Texoma Healthcare Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for four of nine residents (Resident #3, #5, #6, and #8) reviewed for accident prevention. The facility failed to ensure Resident #6 did not have scissors and odor ban disinfectant spray in his room on 07/27/26. The facility failed to ensure Resident #5 did not have a container of Tide Pods laundry soap in her room on 07/27/26. The facility failed to ensure Resident #8 did not have Nystatin cream, scissors and safety pin in his room on 07/27/26. The facility failed to ensure that Resident #3 did not have scissors and 2 nail clippers in his room on 07/27/26. This failure could place residents at risk of injuries or accidents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Residents #5, #7 and #1) reviewed for respiratory care. The facility failed to ensure Resident #5's Oxygen Nasal Canula and breathing treatment masks storage bags were changed every 7 days on 07/27/26. The facility failed to ensure Resident #7's breathing treatment masks storage bag was changed every 7 days on 07/27/26. The facility failed to ensure Resident #1's CPAP storage bag was changed every 7 days on 07/27/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by recognizing the resident's individuality for one of nine residents (Residents #2) reviewed for residents' rights and dignity. The facility failed to ensure that Resident #2's Foley bag was in a privacy bag while in his wheelchair on 07/27/26. This failure could place the residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary care team to reflect a residents changed in condition following a fall for one of nine residents (Resident #9) reviewed for care plan implementation. The facility failed to ensure Resident #9's comprehensive care plan was updated following a fall resulting in a left ankle fracture on 07/02/26. These failures could place the residents at risk of not having their needs meet and receiving the necessary care and services.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure parental fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive care plan and the resident's goals and preferences for 1 of 9 residents (Resident #4) reviewed for PICC lines (Peripherally Inserted Central Catheter). The facility failed to change the PICC line (an intravenous catheter that is suitable for long term infusion therapy) dressing on Resident #4 for more than 7 days on 07/27/26. These failures placed the residents at risk of infection or dislodgement.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure prescribed medications were stored in a locked compartment for 1 of 9 residents (Resident #6) reviewed for medication storage. The facility failed to ensure Resident #1's prescribed medications were not left on top of the resident's bed side table by MA D on 07/27/26 These failures could place residents at risk of wrong medication administration, not getting the getting the full benefit of the medication, accidental overdose, misuse of medications, diversion and possible adverse reactions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of ten residents (Resident #1 and Resident #14) reviewed for respiratory care. 1. The facility failed to ensure Resident #4's oxygen nasal canula and Nebulizer mask were properly stored when not in use on 07/11/26. 2. The facility failed to ensure Resident #1's nebulizer mask was properly stored when not in use on 07/11/26. 3. The facility failed to ensure Resident #3's nebulizer mask was properly stored when not in use on 07/11/26. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met. Findings Include 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for one of seven residents (Resident #2) reviewed for quality of care. The facility failed to ensure that Resident #2's wound dressing on pressure ulcer on left plantar foot (bottom sole of left foot) was dated and signed on 07/11/26 The failure could place residents at risk for worsening pressure injuries and could result in a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to make prompt efforts to resolve grievances of resident rights and failed to follow their grievance policy for one of seven residents (Resident #1) reviewed for grievances, in that, The facility failed to document, resolve and follow-up with grievances on 06/09/26 and 06/12/26 for Resident #1 brought up by Resident #1's guardian concerns about Resident #1's dietary tray and milk being left longer than 1.5 hours. This failure could affect residents by placing residents at risk of a decline in quality of life and a delay in resolving grievances.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must provide foot care and treatment, in accordance with professional standards of practice for two resident of six residents (Resident #23, and Resident #35) reviewed for quality of care.1. The facility failed to ensure Resident #23's feet did not have dry, flaky skin.2. The facility failed to ensure Resident #35 had his toenails trimmed. This failure could place residents at risk of decline in quality of care, increased skin irritation and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring and administering of all medications to meet the needs of each resident for three of six residents (Resident #9, Resident #96, and Resident #69) reviewed for pharmacy services. 1. The facility failed to ensure LVN E followed the manufacturer's instructions to prime the Novolin R Insulin (hormone) Pen for prior to dialing in the required amount of insulin to administered to Resident #9. 2. The facility failed to ensure LVN E followed the manufacturer's instructions to prime theHumalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of insulin to be administered to Resident #96. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's 1 of 1 kitchen.: The dietary staff failed to ensure temperatures were taken of all cooked and cold food before serving them to residents during lunch meal service on 3/17/26. The dietary staff failed to properly sanitize the thermometer while taking the temperature of each food. The dietary staff failed to use proper hand hygiene during lunch service on 3/17/26. These failures could place residents at risk for food-borne illness if consumed and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six of eight (Resident #96, Resident #9, Resident # 69, Resident # 70, Resident #46 and Resident #8) observed for infection control. 1. The facility failed to ensure LVN E sanitized the glucometer with a recommended germicidal wipe between resident use when she obtained a fingerstick blood sugar on Resident #9 and then proceeded to obtain a fingerstick blood sugar on Resident #96 with the contaminated glucometer and then placed the un-sanitized glucometer back into the medication cart on 03/17/26. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and in compliance with the state laws, which included the appropriate accessory and cautionary instructions and the expiration date when applicable for the facility's one of two (ADON C's office refrigerator) refrigerators reviewed for medication storage. The facility failed to ensure a vial of Tuberculin Purified protein derivative that was opened and used, was dated in ADON C's refrigerator used for medication storage. This failure could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and handle food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure all hot and cold held food temperatures were taken and record on the Supper (dinner) temperature log for dates 12/29/2025, 01/02/2026, 01/05/2025, 01/07/2026, and 01/08/2026.2. The facility failed to ensure staff followed food safety and sanitation protocols to prevent cross contamination of raw chicken and ready to eat sliced cheese. 3. The facility failed to ensure the milk temperature was held at least 41 F or less. These failures could place residents at risk for foodborne illness and foodborne intoxication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality for 1 (Resident #19) of 10 resident reviewed for food and nutrition services. The facility failed to follow physician-ordered diet changes to ensure Resident #19's dessert was mechanical soft, and included crushed pineapple, as the meal ticket stated, and not wafer cookies. This failure could place residents at risk of becoming malnourished and choking.

Inspectors wroteObservation on 10/07/25 at 10:08 AM revealed ice accumulation on left side doorway of 1 to 3 inches width for about 2 feet length, 1-3 inches covering the top of the doorway, and about 1-2 inches on inner part of the freezer door covering the bottom and top of the door. Walk-in freezer door was unable to latch open about 1/4 inch with ice accumulation seen on bottom and right side of doorway. Interview on 10/07/25 at 10:11 AM with Dietary [NAME] A revealed the facility had been having issues for about 2 months with the walk-in freezer having excess ice accumulation and not latching. She stated it had gotten worse the last month. Interview on 10/07/25 at 10:13 AM with Dietary Aide B revealed the last month the walk-in freezer had a lot of ice accumulation daily. She stated they try to scrap off the ice in the walk-in freezer daily. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 (Resident #1) residents reviewed for infection control. The facility failed to ensure the treatment nurse changed gloves and washed her hands while providing wound care for Resident #1 on 10/07/2025. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to a dignified existence and self-determination facility for 1 of 9 (Resident #1) residents reviewed for resident rights. The facility failed to ensure Resident #1 was treated with respect and dignity when she refused a shower on 05/21/25 around 9:30 PM and was showered despite her refusals by CNA A. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. The noncompliance was identified as Immediate Jeopardy Past Noncompliance (PNC). The Immediate Jeopardy began on 05/21/25 at 9:30 PM and ended on 05/28/25. The facility had taken actions noted in the findings that corrected the noncompliance before the incident investigation began on 06/17/25.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free from abuse for two (Resident #1 and Resident # 2) of 9 residents reviewed for abuse. The facility failed to protect Resident #1, who was on mental health services, from mental anguish on 05/21/25 at 9:30 PM when, when despite her refusals, she was physically lifted, under her armpits, by CNA A from her bed to the shower chair was given a shower by despite her refusals. As a result, Resident #1 experienced mental anguish and anger. Resident #2 who was on mental health services experienced mental anguish/being upset after hearing her roommate being forced to shower by facility aides. This failure could place residents at risk for not having measures in place to protect them from serious harm, mental anguish, abuse, or neglect. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Residents #1, #2, #3, and #9) of 9 residents reviewed for comprehensive care plans. 1. The facility failed to create a care plan that reflected Resident #1's preference for bed baths and shower refusals. 2. The facility failed to create a care plan that reflected Resident #2's shower refusals. 3. The facility failed to create a care plan that reflected Resident #3's shower refusals. 4. The facility failed to create a care plan that reflected Resident #9's vision needs. This failure puts residents at risk of not being provided personalized care and negatively impact their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an effective pest control program was implemented so the facility is free of pests and rodents for 1 of 9 residents (Resident #7), 1 out of 5 halls (hall A) and 1 out of 5 exterior perimeters of resident halls (hall A) reviewed for pest control. 1. The facility failed to effectively treat Resident #7's room for ants. 2. The facility failed to keep an effective pest control program, so the facility was free of ants on the exterior perimeter of resident hall A. 3. The facility failed to keep an effective pest control program, so the facility was free of ants in 2 rooms in the A hall. These failures placed residents at risk for the spread of infection and disease, and a reduced quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident who experiences a significant change in status is comprehensively assessed within 14 days for 1 of 9 residents (Residents #4) reviewed for significant change. The facility failed to ensure Resident # 4 had a Significant Change Assessment completed after she had a change in vision needs. This failure could place residents at risk of not having assessments completed when there has been a significant change in their condition and could lead to failure to not provide necessary care.

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (D hall Nurses Cart) of 2 medication nurses carts reviewed for pharmacy services in that: The facility failed to ensure RN U responsible for the D hall Nurses Cart removed medications in unsecure containers from the Nurses Cart. This failure could place residents at risk of not having the medication available due to possible drug diversion.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure the dining room's ice machine's drip tray was cleaned and sanitized, and free from build-up of slime, mold, and an old, used and soaked paper napkin. This failure placed residents at risk of food contamination and foodborne illness.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for nine of nine confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 9 confidential residents. These failures placed residents at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings Include: During a confidential group interview on 11/19/24 at 10:02 a.m., with 9 residents, all residents stated that there are no weekend activities. They stated that they can attend church on Sundays, but no other activities are provided. They stated that they would love to have weekend activities, as it gets boring. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for three of five residents (Resident #82, Resident # 85, and Resident #21) reviewed for quality of care. The facility failed to ensure LVN H provided Resident #82, Resident #85 and Resident #21 their physician ordered wound care on 11/16/24 and 11/17/24. This failure could place residents at risk of developing infections or worsening of their wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that accommodates resident preferences for 2 of 32 residents (Resident #76 and Resident # 31) reviewed for resident food and drink preferences. The facility failed to follow the breakfast menu and obtain resident input on changes made to the menu. This failure could affect residents by contributing to dissatisfaction, poor intake, and weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure food items in the facility walk-in refrigerator were covered, labeled, and dated. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one of eight residents (Resident #82) reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths for Resident #82. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #75) of 2 residents reviewed for enteral nutrition. The facility failed to ensure Resident #75's water flush administered via tube feeding pump was not being administered as ordered by the physician. This deficient practice could affect residents who receive tube feedings by not receiving the appropriate nutrition/ hydration.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of seven residents (Resident #15 and Resident #97) reviewed for pharmacy services. 1. LVN J failed to follow the manufacturer's instructions to prime the Lantus Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #15. 2. LVN J failed to follow the Physician orders and facility procedures for administering one medication at a time with water flush between each medication when she crushed Resident #97's Sertraline (antidepressant) 25 mg 1 tablet and Levothyroxine (hormone) 50 mcg 1 tab and combined them in one medication cup for administration on 11/18/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative, consistent with his or her authority, when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #1) of 3 residents reviewed for notification of changes in condition. The facility failed to ensure Resident #1's resident representative was immediately notified when the resident had a change in condition that required Resident #1 to be transported via ambulance to the hospital due to him being unresponsive. This failure could result in resident representatives not being able to make important medical decisions regarding their family member.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for two of seven residents (Residents #2 and Resident #3) reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths for Resident #2 and Resident #3. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of three (Resident #1) residents reviewed for pharmacy services. The Facility failed to ensure Facility staff ordered medications in a timely manner for Resident #1 upon his admission on [DATE] which resulted in missed doses of Anastrozole 1 mg, Liothyronine Sodium 5 mg, Bupriopion HCL ER 150 mg, Cefadroxil 500 mg and Propranolol HCL 20 mg on 07/24/24. This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for two (Charge Nurse and Med Tech A ) of two staff observed for confidentiality of records. The facility failed to ensure the Charge Nurse and Med Tech A locked and closed the laptop during the medication pass exposing all resident on the hall's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for one of three (Resident #1) residents whose MDS records were reviewed for accuracy in that: Resident #1's care plan did not reflect that the resident had pneumonia. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of two medication carts (Med cart #1 and Med cart #2 ) reviewed for storage, in that: The facility failed to ensure Med cart #1 and Med cart#2 was locked when left unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerator and freezer items were dated, labeled, and sealed. 2. The facility failed to ensure Dietary Cooks H and I performed hand hygiene during lunch meal preparation on 10/11/23. 3. The facility failed to ensure Dietary [NAME] I sanitized food thermometer when checking food temperatures on 10/11/23. at lunch. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review. the facility failed to provide a safe, functional, sanitary, and comfortable environment for dining room and three of five resident halls (B hall, C hall and D hall) reviewed for physical environment. 1. The facility failed to ensure D hall hallway area was maintained with floorboards in place and intact walls to preclude the entry of insects or rodents. 2. The facility failed to ensure resident rooms on B hall, C and D hall had door protection coverings that were secure to the room entry door and not impeding resident entry and egress. 3. The facility failed to ensure a resident room on C Hall RM [ROOM NUMBER], had a shower in working order. These failures could place residents at risk for an unsanitary and unsafe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity, for 1 (Resident#85) of 24 residents reviewed for dignity issues. The facility failed to ensure Resident #85 was treated with dignity. This failure could place residents at risk of feeling uncomfortable, disrespected and decline in self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible for one (Resident#7) of three residents reviewed for indwelling catheter care. The facility failed to ensure Resident #7's indwelling catheter bag was maintained off the floor. This failure could place residents at risk of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #52) of four residents reviewed for respiratory care. The facility failed to replace/change the humidifer weekly or when the humidifer was empty. These failures could place residents at risk for hyperoxygenation, skin issues, and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration dates for 1 (Medical Specialty medication room) of 2 medication rooms reviewed for medication storage. The facility failed to ensure one medication room on Medical Specialty Unit was free of expired medications. This failure could place residents at risk for increased or decreased potency of vaccination.