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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
16E
1F
Potential for minimal harm
0A
0B
0C
July 9, 2026Complaint inspection · 2 citations
- E
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Inspectors wroteBased on record review and interview, the facility failed to ensure a volunteer with adverse actions was not allowed to volunteer at the facility for 1 (Volunteer #1) of 1 sampled volunteer reviewed for adverse actions. The ADON identified seven volunteers performed services 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 record review and interview, the facility failed to provide supervision to prevent elopement for 1 (#3) of 3 sampled residents reviewed for elopement. The ADON identified 11 residents at risk for elopement.
September 18, 2025Standard inspection, Complaint inspection · 3 citations
- J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteOn [DATE], an IJ was determined to exist related to the facility's failure to ensure a resident who had chosen to have a full code status was provided CPR after a life threating medical emergency was discovered. On [DATE] CNA #1 found Res #3 in their room and unresponsive. CNA #1 reported the situation to LPN #1 who checked the blood pressure of the resident then told CNA #1 the resident was dead and to clean them up. CNA #1 stated no code had been called for Res #3 and no CPR had been attempted. On [DATE] at 12:02 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 12:20 p.m., the DON was notified of the IJ situation and provided the IJ template. On [DATE] at 4:09 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. [...]
- 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 equipment in the kitchen was sanitized. The ADON reported 70 residents received meals from the kitchen.
- 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 that oxygen cylinders were stored securely. The ADON reported 19 residents utilized supplementary oxygen.
May 2, 2024Standard inspection, Complaint inspection · 13 citations
- E
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 include a focus of wandering in a comprehensive care plan for one (#4) of two residents reviewed for wandering. The ADON identified two residents in the facility that wandered.
- E
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 serve foods at a palatable temperature from one of two kitchen service areas. The DON identified 40 residents who ate meals served from the satellite kitchen.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on record review and interview, the facility failed to ensure three substantive meals were served daily. The ADON reported 73 residents received meals from the kitchen.
- E
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 the physical environment of the main kitchen and failed to serve cold foods in the satellite dining room in a sanitary manner. The DON identified 79 residents who ate meals prepared in the main kitchen.
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on record review and interview, the facility failed to provide residents binding arbitration agreements that: a. informed the resident or their representative of their right not to sign the agreement as a condition of admission or continued care; and b. does contains an explicit acknowledged by the resident or their representative that they understood the provisions of the agreement; and c. does not include the name of a second nursing facility, in which the resident does not reside or is aware of, in the agreement for two (#50 and #63) of two sampled resident reviewed for arbitration agreements. The facility SSD stated 60 residents that resided in the facility had signed binding arbitration agreement.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview, the facility failed to assist a resident with their meal in a dignified manner for one (#10) of eight residents observed for dining. The DON identified three residents who required total assistance with meals.
- 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 provide education about advance directives and provide an opportunity for a resident to have or decline an advance directive for one (#63) of 24 sampled residents reviewed for advance directives. A facility daily census report, dated 04/29/24, documented 73 residents resided at the facility.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview, the facility failed to provide privacy for one (#44) of one resident observed to have a facility camera in their room. The DON identified there were two residents for which the facility had placed a camera in the residents' rooms.
- 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 the accuracy of a baseline care plan for one (#219) of two residents sampled for baseline care plan. The administrator reported the census was 73.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interview, the facility failed to ensure the consulting pharmacist documented the correct dosage of a psychotropic medication on a request for dosage reduction for one (#11) of five residents whose clinical records were reviewed for unnecessary medications. The ADON identified 16 residents who received psychotropic medications.
- 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 notify the physician of a wound for one (# 219) of one resident sampled for wounds. The ADON identified seven residents in the facility with wounds.
- 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 and interview, the facility failed to prevent a medication room door from being propped open by a chair and the medication room being open and unattended by appropriate staff. A facility daily census report, dated 04/29/24, documented 73 residents resided at the facility.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure the lint screens were cleared as recommended for three of three dryers observed in the laundry room. The administrator reported the facility census was 73.
December 5, 2023Complaint inspection · 1 citation
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on record review and interview, the facility failed to prevent a nurse aide whose CPR certification did not include hands-on training and an in person skilled assessment, from providing chest compressions to a resident who was deemed by staff to require cardiopulmonary resuscitation for one (#1) of one sampled resident reviewed for quality of care. A midnight census report, dated [DATE], documented 72 residents resided in the facility.
March 30, 2023Standard inspection · 17 citations
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents were free from physical restraints for one (#7) of three residents reviewed for physical restraints. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
- E
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, observation, and interview, the facility failed to review and revise a care plan for two (#45 and #56) of 24 sampled residents whose care plans were reviewed. The Residents Census and Conditions of Residents report documented 78 residents resided in the facility.
- E
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 record review, observation, and interview, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and obtain informed consent prior to installation of bedrails for three (#7, 35, #55) of three residents reviewed for bed rails. The Resident Census and Conditions of Residents form documented 78 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: a. GDR declinations from the physician included a rationale for one (#6) of five residents reviewed for unnecessary medications and b. GDR requests were reviewed by the physician for one (#21) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure medication error rate was less than 5% for two (#50, #56) of five residents observed during medication pass. A total of 26 opportunities were observed with three errors. Total error rate was (7.6%) The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
- E
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. the kitchen was clean and maintained in good repair, b. food was stored in a sanitary manner, c. the kitchen was free of pest, and d. food products were properly labeled/identified. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
- E
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 and interview, the facility failed to conduct regular inspections of all bed rails as part of a regular maintenance program for three (#7, 35, #55) of three residents reviewed for bedrails. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on record review, observation and interview, it was determined the facility failed to provide a safe, clean, sanitary, homelike environment. The facility failed to ensure: a. a shower room was clean and in working order and b. the laundry was free of dirt and dust. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
- E
Put firmly secured handrails on each side of hallways.
Inspectors wroteBased on observation and interview, the facility failed to equip corridors with firmly secured handrails on each side. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain an effective pest control program. The Resident Census and Conditions of Residents documented 78 residents resided in the facility.
- 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 ensure residents who were discharged from Part A skilled services, had days remaining, and remained in the facility were issued SN ABN notices for two (#10 and #36) of three residents reviewed for beneficiary notices. The facility identified 28 residents who were discharged from part A skilled services with benefit days remaining in the previous six months.
- 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 refer a resident with a new serious mental disorder to the state for a level II PASRR evaluation for one (#15) of two residents sampled for PASRR screening and evaluations. The Resident Census and Conditions of Residents form documented 78 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 record review and interview the facility failed to develop a comprehensive care plan for diuretic use for one (#21) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 78 residents resided in 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 one (#39) of five residents observed during med pass had an accurate medication reconciliation count. The Resident Census and Conditions of Residents form documented 78 residents resided in 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 monitor one (#56) of five sampled residents for uneccessary medications. The Resident Census and Conditions of Residents report documented 14 residents were taking an antipsychotic medication.
- 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 and interview, it was determined the facility failed to ensure: a. medications were labeled and b. expired mediations were removed from the medication storage room. This had the potential to affect all 78 residents who resided in the facility.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on record review, observation, and interview, the facility failed to provide food that accommodated resident allergies for one (#17) of two residents reviewed for dining. The Resident Census and Conditions of Residents documented 76 residents received services from the kitchen.
Fire safety inspections
16 fire safety citations on file: 4 on May 2, 2024, 9 on March 30, 2023, 3 on March 20, 2019.
Every fire safety citation16 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 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 2, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 30, 2023 · Corrected (the home has a date of correction)
- 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.
K 222 · March 30, 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 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 20, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 20, 2019 · Corrected (the home has a date of correction)
- 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.
K 222 · March 20, 2019 · Corrected (the home has a date of correction)