Gracewood Health & Rehab
6201 East 36th Street, Tulsa, OK 74135 · Tulsa County · (918) 622-3430
121 certified beds, about 70 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2003
CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
3 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 375438 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on April 6, 2026, inspectors cited 5 health deficiencies (the Oklahoma average is 6.4, the national average 9.2).
Of 24 health citations since September 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.92 hours per resident per day, against 3.79 across Oklahoma and 3.86 nationally. Registered nurses accounted for 0.36 of those hours.
76.2% of nursing staff left within the year CMS measured (Oklahoma average 55.5%).
CMS links it to Bradford Montgomery, an affiliated group of 11 nursing homes.
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.
109/23
111/23
110/24
1401/25
704/26
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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
13D
8E
2F
Potential for minimal harm
0A
0B
0C
April 6, 2026Standard inspection, Complaint inspection · 7 citations
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was not physically abused by another resident for 1 (#79) of 4 sampled residents reviewed for abuse. The administrator identified 69 residents resided in the facility. A Resident to Resident Incidents policy, dated 01/2024, read in part, Upon admission to the facility, each person will be assessed through the MDS process to determine if they are at risk for abusing others. Care plans will address interventions designed to prevent occurrences. An Oklahoma State Department of Health final report, dated 05/11/25, showed a staff member witnessed Resident #79 pour water on Resident #61. Resident #61 then pushed Resident #79 causing them to fall. Resident #79 was sent to the hospital. An undated nurse note showed that around 5:30 p.m., Resident #79 was found yelling and was on the ground in the smoking area. [...]
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. food items were properly sealed, dated, and labeled; b. bulging containers were removed from circulation in the dry storage; c. ensure food preparation utensils were stored in a clean environment; and d. ensure areas near food preparation were clean and free from pests, including a microwave for resident use. The administrator identified 69 residents ate meals from the kitchen.
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview the facility failed to:a. ensure a safe and sanitary kitchen floor, b. residents were not served meals on paper products, andc. ensure hot water was available in their restroom for 1 (#21) of 17 sampled residents reviewed for access to hot water in their restroom. The administrator identified 69 residents ate from the kitchen.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to provide a SNF ABN to 2 (#10 and #37) of 3 sampled residents reviewed for beneficiary notices. The administrator identified four residents discharged from the facility with Medicare benefit days remaining.
- 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 record review and interview, the facility failed to ensure behaviors were addressed in the care plan for 1 (#61) of 17 sampled residents reviewed for care plans. The administrator identified 69 residents resided in the facility. An Oklahoma State Department of Health final report, dated 05/11/25, showed a staff member witnessed Resident #79 pour water on Resident #61. Resident #61 then pushed Resident #79 causing them to fall. An annual assessment, dated 02/23/26, showed Resident #61 had diagnoses which included bipolar, PTSD, depression, and anxiety. The assessment showed Resident #61 had a BIMS score of 12 which indicated moderate cognitive impairment. A nurse's note, dated 03/06/26, showed Resident #61 became upset when they were unable to go smoke during a tornado warning. Resident #61 threw water in the hall and onto another resident. [...]
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate supervision to prevent an elopement for 1 (#20) of 2 sampled residents reviewed for elopement. The administrator identified 21 residents resided in the memory care unit.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for 1 (#11) of 1 sampled resident with a PEG tube observed during medication administration. The DON identified two residents had PEG tubes.
January 14, 2025Standard inspection, Complaint inspection · 14 citations
- E Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were provided with privacy curtains. The administrator identified 78 residents resided at the facility.
- E Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities were provided for four (#18, 22, 26, and #42) of four sampled residents who were reviewed for activities. The administrator identified 78 residents who resided at 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 pharmacist medication regimen reviews were conducted monthly for five (#24, 57, 62, 22, and #59) of five sampled residents who were reviewed for unnecessary medications. The DON identified 78 residents who received medications in the facility.
- 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, record review, and interview, the facility failed to: a. ensure medications were secured for one (300 hall treatment cart) of six medication carts observed; b. ensure medications were dated when opened and/or insulin was discarded after 28 days for two (200 hall treatment cart and 300 hall treatment cart) of three medication carts observed; and c. ensure expired medications were not in use for one (100 hall medication cart) of three medication carts observed. LPN #2 identified six medication carts in the facility.
- E Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure resident records were complete and accessible for four (#57, 24, 22, and #59) of 18 sampled residents whose records were reviewed. The DON identified 78 residents who resided in the facility.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for one (#279) of one sampled resident with a peg tube observed during medication administration. The nurse manager identified two residents who had peg tubes.
- 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 call lights were operational and available for residents. The administrator identified 78 residents who resided at 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 ensure nail care was provided for one (#57) of one sampled resident who was reviewed for ADL care. The nurse manager identified 56 residents who were dependent on staff for nail care.
- 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 monitor and evaluate a resident's response to an intervention for one (#26) of one sampled resident who was reviewed for quality of care. The administrator identified 78 residents who resided at the facility.
- D Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were assessed for the use of bed rails for one (#57) of one sampled resident who was reviewed for bed rails. The DON identified one resident who had bed rails.
- D Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nurse staffing was posted for public view. The administrator identified 78 residents resided at the facility.
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive unnecessary medications for one (#22) of five sampled residents who were reviewed for psychotropic medications. The nurse manager identified 78 residents who received medications.
- D Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for two (#24 and #62) of five sampled residents whose labs were reviewed. The DON identified 78 residents who had orders for labs.
- D Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident beds were regularly inspected for safety for one (#57) of one sampled resident who was reviewed for bed rails. The DON identified one resident who had bed rails.
October 3, 2024Complaint inspection · 1 citation
- F Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff was licensed in accordance with applicable State laws. The DON identified 78 residents who resided in the facility.
November 13, 2023Complaint inspection · 1 citation
- 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 assistance with showers was provided for one (#1) of three reviewed for bathing. The DON identified 52 residents who required assistance with bathing.
September 28, 2023Standard inspection · 1 citation
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to implement interventions to prevent future falls and failed to update the resident's care plan for one (#21) of one resident reviewed for falls.
Fire safety inspections
9 fire safety citations on file: 2 on April 6, 2026, 4 on January 14, 2025, 3 on September 28, 2023.
Every fire safety citation9 citations
- F Inspect, test, and maintain automatic sprinkler systems.
- E Provide properly protected cooking facilities.
- F Inspect, test, and maintain automatic sprinkler systems.
- E Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E Provide properly protected cooking facilities.
- E Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oklahoma | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.92 | 3.79 | 3.86 |
| Registered nurses | 0.36 | 0.34 | 0.69 |
| All nursing staff on weekends | 3.73 | 3.44 | 3.42 |
| Nurse aides | 2.89 | ||
| Licensed practical nurses | 0.68 | ||
| Nursing staff turnover (share who left in a year) | 76.2% | 55.5% | 45.8% |
| Registered nurse turnover | 80.0% | 53.6% | 42.9% |
| Administrators who left | 2 |
CMS expects 2.92 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.00 on weekdays and 3.73 on weekends, 7% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.66 in April to June 2025 to 3.92 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.92 | 0.36 | 4.00 | 3.73 | 0.0% | 0 of 90 | 70 |
| Oct to Dec 2025 | 3.75 | 0.36 | 3.76 | 3.72 | 0.0% | 0 of 92 | 71 |
| Jul to Sep 2025 | 3.75 | 0.37 | 3.78 | 3.67 | 0.0% | 0 of 92 | 73 |
| Apr to Jun 2025 | 3.66 | 0.36 | 3.76 | 3.41 | 0.0% | 0 of 91 | 76 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oklahoma, Jan to Mar 2026 | 3.79 | 0.32 | 3.94 | 3.42 | 2.2% | 1.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oklahoma | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.9 | 13.6 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 2.0 | 1.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.1 | 2.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 6.0 | 4.7 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 8.1 | 13.7 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.7 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 33.9 | 17.5 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.5 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.7 | 3.0 | 1.8 |
Owners and operators
Legal business name: GRACEWOOD HEALTH & REHAB LLC. CMS links this home to Bradford Montgomery, a group of 11 nursing homes averaging 2.3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Montgomery, Bradford | 5% or greater direct ownership interest | Individual | 100% | 10/31/2015 |
| Poppell, Connie | W-2 managing employee | Individual | 10/31/2015 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 7 problems in this area, most recently on April 6, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 3 problems in this area, most recently on April 6, 2026: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on January 14, 2025: "Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures."
- When is the care plan meeting, and can family attend it?Inspectors cited 2 problems in this area, most recently on April 6, 2026: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.
Other nursing homes nearby
- Trinity Woods, Inc. Tulsa, 1.3 mi · 5 of 5 stars · 4 citations
- Emerald Care Center Tulsa Tulsa, 1.6 mi · 1 of 5 stars · 67 citations
- Southern Hills Rehabilitation Center Tulsa, 1.9 mi · 3 of 5 stars · 22 citations
- Oklahoma Memory Care Institute Tulsa, 1.9 mi · 2 of 5 stars · 31 citations
- Tulsa Center for Rehabilitation and Healthcare Tulsa, 2.5 mi · 2 of 5 stars · 18 citations
- Leisure Village Health Care Center Tulsa, 2.8 mi · 1 of 5 stars · 41 citations
- Montereau, Inc. Tulsa, 3.2 mi · 3 of 5 stars · 20 citations
- Colonial Manor Nursing Home Tulsa, 3.6 mi · 4 of 5 stars · 18 citations
Oklahoma contacts for a concern about a nursing home
These are the official offices in Oklahoma. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oklahoma State Department of Health, Long Term Care Service, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oklahoma Long-Term Care Ombudsman, Office of the Attorney General, 1-800-211-2116. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: OSDH Long Term Care Surveys search, where Oklahoma publishes its own records on licensed homes.
Common questions
- What is Gracewood Health & Rehab's Medicare star rating?
- CMS rates Gracewood Health & Rehab 2 out of 5 stars overall, with 2 for health inspections, 3 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Gracewood Health & Rehab get at its last inspection?
- 5 health deficiencies at the standard inspection on April 6, 2026. The Oklahoma average is 6.4.
- Has Gracewood Health & Rehab been fined?
- CMS lists no fines in the last three years.
- Does Gracewood Health & Rehab accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Gracewood Health & Rehab?
- CMS lists 2 owners and managers, and links the home to Bradford Montgomery. Legal business name: GRACEWOOD HEALTH & REHAB LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.