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 44 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
26D
16E
0F
Potential for minimal harm
0A
0B
0C
July 10, 2025Complaint inspection · 7 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 Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a Resident #4 received timely CPR per the physician's order when the resident was found unresponsive and without vital signs. The resident was pronounced deceased by EMS.On [DATE] at 11:26 a.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 11:43 a.m., the administrator and DON were notified of the existence of the IJ situation and was provided the IJ template. On [DATE] at 4:28 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, [DATE] 3:58pm1. The facility failed to initiate CPR immediately when a resident with a full code status was found without signs of life.2. [...]
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure:a. urinary catheter care was completed as ordered for 1 (#7); andb. orders for urinary catheter care were transcribed and completed for 1 (#1) of 3 sampled residents reviewed for urinary catheters. The administrator identified three residents with urinary catheters resided in the facility.
- E
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 observation, record review, and interview, the facility failed to ensure orders for PEG tube care were transcribed and completed for 2 (#6 and #7) of 2 sampled residents reviewed for PEG tube care. The administrator identified five residents had PEG tubes.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident records were accurate for 3 (#1, 6, and #7) of 3 sampled residents reviewed for accurate records. The administrator identified 47 residents resided in the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure interventions to promote pressure ulcer healing were implemented for 1 (#1) of 3 sampled residents reviewed for pressure ulcers. The administrator identified three residents with pressure ulcers resided in the facility.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on record review and interview, the facility failed to ensure PICC/central line care was provided and the site was assessed for 1 (#1) of one sampled resident reviewed for PICC lines. The administrator identified no residents with PICC lines resided in the facility at the time of the survey.
- D
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 a resident received their pain medication as ordered by the physician for 1 (#6) of 1 sampled residents reviewed for medications provided accurately. The administrator identified 47 residents resided in the facility.
December 2, 2024Complaint inspection · 5 citations
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure grievance forms were posted in the designated location per facility policy. The administrator identified 39 residents resided in the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure a MDS was coded accurately for one (#5) of six sampled residents whose MDS assessments were reviewed. The administrator identified 39 residents resided in the facility. They identified one resident received noninvasive ventilator services.
- 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 a resident's care plan included the use of a noninvasive ventilator for one (#5) of two sampled residents reviewed for respiratory services. The administrator identified 16 residents received respiratory services.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had a physician order for the use of a noninvasive ventilator for one (#5) of two sampled residents reviewed for respiratory services. The administrator identified 16 residents received respiratory services.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation and interview, the facility failed to ensure emergency call cord was available in a resident's bathroom for one (#2) of three sampled residents whose emergency bathroom call system was observed. The administrator identified 39 residents resided in the facility.
September 6, 2024Standard 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 medication carts were secured when not in use for three observations at random times throughout the survey on hall 400. The Executive Director identified 43 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 the appropriate dishwasher temperature and sanitization concentration levels were reached on a high temperature dishwasher. The ED identified 43 residents 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: a. enhanced barrier precautions were utilized for two of two (#2 and #21) residents observed with indwelling devices and open wounds, b. infection control practices were adhered to after providing resident care. The Executive Director identified 43 residents resided in the facility. The Resident Matrix, dated 09/03/24, documented five residents that resided in the facility had gastric tubes, three of which had urinary catheters, and two also had pressure ulcers.
- 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 an advanced directive for one (#44) of 12 sampled residents whose advance directive acknowledgements were reviewed. The Executive Director identified 43 residents resided in the facility.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview, the facility failed to ensure: a. privacy was maintained during provision of care for two (Resident #25, and an unidentified resident) of four residents whose protected health information and privacy was reviewed during a tour of the facility, and b. protected health information was secure, for two, (Resident #21 and #40). The Executive Director identified 43 residents in the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident Assessments were accurately coded for two (#21 and #34) of 13 residents reviewed for assessments. The Executive Director identified 43 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 in a timely manner for one (#38) of 13 sampled residents reviewed for baseline care plans. The Administrator identified 43 residents resided in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure neurological checks were conducted and monitored after an unwitnessed fall for one (Resident #29) reviewed for falls. The ED identified 43 residents resided in the facility.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to ensure staffing information, which included the facility name, date, actual hours worked for RNs, LPNs, CMAs, and CNAs, and the resident census was updated. The ED identified 43 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 record review and interview, the facility failed to ensure medication was administered according to physician orders for one (#16) of five residents reviewed for medications. The Executive Director identified 43 residents resided in the facility.
- D
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 emergency call cords were within reach for one dependent resident (#21) while lying in bed of 13 sampled residents reviewed for access to call light. The Executive Director identified 43 residents resided in the facility.
May 30, 2024Complaint 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 obtain finger stick blood sugars in a manner to prevent cross contamination for three of four observations. The administrator identified 15 residents who received finger sick blood sugars.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record review and interview, the facility failed to address and document a grievnaces of clothing and medical equipment for one (#1) of four sampled residents reviewed for grievnaces. The administrator identified 43 residents currently resided 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 complete a discharge summary with a recapitulation of stay for one (#1) of one sampled resident reviewed. The administrator identified eight residents who have discharged from the he facility since 04/02/24.
August 3, 2023Standard inspection · 8 citations
- E
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 a SNF ABN form was provided when a resident discharged from Medicare Part A stay with benefit days remaining for two (#11 and #49) of three sampled residents reviewed for beneficiary notices. The MDS Coordinator identified 10 residents who had discharged from Medicare Part A stay with benefit days remaining in the past six months.
- E
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 bathing was provided for one (#13) of three sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 residents required assistance with bathing.
- E
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: a. the count was verified for controlled medications awaiting destruction for eight (#24, 49, 101, 102, 103, 104, 105 and #106), and b. the count was verified when controlled medications were acquired from pharmacy for three (#49, 101, and #102) of eight sampled residents whose narcotic sheets were reviewed during medication storage. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 residents resided in the facility.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medication error rate did not exceed five percent. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 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 one (#24) of 15 residents reviewed for comprehensive care plans. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 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 ensure residents had an appropriate diagnosis for use of an antipsychotic medication for one (#36) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 33 residents received psychoactive medications.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure there was not a significant medication error for one (#22) of four residents observed during medication administration. The Resident Census and Conditions of Residents report, dated 07/31/23, documented 46 residents resided in the facility.
- 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 ensure medication carts left unattended were securely locked at all times for one of two medication carts observed. The Resident Census and Condition of Residents report, dated 07/31/23, documented 46 residents resided in the facility.
March 10, 2022Standard inspection · 10 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 wroteA past noncompliance immediate Jeopardy (IJ) situation was determined to exist effective [DATE] related to the facility's failure to immediately perform Cardio Pulmonary Resuscitation (CPR) on a Resident (Res) with full code status who was found not breathing and without a detectable heart beat. Res #42 was found by an unidentified Certified Nurse Aide (CNA) in bed and appeared not to be breathing. The unidentified CNA reported the findings to the Licensed Practical Nurse (LPN) immediately at approximately 6:00 a.m., who then assessed the resident and found him to have no signs of life. The LPN then notified the resident's family member, the administrator, the Director of Nursing (DON), and the Police. The LPN did not initiate CPR on Res #42 who had on file an order for full code. Approximately 53 minutes later, EMSA and the fire department arrived to initiate CPR. [...]
- 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 observation, interview, and record review, the facility failed to complete a 48 hour base line care plan for two, (#29 and #31) of 13 residents whose care plans were reviewed. The Census and Conditions of Residents form documented 37 residents resided at 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 wroteThe facility failed to develop comprehensive person-centered care plans for four (#29, 30, 31, and #41) of 12 sampled residents whose care plans were reviewed. The administrator identified 37 residents who 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 wrote2. Res #33 admitted to the facility with diagnoses which included COPD, diabetes mellitus with diabetic polyneuropathy, major depressive disorder, and anxiety disorder. A MMR, dated 7/22/21, documented the pharmacist requested a reduction of Buspirone and/or Mirtazapine. The physician documented ''No'' to a dose reduction on 08/18/21. The physician did not provide a rational to the request. A MMR, dated 01/22/22, documented the pharmacist requested a reduction for Lexapro and/or Remeron. The physician's response to the MRR was not available in the resident's EHR. On 03/09/22 at 3:04 p.m., the administrator stated she was not able to find a response from the physician for the MMR form dated 01/22/22. The administrator stated she was not aware if the form had been sent or seen by the physician. 3. [...]
- 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, interview, and record review, the facility failed to ensure controlled drugs along with other drugs subject to abuse were stored in locked compartments with a separately locked, permanently affixed compartment. The census and conditions form documented 37 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 store, prepare, and serve food in a sanitary manner. The Resident Census and Conditions of Residents report documented 37 residents resided at the facility.
- D
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, interview, and record review, the facility failed to provide a clean, comfortable, and sanitary environment for one (31) of 16 residents reviewed for environment. The Resident Census and Conditions of Residents report documented 37 residents resided at the facility.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, it was determined the facility failed to complete and transmit a discharge minimum data set (MDS) assessment in a timely manner for one (#2) of one resident sampled for transmission of assessments. The Census and Conditions of Residents form documented 37 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, interview, and record review, the facility failed to provide showers or baths to dependent residents for one (#34) of three residents reviewed for ADL assistance. The Resident Census and Conditions of Residents report documented 37 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, interview, and record review, the facility failed to administer and observe the resident taking medication for one (#1) of 16 sampled residents observed on initial tour. The administrator identified 37 residents who resided in the facility.
Fire safety inspections
12 fire safety citations on file: 4 on September 6, 2024, 3 on August 3, 2023, 5 on March 10, 2022.
Every fire safety citation12 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 · September 6, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 6, 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 · September 6, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 6, 2024 · 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 · August 3, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 3, 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 · August 3, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 10, 2022 · 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 10, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 10, 2022 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 10, 2022 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 10, 2022 · Corrected (the home has a date of correction)