Deficiencies (last 3 years)
Deficiencies (over 3 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
140 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 4
May 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and thoroughly investigate injuries of unknown origin, specifically a dislocated shoulder of Resident #80.
Findings
The facility failed to timely report an injury of unknown origin to the Oklahoma State Department of Health and did not thoroughly investigate the injury. Additionally, the facility failed to provide adequate activities of daily living (ADL) care, including nail care for Resident #3, and failed to provide appropriate range of motion services and contracture interventions for Residents #75, #97, and #80.
Complaint Details
The complaint investigation focused on the failure to timely report and investigate injuries of unknown origin, specifically the dislocated shoulder of Resident #80. The injury was unwitnessed, and the resident was unable to explain what happened. The facility did not report the injury to the Oklahoma State Department of Health and did not document a thorough investigation including staff or physician interviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse or injuries of unknown origin to proper authorities for Resident #80. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate injuries of unknown origin for Resident #80. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate nail care for Resident #3. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide range of motion services for Residents #75 and #97 and contracture interventions for Resident #80. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 140
Residents dependent on staff for nail care: 27
Residents with contractures: 12
Residents with limited range of motion: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | On duty when Resident #80's family complained about shoulder pain; stated uncertainty about cause of injury and investigation completion; stated sometimes put hand rolls in Resident #80's hand but no formal interventions. | |
| DON | Director of Nursing | Reported census of 140 residents; stated Resident #80's injury was not reported to the state; performed internal investigation; stated restorative services were not being performed as indicated; stated Resident #80's injury was unwitnessed and resident unable to explain. |
| CNA #1 | Stated CNAs were supposed to provide nail care on shower day unless resident was diabetic. | |
| CNA #2 | Stated Resident #3's toenails were long and needed trimming but unsure if resident was diabetic. | |
| MDS coordinator | Stated interventions should be in place for Resident #80's contracted right hand and care plan should include those interventions. |
Inspection Report
Annual Inspection
Census: 140
Deficiencies: 9
May 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to abuse reporting, investigation, care planning, activities of daily living, range of motion services, medication security, infection control, and immunization policies.
Findings
The facility was found deficient in timely reporting of injuries of unknown origin, thorough investigation of alleged abuse, development of comprehensive care plans, provision of activities of daily living care, range of motion services, medication cart security, infection prevention practices, and documentation of immunization offers and administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to timely report injuries of unknown origin to the Oklahoma State Department of Health for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate injuries of unknown origin for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop comprehensive care plans for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activities of daily living care, specifically nail care, for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate range of motion services and contracture interventions for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication/treatment carts were locked when unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow evidence-based practices during catheter care and ensure clean laundry was transported appropriately. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were offered pneumococcal immunization and properly document offers and refusals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident was offered the COVID-19 vaccination and properly document vaccination status. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents: 140
Residents dependent on staff for nail care: 27
Residents with contractures: 12
Residents with limited range of motion: 43
Medication/treatment carts: 15
Residents with urinary catheters: 11
Residents whose laundry was cleaned by the facility: 110
Sampled residents reviewed for immunizations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | On duty when resident's family complained about shoulder pain; stated no formal interventions for contracted hand | |
| LPN #3 | Observed providing catheter care without gown; acknowledged should have worn gown | |
| LPN #4 | Stated sometimes put hand rolls in resident's hand but no formal interventions | |
| LPN #5 | Forgot to lock medication/treatment cart | |
| DON | Director of Nursing | Reported census, acknowledged deficiencies in reporting, investigation, restorative services, medication cart security, infection control, and immunization documentation |
| MDS coordinator | Stated interventions should be in place for contracted hand and urinary catheter care plans | |
| CNA #1 | Stated CNAs responsible for nail care on shower days | |
| CNA #2 | Noted resident's toenails were long but unsure if resident was diabetic | |
| Laundry personnel #1 | Delivered clean laundry uncovered to residents | |
| Laundry supervisor | Stated laundry should be covered when delivered | |
| Administrator | Locked unattended medication cart and sought responsible staff |
Inspection Report
Routine
Census: 125
Deficiencies: 2
Feb 9, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service standards, including ensuring food is palatable, nutritious, served at appropriate temperatures, and prepared in a form that meets individual resident needs.
Findings
The facility failed to ensure food was palatable, nutritious, and served at preferred temperatures, with multiple residents reporting cold or unpalatable food. Pureed foods were often grainy and not smooth, posing potential choking hazards. Portion sizes were inconsistent, and staff lacked proper training on food preparation and serving utensils.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure food contained nutritive value, was palatable, and served at preferred temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was provided in a form designed to meet individual needs to prevent choking. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents receiving food: 125
Pureed beef temperature: 113
Pureed vegetable temperature: 106
Milk temperature: 58
Mixed vegetable temperature: 112
Mechanical beef temperature: 97
Number of residents requiring pureed diets: 5
Inspection Report
Routine
Census: 127
Deficiencies: 11
Feb 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, notification of changes, accurate assessments, baseline care plans, assistance with activities of daily living, chemical safety, pharmaceutical services, medication labeling and expiration, food quality and safety, and food preparation standards.
Findings
The facility was found deficient in multiple areas including failure to ensure accurate code status documentation, failure to notify resident representatives of changes in condition, inaccurate medication and weight documentation in MDS, incomplete baseline care plans, failure to provide showers, unsecured chemicals, failure to reconcile controlled medications, expired and unlabeled medications, poor food quality and temperature, improper food preparation for pureed diets, inconsistent food portioning, and inadequate sanitary practices in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure accurate code status for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident representatives were notified of changes in condition for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications and weights documented in the MDS were accurate for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a baseline care plan was completed within 48 hours for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure showers were provided for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure chemicals were secured in a housekeeping closet. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure controlled medications were reconciled for one medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were labeled and not expired on multiple medication/treatment carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was provided in a form designed to meet individual resident needs to prevent choking. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a sanitary environment and provide food and drink at safe temperatures in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents identified: 127
Controlled substances count shift verification: 12
Medication carts observed: 7
Medication/treatment carts in facility: 13
Residents receiving food: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Provided statements regarding code status, notification of changes, medication reconciliation, chemical storage, and medication cart security. |
| MDS Coordinator | Reviewed MDS assessments and weights, provided statements on medication coding and accuracy. | |
| CMA #1 | Certified Medication Aide | Observed handling medication cart keys and medication administration; noted medication cart was unlocked. |
| CMA #2 | Certified Medication Aide | Observed receiving medication cart keys and noted lack of medication cart reconciliation. |
| LPN #1 | Licensed Practical Nurse | Observed with treatment cart and provided statements on medication expiration and labeling. |
| LPN #2 | Licensed Practical Nurse | Observed with treatment cart and provided statements on medication labeling and expiration. |
| Cook #1 | Observed preparing pureed food and providing statements on food preparation and quality. | |
| Dietitian | Registered Dietitian | Provided statements on food preparation, nutritive value, and kitchen sanitation. |
| Dietary Manager | Provided statements on food portioning, weighing, and food quality. | |
| CNA #1 | Certified Nursing Assistant | Reported inability to provide showers and communication with nursing staff. |
Inspection Report
Deficiencies: 1
Oct 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services requirements, specifically ensuring that narcotic pain medications were available to residents as ordered.
Findings
The facility failed to ensure timely availability of as-needed narcotic pain medications for two of four sampled residents, resulting in delayed pain management due to lack of communication between the pharmacy and facility and missing hard scripts for medication orders.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure as needed narcotic pain medication was available for two of four sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with narcotic pain medication orders: 83
Sampled residents reviewed for access to pain medication: 4
Residents affected by deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Reported discovery of missing narcotic pain medication and communication issues with pharmacy. | |
| Director of Nursing (DON) | Provided information about residents with narcotic orders, pharmacy communication issues, and missing hard scripts. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 3
Apr 25, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to notify legal representatives of significant weight loss, failure to provide showers to dependent residents, and failure to administer medications as ordered.
Findings
The facility failed to notify a resident's legal representative of significant weight loss, failed to ensure dependent residents received showers as ordered, and failed to administer medications according to physician orders for several residents. Documentation and adherence to care protocols were inadequate.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to notify legal representatives of significant weight loss, failure to provide showers to dependent residents, and failure to administer medications as ordered. The complaints were substantiated based on observations, record reviews, and interviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify the resident's legal representative of significant weight loss for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dependent residents received showers for three of four sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were administered as ordered by the physician for two of six sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident census: 108
Weight loss percentage: 5.2
Missed bathing opportunities: 2
Missed bathing opportunities: 7
Missed bathing opportunities: 3
Missed bathing opportunities: 1
Missed bathing opportunities: 6
Medication administration omissions: 6
Medication administration outside parameters: 2
Medication administration outside parameters: 1
Medication administration outside parameters: 2
Medication administration outside parameters: 2
Inspection Report
Routine
Census: 108
Deficiencies: 12
Apr 25, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care planning, medication administration, nutrition, and vaccination protocols.
Findings
The facility was found deficient in multiple areas including failure to offer or document advance directives, failure to notify legal representatives of significant weight loss, inaccurate MDS assessments, incomplete care plans related to pain and significant changes, failure to provide showers as ordered, inadequate monitoring of fluid restrictions, failure to ensure physician responses to pharmacist recommendations, and failure to offer or document influenza and pneumococcal vaccinations.
Deficiencies (12)
| Description |
|---|
| Failure to ensure residents were offered the choice to formulate advance directives and maintain valid code status forms. |
| Failure to notify resident's legal representative of significant weight loss. |
| Failure to accurately code MDS assessments and complete significant change assessments. |
| Failure to incorporate PASARR level II evaluation into resident care plan. |
| Failure to accurately complete PASARR preadmission screening for mental disorders. |
| Failure to develop and implement care plans related to residents' pain. |
| Failure to review and revise care plan after significant change. |
| Failure to ensure dependent residents received showers as ordered. |
| Failure to ensure 2 liter fluid restriction was monitored and documented. |
| Failure to administer medications as ordered by physician and document administration accurately. |
| Failure to ensure physician responses to pharmacist drug regimen reviews were documented. |
| Failure to offer influenza and pneumococcal vaccinations and document offers or declinations. |
Report Facts
Resident census: 108
Residents with advance directives: 42
Residents requiring behavioral health services: 24
Weight loss percentage: 5.2
Medication administration opportunities missed: 17
Medication administration opportunities missed: 8
Weight: 153.8
Weight: 145.8
Shower opportunities missed: 2
Shower opportunities missed: 7
Shower opportunities missed: 3
Shower opportunities missed: 1
Shower opportunities missed: 6
Medication administration opportunities outside parameters: 2
Medication administration opportunities outside parameters: 2
Medication administration opportunities outside parameters: 1
Medication administration opportunities outside parameters: 2
Medication administration opportunities outside parameters: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | Provided information on MDS assessments and PASARR evaluations | |
| MDS Coordinator #2 | Provided information on discharge MDS assessment coding error | |
| Corporate nurse consultant #1 | Interviewed regarding advance directives, DNR form validity, weight loss notification, medication administration, and pharmacist review responses | |
| LPN #4 | Interviewed regarding care plans for pain and care plan reviews | |
| DON | Director of Nursing | Interviewed regarding weight loss notification, shower provision, fluid restriction monitoring, medication administration, and pharmacist review responses |
| CNA #2 | Interviewed regarding shower documentation and resident refusals | |
| Corporate RN #1 | Interviewed regarding shower documentation and medication administration |
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