Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
4E
0F
Potential for minimal harm
0A
0B
0C
March 5, 2026Complaint inspection · 2 citations
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview, the facility failed to complete a quarterly assessment for 1 (#2) of 3 sampled residents reviewed for quarterly assessments. The administrator identified 52 residents resided in the facility.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a person-centered care plan for a contracture was developed for 1 (#1) of 3 sampled residents reviewed for care plans. The DON identified two residents with contractures resided in the facility.
July 21, 2025Complaint inspection · 5 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteOn [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a change in condition for:1. Resident #8 who reported chest pain on [DATE] at 7:46 a.m. A progress note showed vital signs were taken, but no other action was documented, and2. Resident #7 who was reported by RN #1 to be slumped over the table in the dining room on [DATE] during the noon meal. The note showed Resident #7 was removed from the dining room and taken to their room. No other actions were documented. On [DATE] at 12:06 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 12:45 p.m., the DON and administrator were notified of the IJ situation and provided the IJ template. [...]
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on record review and interview, the facility failed to ensure individual financial records were available through quarterly statements and upon request for 3 (#2, 4, and #6) of 3 sampled residents reviewed for personal funds. The administrator identified 27 residents with trust fund accounts.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to revise a care plan for 2 (#7 and #8) of 8 residents sampled who were reviewed for care plans. The administrator identified 55 residents resided at the facility.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation and interview, the facility failed to ensure medications were administered by the person preparing the medication for 1 of 1 observation. The administrator identified 55 residents received medications.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (#8) of 1 sampled resident reviewed for medication administration. The administrator identified 55 residents received medications at the facility.
February 6, 2025Standard inspection · 1 citation
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to maintain a clean ice machine. The roster matrix documented 53 residents who utilize ice from the ice machine.
October 25, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review, and interview, the facility failed to protect a resident from abuse for one (#1) of six sampled residents whose clinical records were reviewed for abuse. The Resident Listing Report, dated 10/24/24, documented 54 residents.
February 8, 2024Complaint inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff followed the infection control guidelines to prevent the potential spread of communicable disease. The DON identified 40 residents resided in the facility.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents' call lights were in reach for four (#3, 5, 6, and #7) of four sampled residents who were reviewed for call light placement. The DON identified 40 residents who resided in the facility.
December 1, 2023Standard inspection, Complaint inspection · 4 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to follow infection prevention and control procedures during an outbreak of COVID-19. The administrator identified 39 residents resided at the facility and five were positive for COVID-19.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, the facility failed to ensure the state was notified of a new serious mental illness diagnosis for #9 and failed to ensure a PASARR II evaluation was available for implementation of recommendations one (#7) of two residents reviewed for PASARR. The administrator identified 12 residents with a level II PASARR who resided in the facility.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was updated/revised for one (#9) of 15 residents reviewed for care plans. The administrator identified 39 residents resided at the facility.
- D
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Inspectors wroteBased on record review and interview, the facility failed to ensure binding arbitration agreements provided the selection of a neutral arbitrator agreed upon by both parties and provided a selection of a venue that was convenient to both parties. The administrator identified two residents who had signed binding arbitration agreements who resided in the facility.
February 8, 2023Standard inspection · 3 citations
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure a pharmacy recommendations had a documented clinical rationale for continuing psychotropic medications for one (#22) of five residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents form identified 31 residents received psychoactive medication.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure enteral feeding tubes were secured to prevent displacement for one (#14) of three sampled residents who were reviewed for enteral feeding tubes and failed to ensure enteral nutrition was held during incontinent care for one (#21) of three sampled residents who were reviewed for enteral feeding tubes. The Resident Census and Conditions of Residents form identified five residents who received enteral tube feedings.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary environment with the ceiling return air vents for two (#17 and #196) of three resident rooms reviewed for the environment. The DON identified 39 rooms were occupied by residents.
Fire safety inspections
11 fire safety citations on file: 2 on February 6, 2025, 2 on December 1, 2023, 7 on February 8, 2023.
Every fire safety citation11 citations
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 6, 2025 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 6, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 1, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 1, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 8, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 8, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 8, 2023 · deficient, provider has
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · February 8, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 8, 2023 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · February 8, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 8, 2023 · Corrected (the home has a date of correction)