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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
14E
0F
Potential for minimal harm
0A
0B
0C
May 7, 2025Standard inspection, Complaint inspection · 9 citations
- E
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 comprehensive care plans were developed for 2 (#80 and #108) of 20 sampled residents whose care plans were reviewed. The DON reported 140 residents resided in the facility.
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. range of motion services were provided for 2 (#97 and #75); and b. provide contracture interventions for 1 (#80) of 3 sampled residents who were reviewed for range of motion. The DON identified 12 residents with contractures and 43 residents with limited range of motion.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to: a. follow EBP during the provision of care for 1 (#108) of 2 sampled residents reviewed for catheter care; and b. ensure clean laundry was transported appropriately. The DON reported 11 residents had urinary catheters and 110 residents' laundry was cleaned by the facility.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered the pneumococcal immunization for 3 (#28, 83, and #330) of 5 sampled residents reviewed for immunizations. The DON identified 140 residents resided in the facility.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to ensure injuries of unknown origin were reported to the Oklahoma State Department of Health as required for 1 (#80) of 3 sampled residents reviewed for abuse. The DON reported 140 residents resided in the facility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to ensure injuries of unknown origin were thoroughly investigated for 1 (#80) of 3 sampled residents reviewed for abuse. The DON reported 140 residents resided in the facility.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide ADL care for 1 (#3) of 3 sampled residents reviewed for ADL care. The DON identified 27 residents were dependent of staff for nail care.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were secure for 1 (500 hall medication/treatment cart) of 2 medication/treatment carts observed on the 500 hall. The DON identified 15 medication/treatment carts in the facility.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was offered the COVID-19 vaccination for 1 (#83) of 5 sampled residents reviewed for the COVID-19 vaccination. The DON identified 140 residents resided in the facility.
February 9, 2024Standard inspection, Complaint inspection · 11 citations
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview, the facility failed to ensure medications were labeled and not expired for three (200 hall treatment cart, 600 hall treatment cart, and 500 hall medication cart) of seven medication/treatment carts observed. The DON identified 13 medication/treatment carts in the facility.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was provided to residents in a manner required for their needs to prevent choking. Cook #1 stated five residents received pureed diets from the kitchen.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to ensure accurate code status for one (#55) of four sampled residents who were reviewed for advance directives. The administrator identified 127 residents who resided in the facility.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure resident representatives were notified of changes in condition for one (#89) of one sampled resident who was reviewed for notification of change. The administrator identified 127 residents who resided in the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications and weights documented in the MDS were accurate for one (#68) of 25 sampled residents who were reviewed for MDS accuracy. The administrator identified 127 residents resided in the facility.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was completed within 48 hours for one (#120) of one sampled resident reviewed for baseline care plan. The administrator identified 127 residents resided in the facility.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure showers were provided for one (#172) of seven sampled residents reviewed for bathing. The administrator reported 127 residents resided in the facility.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to ensure chemicals were secured for one (300 hall) of five halls observed for storage of chemicals. The Resident Listing Report, dated 02/05/24, documented 14 residents resided on the 300 hall.
- 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, record review, and interview, the facility failed to ensure controlled medications were reconciled for one (500 hall) medication cart of seven medication/treatment carts observed. The administrator identified 127 residents who resided in the facility.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food contained nutritive value, was palatable, and served at preferred temperatures. The Resident Matrix provided by the facility on 02/05/24, documented 125 residents received food from the kitchen.
- 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 ensure a sanitary environment, provide food and drink at safe temperatures The Resident Matrix provided by the facility on 02/05/24, documented 125 residents received food from the kitchen.
October 13, 2023Complaint inspection · 1 citation
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure as needed narcotic pain medication was available for two (#4 and #6) of four sampled residents were reviewed for access to pain medication. The DON identified 83 residents with orders for narcotic pain medication.
April 25, 2023Standard inspection · 14 citations
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to ensure: a. residents were offered the choice to formulate advance directives for six (#4, 5, 15, 22, 61, and #85), and b. a code status form was valid for one (#87) of seven sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 04/24/23, documented 108 residents resided in the facility. It documented 42 residents who had advance directives.
- E
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 develop and implement care plans related to the residents' pain for two (#31 and #33) of 27 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents resided in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received showers for three (#62, 108, and #111) of four sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents required assistance with bathing.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to ensure: a. weights were obtained as ordered, b. the physician was notified of a significant weight loss, and c. food intake was monitored and recorded for one (#61) of one sampled resident reviewed for nutrition. The Resident Census and Condition of Residents report, dated 04/24/23, documented 108 resided in the facility.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for two (#22, 24 and #109) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 04/24/23, documented 108 residents resided in the facility.
- 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 residents' physician addressed irregularities documented on the MRR per facility policy for four (#5, 10, 22 and #24) of five residents reviewed for unnecessary medications. A facility drug regimen review policy documented the physician was to provide a written response to the report within one month after the report was sent, and the facility must maintain copies of the reports for one year. 1. Res #22 had diagnoses which included recurrent depressive disorders, schizoaffective disorder bipolar type, hypertension, and hypothyroidism. A physician order, dated 06/04/21, documented to administer cetirizine 10 mg at bedtime for seasonal allergies. A physician order, dated 09/22/21, documented to administer chlorpromazine 300 mg at bedtime for schizoaffective disorder bipolar type. [...]
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to: a. offer the influenza vaccination to each resident annually for three (#3, 10, and #77) and b. offer the pneumococcal immunization for four (#3, 5, 62 and #77) of five sampled residents reviewed for influenza and pneumococcal immunizations. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents resided in the facility.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to notify the resident's legal representative of a significant weight loss for one (#61) of one sampled resident reviewed for change in condition. The Resident Census and Conditions of Residents report, dated 04/24/23, documented 108 residents resided in the facility.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure MDS assessments were coded accurately for two (#107 and #5) of 32 sampled residents whose medical records were reviewed. The Resident Census and Conditions of Residents report, dated 04/18/23, documented 108 residents resided in the facility.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to complete a significant change MDS for a resident started on hospice for one (#77) of two sampled residents reviewed for hospitalization. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents resided in the facility.
- 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 incorporate the from the PASARR level II determination and the PASARR evaluation report into a resident's care plan for one (#77) of three sampled residents reviewed for PASARR's. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 24 residents required behavioral health services.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interview, the facility failed to accurately complete a preadmission screening for individuals with a mental disorder for one (#101) of three sampled residents reviewed for PASARR's. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 24 residents required behavioral health services.
- 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 review and revise a care plan after significant change for one (#33) of 27 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents resided in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a 2 liter fluid restriction per day had been conducted for one (#73) of one sampled resident whose medical record was reviewed. The Resident Census and Conditions of Residents report, dated 04/18/23, documented 108 residents resided in the facility.
Fire safety inspections
4 fire safety citations on file: 1 on May 7, 2025, 3 on April 25, 2023.
Every fire safety citation4 citations
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 7, 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 · April 25, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 25, 2023 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 25, 2023 · Corrected (the home has a date of correction)