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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
13D
11E
0F
Potential for minimal harm
0A
0B
0C
August 6, 2025Standard inspection · 3 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff followed infection control practices between residents while administering medications for 3 (#9, 17, and #23) of 8 sampled residents reviewed for medication administration. The DON identified 43 residents were administered medications by facility staff.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, the facility failed to ensure an antipsychotic medication was not prescribed for the diagnosis of dementia for 1 (#25) of 5 sampled residents reviewed for unnecessary medications. The DON identified five residents were prescribed antipsychotic medications.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure an MDS discharge assessment record was transmitted in the required timeframe for 1 (#1) of 14 sampled residents reviewed for MDS assessments. The DON identified 44 residents required MDS assessments to be completed at the facility.
March 17, 2025Complaint inspection · 1 citation
- J
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteOn 03/12/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were discharged with proper notice. On 03/06/25 Resident #1 returned to the facility after an overnight stay with family. Resident #1 was informed they were no longer a resident of the facility and were not allowed to return to the facility. On 03/12/25 at 5:57 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to a resident who was not allowed to return to the facility after an overnight stay with family. On 3/12/25 at 6:05 p.m., the DON and the corporate regional administrator were notified of the IJ situation and were asked to provide a plan of removal. On 03/13/25 at 2:35 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. [...]
July 26, 2024Complaint inspection · 1 citation
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to ensure controlled medications were not misappropriated for three (#4, 7, and #8) of three sampled residents who were reviewed for misappropriation. The DON identified 42 residents who resided in the facility.
April 4, 2024Standard inspection, Complaint inspection · 14 citations
- E
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 complete a baseline care plan for three (#31, 45, and #246) of 12 residents whose care plans were reviewed. The DON identified 41 residents who resided in the facility.
- 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 a comprehensive care plan to include the use of bed rails for four (#16, 23, 146, and #246) of four sampled residents reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails.
- 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 observation, record review, and interview, the facility failed to attempt alternative interventions prior to the use of bed side rails for three (#16, 23, and #146) of three sampled residents reviewed for accident hazards and failed to assess resident's risk of entrapment prior to use of bed side rails for two (#16 and #146) of three sampled resident reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails.
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and interview the facility failed to complete required nurse aide yearly performance reviews for two (CNA #2 and CNA #4 ) whose employee files were reviewed for competencies. The DON identified 13 nurse aides currently employed by the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program to prevent the transmission of infections: a) for resident #10 during catheter care, b) for resident #21 during incontinent care, and c) implement a water treatment program for the prevention of Legionella. The administrator identifed five residents with a catheter/receive incontinent care.
- 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 residents were offered the choice to formulate advanced directives for two (#4 and #7) of two sampled residents reviewed for advanced directives. The DON identified 41 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 an admission assessment for residents were completed within the required timeframe for one (#246) of 13 residents whose assessments were reviewed. The DON identified 41 residents who resided in the facility.
- 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 within the required time frame two (#14 and #32) of 13 residents whose assessments were reviewed. The administrator identified 41 residents who currently resided in the facility.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure assessments were encoded and submitted to CMS within seven days of completion of the assessment for one (#16) of 13 residents whose assessments were reviewed. The administrator stated 41 residents were residing in the facility.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review and interview, the facility failed to develop a discharge summary including a recapitulation of the resident's stay, a reconciliation of the resident's medications, and a post discharge plan of care, for one (#44) of two residents reviewed for discharge from the facility. The DON identified 41 residents who resided in the facility.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the physician was notified of significant weight loss and failed to implement interventions to maintain and/or prevent further weight loss for one (#34) of two sampled resident reviewed for weight loss. The DON identified 41 residents who resided in the facility.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents' nutritional issues were supervised by a physician for one (#34) of two residents sampled for weight loss. The DON identified 41 residents who resided in the facility.
- 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, record review, and interview, the facility failed to maintain an ice machine in a sanitary condition. The DON stated all 44 residents received ice from the ice machines.
- 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 conduct regular inspections of resident beds and failed to inspect resident beds for safety prior to the attachment and use of bedrails for three (#16, 23, and #146) of three sampled residents reviewed for accident hazards. The DON stated 17 residents at the facility used bed rails. A Resident Listing Report, dated 04/01/24 documented 44 resident resided at the facility.
March 27, 2024Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure physician orders were followed in relation to wound care for one (# 7) of three residents reviewed for wound care. The administrator reported the census was 41.
January 29, 2024Complaint inspection · 3 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, the facility failed to ensure the abuse policy was implemented for verbal abuse for one (#6) of five sampled residents who were reviewed for abuse. The administrator identified 46 residents who resided at the facility.
- E
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 allegations of verbal abuse were reported to the administrator and OSDH for one (#6) of five sampled residents who were reviewed for abuse. The administrator identified 46 residents who resided at the facility.
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on record review and interview, the facility failed to ensure staff had received abuse training upon hire for four (CNA #1, CNA #2, CNA #3, and housekeeper #1) of five employee files reviewed for abuse training. The administrator identified seven employees hired in the past four months.
February 24, 2023Standard inspection · 3 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, and interview, the facility failed to initiate fall interventions, to reduce the risk of a fall with major injury, for one (#23) of five residents sampled for falls. The Resident Census and Condition of Residents, form documented 39 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 properly store and date food items to ensure food service safety. The facility reported 39 residents received meals from the facility kitchen.
- 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, observation, and interview, the facility failed to update the plan of care with fall interventions for one (#23) of five residents sampled for falls with injuries. The Director of Nursing reported one resident with a fall with major injury.
Fire safety inspections
16 fire safety citations on file: 2 on April 4, 2024, 12 on February 24, 2023, 2 on February 20, 2020.
Every fire safety citation16 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 24, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 24, 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 · February 24, 2023 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · February 24, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 24, 2023 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · February 24, 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 · February 24, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 24, 2023 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 24, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · February 20, 2020 · 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 20, 2020 · Corrected (the home has a date of correction)