Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspen Health And Rehab during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions filed grievances about peer interactions and unsupervised children. After submitting complaints, the resident was told by staff to consider whether the facility was the right place for them and was cautioned about complaining too much. The resident reported feeling threatened and silenced, and staff interviews confirmed that inappropriate comments were made regarding the resident's right to voice grievances.
Unsupervised children brought to the facility by staff were observed making excessive noise, playing with equipment, accessing resident snacks, and entering resident rooms and common areas without supervision. Multiple residents and staff reported that the children’s presence disrupted the environment and created discomfort, with some residents feeling responsible for supervising the children.
Staff failed to follow a resident's written plan of care by transferring the individual manually without a mechanical lift, despite documented requirements for mechanical lift use and two-person assistance due to impaired mobility and left side weakness. The transfer was performed by a CNA and an LPN, resulting in the resident experiencing knee pain and a temporary decrease in therapy participation.
Multiple residents reported being physically mistreated, neglected, and spoken to harshly by CNAs, including being thrown onto a bed, denied timely toileting assistance, and left in soiled linens. Residents also described staff ignoring call lights and handling them roughly during care, with some residents afraid to report these incidents. Staff interviews and grievance logs confirmed these patterns of abuse and neglect.
The facility did not discontinue a muscle relaxant as ordered for one resident and failed to obtain daily weights as ordered for another resident with edema. Additionally, a blood pressure medication that was ordered to be discontinued was not removed from the administration record and was sent home with the resident upon discharge. These deficiencies were linked to missed documentation reviews and lack of awareness among nursing staff.
The facility did not complete laboratory tests as ordered by physicians for two residents, one with COPD and another with CHF, despite established processes for monitoring and implementing lab orders. The DON and medical records staff confirmed the labs were not completed and could not explain the failure.
A resident with dementia reported an allegation of sexual abuse to the ADON, who promptly informed the administrator and DON. Despite facility policy requiring immediate reporting of abuse allegations to the State Agency within two hours, the report was not submitted until the next day. The administrator stated they were unaware of the two-hour reporting requirement.
A resident with sleep apnea, who had a physician's order to use a BiPap at bedtime and confirmed nightly use, was not accurately assessed for non-invasive mechanical ventilator use in their quarterly MDS assessment. The MDS coordinator later confirmed the assessment was inaccurate.
The facility did not secure protected health information for six residents, as sensitive details were found handwritten on sheets of paper in a wall bin outside the social services office. The information included names, room numbers, diagnoses, and other personal details. The administrator acknowledged that these records were not secured.
A resident with paralytic syndrome affecting the right side had no interventions developed for a contracture in their right hand. Despite being cognitively intact and participating in a restorative program, the resident's care plan lacked specific measures for their limited range of motion. The DON confirmed that no interventions had been implemented since admission, and charge nurses were expected to report changes during weekly assessments.
The facility failed to consistently monitor and document side effects for residents on psychotropic medications, as required by their care plans. A resident with depression did not have a timely dosage adjustment, and several residents with psychiatric disorders had incomplete side effect monitoring records. The DON acknowledged these deficiencies but could not explain the lapses.
A facility failed to assess the continued need for an indwelling urinary catheter for a resident admitted with a catheter due to a femur fracture. The resident indicated they could use a urinal, and an LPN found no diagnosis justifying the catheter's use. The DON confirmed the absence of a required diagnosis, affecting one of four residents reviewed for catheter use.
The facility failed to document the temperature of the second-floor medication room and refrigerator consistently, with only a few entries recorded in June 2024. Additionally, treatment and medication carts were found unlocked when unattended, contrary to facility policy. Staff interviews revealed confusion about responsibilities for temperature documentation and cart security, with the DON confirming the lead CMA's role in these tasks.
The facility was found to have garbage containers in the kitchen without lids, as observed during a survey. A large garbage can without a lid was seen next to a food preparation table, filled with food waste, and three other uncovered containers were noted beside a refrigerator. A staff member confirmed that the garbage cans should be covered, and the DM admitted there was no policy but agreed that lids should be used.
Resident Discouraged from Filing Grievances Without Fear of Reprisal
Penalty
Summary
The facility failed to ensure that a resident was able to file grievances without fear of reprisal. A resident with intact cognition and multiple medical diagnoses, including hypertension, renal insufficiency, and diabetes, submitted grievances regarding issues with another resident and concerns about unsupervised children in the facility. Documentation showed that after submitting these grievances, the resident was approached by the social services director (SSD) and activities director (AD), who questioned the resident about their satisfaction with living at the facility and suggested that if they were unhappy, they might consider whether the facility was the right place for them. During this conversation, the resident became visibly upset and expressed feeling silenced, stating they would "just shut [their] mouth and not say a word ever again." Further evidence from a video recording and interviews confirmed that the resident was told to be careful about how much they complained about matters not in their control, and that repeated complaints could result in consideration of alternative placement. The resident reported feeling threatened and stated that the interaction had taken away their joy of being around people. Staff interviews revealed conflicting perspectives, with the SSD acknowledging that telling a resident to be careful about complaining would be inappropriate, while the AD stated that residents could submit as many grievances as they wished. The facility's grievance policy was described as allowing residents to submit grievances without limitation, but the actions taken in this case did not align with that policy.
Unsupervised Children Cause Excessive Noise and Disruption
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by allowing unsupervised children to be present in resident areas, resulting in excessive noise and disruption. Observations included children playing loudly in the billiard room, slamming billiard balls, and wearing staff communication headsets. Children were also seen accessing resident snacks from the snack cart and entering elevators and hallways without supervision. Multiple residents reported that children entered their rooms without permission, played on therapy equipment, and created disturbances in common areas. One resident described a child lying on their bed without consent, and another expressed discomfort with having to supervise children who were not their responsibility. Staff confirmed that the children, who were brought to the facility by employees, were often unsupervised and did not remain in designated areas. The administrator acknowledged that children were informed of expected behavior but maintained that their presence was therapeutic for residents. Despite this, both residents and staff reported that the children’s activities led to excessive noise and a lack of supervision, negatively impacting the environment and comfort of the residents.
Failure to Follow Resident Transfer Plan of Care
Penalty
Summary
Facility staff failed to follow the written plan of care for a resident who was documented as requiring transfer with a mechanical lift and two-person assistance due to confusion, left side weakness, and impaired mobility following a stroke. The resident's care plan and comprehensive assessment indicated substantial to maximal assistance was needed for transfers, and the use of a mechanical lift was specified in the closet care plan. Despite these documented requirements, staff transferred the resident manually without the mechanical lift. The incident occurred when a CNA and an LPN entered the resident's room to transfer the resident from a wheelchair to a bed. The LPN instructed the resident to place their hands around the nurse's neck and attempted to lift the resident out of the wheelchair, but was unable to clear the wheelchair armrest. Multiple attempts were made, during which the resident's feet became caught in the wheelchair foot pedals, and the resident was ultimately lifted over the armrest and onto the bed without proper support. The family member present reported the transfer was performed in a rough manner, resulting in the resident's head and legs being left dangling off the bed before being quickly repositioned by the nurse. Following the transfer, the resident complained of left knee pain and was unable to participate in physical therapy at their previous level for several days. An x-ray showed no acute fracture or dislocation, but moderate osteoarthritic changes were noted. The therapist confirmed the resident's knee pain limited therapy participation temporarily, though the resident returned to baseline function within a week. The facility's investigation, including review of camera footage, substantiated that the staff did not follow the resident's plan of care, as the mechanical lift was not used during the transfer.
Failure to Protect Residents from Abuse and Neglect by Staff
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving three residents. One resident, with a history of polyneuropathy, osteoarthritis, and physical debility, reported being physically mistreated by a CNA, who allegedly threw the resident onto the bed with enough force to move it and caused pain during care. The resident expressed fear of reporting the abuse due to concerns about retaliation. Additionally, the same resident reported that another CNA refused to assist with toileting, instructing the resident to use their brief instead, and failed to provide timely incontinence care, resulting in the resident being left in soiled linens until morning. Other residents also reported neglectful and abusive behaviors by staff. One resident stated that a CNA would turn off their call light and promise to return but never did, indicating a lack of timely response to care needs. Another resident described being handled roughly during bed mobility and having their call light thrown at them after care was provided. This resident also reported being told to urinate in their brief because staff did not have time to assist, and expressed reluctance to report these incidents out of fear of causing problems. The facility's grievance logs documented prior concerns about wait times, staff etiquette, and failure to provide timely incontinence care, but did not identify specific staff members involved. Assessments confirmed that the residents involved were cognitively intact and required varying levels of assistance with activities of daily living, including toileting and bed mobility. Staff interviews corroborated the residents' accounts, with one CNA admitting to neglectful behavior due to feeling rushed and another staff member acknowledging that the reported actions constituted abuse.
Failure to Implement Physician Orders and Obtain Daily Weights
Penalty
Summary
The facility failed to implement physician medication orders and obtain required daily weights for residents as directed. For one resident with chronic pain, a physician's order to discontinue cyclobenzaprine was documented in the progress notes, but the medication continued to be administered after the discontinuation order. The medication administration record did not reflect the discontinuation, and the error was not identified during daily audits by medical records staff or nursing leadership. Another resident with hypertension and generalized edema had a physician order for daily weights, but weights were not obtained on two consecutive days. Additionally, after a physician ordered the discontinuation of losartan due to low blood pressure, the medication remained on the administration record and was sent home with the resident upon discharge. The charge nurses were responsible for obtaining daily weights, but a recent staffing change contributed to the oversight. The nurses on the relevant unit were not aware they needed to review physician progress notes for new orders.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests ordered by physicians were completed for two of three sampled residents whose laboratory records were reviewed. One resident with chronic obstructive pulmonary disease had a physician's progress note instructing staff to obtain readmission labs, but the clinical record did not show that these labs were completed. Despite daily audits by medical records staff to ensure labs were ordered and implemented, no readmission labs were found for this resident. Another resident with congestive heart failure had physician orders for a CBC, CHEM 8, and A1c, but the clinical record did not show these labs were completed as ordered. The Director of Nursing and medical records staff confirmed that the labs had not been completed and were unable to provide a reason for the failure to implement the physician's orders.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with unspecified dementia to the Oklahoma State Department of Health within the required two-hour timeframe. According to facility policy, all alleged violations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In this case, the resident reported to the ADON that an unidentified person had put their finger in her vagina during the evening shift. The ADON immediately notified the administrator and DON of the allegation. However, documentation showed that the initial report to the State Agency was not sent until the following day, well beyond the two-hour requirement. The administrator, who served as the abuse coordinator, stated they were unaware of the two-hour reporting requirement and believed they had 24 hours to report such allegations. This delay in reporting was confirmed by the fax cover sheet and interviews with facility staff.
Inaccurate Assessment of BiPap Use for Resident with Sleep Apnea
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for one of seven sampled residents. A resident with a diagnosis of sleep apnea was observed with a BiPap machine on their nightstand and had a physician's order to use the BiPap at bedtime. However, the resident's quarterly assessment did not indicate the use of a non-invasive mechanical ventilator, despite the resident confirming nightly use of the BiPap. Upon review, the MDS coordinator acknowledged that the assessment was inaccurate and should have reflected the resident's use of the device.
Failure to Secure Protected Health Information
Penalty
Summary
The facility failed to secure protected health information for six residents, as observed during an initial tour. The protected health information was found handwritten on six sheets of paper placed in a wall bin outside the social services office. Each sheet contained sensitive information, including the resident's name, room number, sex, diagnoses, insurance details, number of skilled nursing days available, hospital admission, therapy ordered, prior living environment, and discharge goals. The administrator confirmed that these records were not secured, affecting six residents out of the 113 identified in the facility.
Failure to Develop Interventions for Limited Range of Motion
Penalty
Summary
The facility failed to develop interventions to address the limited range of motion for a resident diagnosed with paralytic syndrome affecting the right dominant side. The resident's care plan, revised in May 2024, noted hemiplegia/hemiparesis of the right side, but did not include specific interventions for the contracture of the right hand. Observations in June 2024 revealed the resident's right hand was closed with no splints or devices in place, and the resident reported an inability to fully open their hand. Interviews with the Director of Nursing (DON) and the MDS coordinator confirmed that no interventions had been implemented for the resident's contracture since admission. Although the resident participated in a restorative program for transfers in September 2023, no specific measures were taken to address the limited range of motion in the right hand. The DON acknowledged the lack of intervention and stated that charge nurses were expected to report any contractures or changes in range of motion during weekly skin assessments.
Inadequate Monitoring of Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of side effects for residents receiving psychotropic medications. Five residents were identified as not having their side effects monitored consistently, as required by their care plans. For instance, Resident #5, who was diagnosed with depression, had a pharmacy recommendation to decrease their Doxepin dosage, which was not implemented in a timely manner. Additionally, the resident's side effects were not documented consistently, with significant gaps in the monitoring records. Resident #27, diagnosed with major depressive disorder and schizoaffective disorder, also experienced inadequate monitoring of side effects for their antidepressant and antipsychotic medications. The documentation showed that side effects were recorded only a few times out of numerous opportunities, despite the care plan's requirement for every shift monitoring. Similar issues were observed with Resident #86, who had multiple psychiatric diagnoses, including bipolar disorder and anxiety, where side effects were documented only a handful of times out of many opportunities. The facility's Director of Nursing (DON) acknowledged the lapses in monitoring and documentation for these residents, as well as for Resident #39 and Resident #52, who also had incomplete side effect monitoring records. The DON was unable to provide explanations for these deficiencies, indicating a systemic issue in ensuring compliance with care plans and physician orders regarding psychotropic medication management.
Failure to Assess Continued Need for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to assess the continued need for an indwelling urinary catheter for a resident who was admitted with a catheter due to a displaced intertrochanteric fracture of the left femur. The resident, who had been using the catheter since hospitalization, indicated they could use a urinal if necessary. Upon review of the medical record, an LPN found no diagnosis justifying the use of the catheter, and the Director of Nursing confirmed there was no diagnosis requiring it. This oversight affected one of the four residents reviewed for catheter use, out of a total of 12 residents with indwelling urinary catheters in the facility.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and security of medication storage, as observed during a survey. The temperature of the second-floor medication room was only documented five times out of 30 opportunities in June 2024, and the temperature of the medication refrigerator was recorded six times out of 60 opportunities. This lack of documentation indicates a failure to adhere to the facility's policy, which requires daily temperature logging to ensure medications and biologicals are stored at appropriate temperatures. Additionally, the facility did not secure treatment and medication carts when unattended. An unlocked treatment cart was observed outside a resident's room, and staff interviews revealed confusion about responsibility for temperature documentation and cart security. A CMA and two LPNs acknowledged that carts should be locked when not in use, and the DON confirmed that the lead CMA was responsible for temperature documentation and ensuring carts were locked. This lack of adherence to security protocols further highlights the facility's failure to comply with its medication storage policy.
Improper Disposal of Garbage in Kitchen
Penalty
Summary
The facility failed to ensure that garbage containers in the food preparation area were covered with lids, as observed during a survey. On June 30, 2024, at 8:04 a.m., a tour of the kitchen revealed a large garbage can without a lid next to the metal food preparation table, filled with refuse including food waste from the breakfast meal. Additionally, three other large garbage containers without lids were observed beside a refrigerator. At 8:10 a.m., a staff member acknowledged that the garbage cans should be covered with lids. On July 1, 2024, at 9:30 a.m., the Dietary Manager (DM) admitted there was no policy regarding refuse containers but confirmed that garbage cans should always be covered with lids.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Broken Arrow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broken Arrow Nursing Home, Inc | 0.8 mi | ★★★★★ | 1 | 0 |
| Village Health Care Center | 1 mi | ★★★★★ | 10 | 1 |
| Senior Suites Healthcare | 1.8 mi | ★★★★★ | 15 | 0 |
| Cedarcrest Care Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Forest Hills Care And Rehabilitation Center | 2.1 mi | ★★★★★ | 0 | 0 |
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