a test tray was sampled for temperature and palatability. The fried potatoes were undercooked and lukewarm, the turnip greens were lukewarm, the cornbread was cold and dry.1. An annual assessment for Res #4, dated 11/21/25, showed the resident had a BIMS score of 15 which indicated intact cognition.On 02/23/26 at 8:30 a.m., Res #4 stated when they ate in their room the food was always cold. Res #4 stated the food did not taste good.2. […]

• No harm, potential for more than minimal, patternF812Feb 25, 2026

  Based on observation, record review, and interview, the facility failed to ensure 2 (dietary aide #1 and the DM) of 2 dietary staff washed their hands immediately upon entry to the kitchen.The infection preventionist identified 48 residents received meals from the kitchen. Findings:On 02/23/26 at 11:55 a.m., dietary aide #1 was observed to enter the kitchen and begin working without washing their hands.On 02/23/26 at 11:59 a.m., dietary aide #1 was observed to enter the kitchen and begin working without washing their hands.On 02/23/26 at 12:00 p.m., the DM was observed to enter the kitchen and begin working without washing their hands.On 02/23/26 at 12:04 p.m., dietary aide #1 was observed to enter the kitchen and begin working without washing their hands.On 02/23/26 at 12:07 p.m., dietary… […]

• No harm, potential for more than minimal, patternF657Sep 17, 2025

  Based on record review and interview, the facility failed to revise the care plan after a fall for 3 (#1, 2, and #3) of 4 sampled residents reviewed for fall interventions.The DON identified 19 falls in the last six months.Findings:A policy titled Falls - Clinical Protocol, revised April 2025, read in part, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall.the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current… […]

• No harm, potential for more than minimal, patternF726Apr 10, 2025

  Based on record review and interview, the facility failed to ensure competencies were completed yearly and upon hire for 5 (LPN #1, LPN #2, CNA #1, CNA #2, and CNA #3) of 5 employees reviewed for competencies. Human Resources reported seven LPNs and 21 CNAs were employed by the facility. Findings: 1. LPN #1 had a hire date of 02/27/25. On 04/09/25 at 4:30 p.m., LPN #1's employment file was reviewed, it did not show a competency/skills check had been completed upon hire. 2. LPN #2 had a hire date of 09/18/19. On 04/09/25 at 4:35 p.m., LPN #2's employment was reviewed, it did not show a competency/skills check had been completed upon hire. 3. […]