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 Bartlesville Health And Rehabilitation Community during CMS and state inspections, most recent first.
A resident with cardiac-related diagnoses and a full code status became clammy, nonresponsive, and then pulseless and apneic. An LPN called 911 and initiated CPR while the resident remained on the bed, without using a back board or moving the resident to a hard surface, contrary to AHA standards and facility policy. The LPN had a lapse in CPR certification, and another LPN present did not know the location of the crash cart or its key when asked to obtain an ambu bag, despite staff being expected to know CPR guidelines, crash cart location, and to use a firm surface for compressions.
A resident with stage five chronic kidney disease and dependent on dialysis reported that nursing staff were not performing required vital checks. Documentation review showed incomplete pre and post dialysis assessments, with only 14 out of 28 sessions documented. The facility lacked a policy for dialysis care, and the DON was unaware of the issue.
The facility failed to ensure dietary staff wore hair nets and beard guards while preparing food. A cook was observed without these protective items, acknowledging the requirement and citing a shortage of beard guards. Both the dietary manager and administrator confirmed the necessity of wearing hair nets and beard guards.
A facility failed to ensure proper infection control during wound and catheter care for a resident, as an LPN did not perform hand hygiene between glove changes. The resident had a history of urinary tract infections. Additionally, the facility did not implement a water management program to prevent Legionella growth, despite having a policy in place.
A resident with dementia and weakness fell, but their representative was not notified as required by the facility's policy. The fall occurred on a specific date, but the representative was only informed several days later. The DON acknowledged that the family should have been notified immediately.
A facility failed to involve the medical director in a resident's care plan development, as required by policy. Despite the resident having intact cognition, the medical director or their representative did not attend the care plan meeting, nor did they review the meeting's results. The MDS coordinator admitted that the physician was notified but did not participate, and the DON confirmed that the physician should be involved in care planning.
A facility failed to monitor a resident after a fall, as required by their policy. The resident, with dementia and weakness, experienced a fall, but the nurse note did not document whether the resident's representative or the DON/ADON were notified, nor if the fall was witnessed or unwitnessed. Neuro checks were not initiated, and no further post-fall documentation was found. An LPN confirmed that a complete assessment and notifications should occur after a fall, with neuro checks if unwitnessed or if there was a head injury. The DON acknowledged the policy was not followed.
A resident with anxiety disorder and depression was prescribed alprazolam on a PRN basis without a 14-day limit or physician's rationale for extended use. The DON confirmed the absence of a physician's explanation, acknowledging the requirement for a 14-day limit on PRN psychotropic medications without justification.
The facility failed to implement its abuse policy for screening potential employees, affecting two CNAs and one LPN. The necessary registry checks and criminal history monitoring were not completed, potentially compromising the safety of 64 residents.
The facility failed to thoroughly investigate abuse allegations for two residents. One resident was allegedly physically restrained by a CNA, and another was found with bruising and reported being hit. Both incidents were reported to the police, and employees were terminated, but there was no documentation of additional interviews with residents or staff.
The facility failed to report an allegation of abuse involving a resident with vascular dementia to the OSDH within the required two-hour timeframe. The incident was visualized on a video monitoring device, reported to the ADON, and subsequently to the DON, but the initial report was delayed and submitted later that day.
Failure to Provide Effective CPR per AHA Standards and Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with American Heart Association (AHA) standards and facility policy for a resident who became unresponsive. The resident, admitted with diagnoses including atherosclerotic heart disease, peripheral vascular disease, and depression, had a documented code status of full code. When the resident was reported by a CNA as acting differently and then found clammy and nonresponsive, the LPN assessed the resident, attempted sternal rubs without response, went to the nurse’s station to call 911, and upon returning found the resident not breathing and without vital signs. The LPN then initiated CPR while the resident remained on the bed, without using a back board or moving the resident to a hard surface, despite acknowledging that CPR is more effective on a hard surface. Emergency services arrived and took over CPR, and the resident later expired at the hospital. Surveyors determined that CPR was not administered according to AHA standards, which emphasize the need for a firm, hard surface to maximize compression depth, and not according to the facility’s Code Blue and Crash Cart policy requiring trained staff to respond to cardiopulmonary arrest. The investigation also found that the LPN who performed CPR had a lapse in CPR certification, with their prior certification expiring in 01/2024 and a new card not issued until a later date, leaving a period during which they were not CPR certified. Another LPN reported not knowing the location of the crash cart or crash cart key when asked to retrieve an ambu bag during the event, and stated that CPR should be performed on a hard surface such as the floor or a back board. The DON stated that CNAs were trained to call the nurse and retrieve the crash cart, that nurses should know where the back board is and use it for CPR, and that nursing staff should be certified in CPR and know AHA guidelines, with CPR certification required bi-annually.
Removal Plan
- Educate all nursing staff on code blue procedures, crash cart policy, and the location of emergency equipment, including the crash cart and back board
- Ensure all remaining nursing staff complete education and acknowledge understanding of the procedures
- Do not assign staff who have not completed education to resident care duties
Incomplete Dialysis Assessments for Resident
Penalty
Summary
The facility failed to ensure that pre and post dialysis patient assessments were completed and routinely documented for a resident requiring dialysis care. The resident, who had stage five chronic kidney disease and was dependent on renal dialysis, reported that nursing staff had not been performing vital checks as required for their dialysis care. A review of the dialysis assessment documentation revealed that out of 28 dialysis sessions, assessments were only documented for 14 sessions, with some forms partially filled out and missing return assessment data. The facility did not have a policy in place for the care of residents receiving dialysis services, and the Director of Nursing was unaware of the incomplete assessments.
Failure to Ensure Dietary Staff Wore Protective Gear
Penalty
Summary
The facility failed to ensure that dietary staff adhered to proper hygiene protocols while preparing food for residents. Specifically, on December 2, 2024, at 8:05 a.m., a cook was observed preparing food without wearing a hair net or beard guard. The cook acknowledged the requirement to wear these protective items and mentioned that the facility was out of beard guards until the next delivery. The dietary manager confirmed that staff should be wearing hair nets and beard guards. Additionally, the administrator reiterated that dietary staff are expected to wear these protective items.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound and catheter care for a resident. A Licensed Practical Nurse (LPN) was observed providing care to a resident with a suprapubic urinary catheter without performing hand hygiene between glove changes. The LPN changed gloves multiple times during the procedure but did not clean their hands at any point, despite acknowledging the importance of hand hygiene in preventing infection transmission. The resident had a history of multiple hospitalizations for urinary tract infections, highlighting the critical need for proper infection control measures. Additionally, the facility did not maintain an effective water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens. Although a water management policy was in place, the maintenance supervisor admitted that monitoring had not yet begun. This oversight indicates a lapse in implementing necessary control measures to ensure the safety of the building's water system.
Failure to Notify Resident's Representative of Fall
Penalty
Summary
The facility failed to notify a resident's representative of a fall, which is a requirement according to their Family Notification Policy. The policy mandates that a primary contact person or Power of Attorney (POA) should be informed of any accidents or injuries, including falls. Resident #57, who has diagnoses of dementia and weakness, experienced a fall on 09/13/24. However, a late entry nurse note from that date did not document any contact with the resident's representative. It was later revealed during an interview on 12/04/24 that the resident's representative was not informed of the fall until 09/18/24, indicating a lapse in communication. The Director of Nursing (DON) confirmed that the family should have been notified immediately after the fall.
Medical Director's Absence in Care Plan Development
Penalty
Summary
The facility failed to ensure the participation of the medical director or their representative in the care plan development for a resident. The facility's policy required a comprehensive care plan to be developed within seven days after the Minimum Data Set (MDS) completion, involving all interdisciplinary team members. However, during a care plan meeting for a resident with intact cognition, the medical director or their representative did not attend, nor was there any documentation indicating their review of the meeting's results. The MDS coordinator confirmed that while the physician was notified of the meeting, they did not attend, and the results were not reviewed by the physician. The coordinator also mentioned that the medical director is usually not involved unless an order is required. The Director of Nursing (DON) acknowledged that the physician should participate in care planning and review the care plans, indicating a lapse in adherence to the facility's policy and procedure.
Failure to Monitor Resident After Fall
Penalty
Summary
The facility failed to monitor a resident after a fall, as required by their policy. Resident #57, who had diagnoses including dementia and weakness, experienced a fall. A late entry nurse note documented the fall but failed to indicate whether the resident's representative or the DON/ADON had been notified, and it did not specify if the fall was witnessed or unwitnessed. Additionally, the note did not document that neuro checks had been initiated. No further post-fall documentation was found in the resident's health record. LPN #1 confirmed that after a fall, a complete assessment should be conducted, and the physician, family, and DON should be notified. The LPN also stated that neuro checks should be implemented immediately if the fall was unwitnessed or if there was a head injury, and the resident should be on priority charting for three days. The DON acknowledged that the facility policy had not been followed after the resident's fall.
Non-compliance with PRN Antianxiety Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the prescription of antianxiety medications on an as-needed (PRN) basis. Specifically, a resident with diagnoses of anxiety disorder and depression was prescribed alprazolam, an antianxiety medication, to be taken every 8 hours as needed. The physician's order for this medication did not include a stop date, nor was there a documented rationale from the physician explaining why the PRN order should extend beyond the standard 14-day limit. During an interview, the Director of Nursing (DON) confirmed that no rationale from the physician had been located, acknowledging that PRN psychotropic medications should be limited to 14 days without a physician's justification for extended use.
Failure to Implement Abuse Policy for Employee Screening
Penalty
Summary
The facility failed to implement its abuse policy for screening potential employees, which is crucial for the prevention of abuse, neglect, and exploitation. Specifically, the facility did not complete registry checks or enroll three employees (two CNAs and one LPN) for criminal history monitoring. The employees had affirmed the conditions for provisional employment related to background checks, and the background summaries indicated they were eligible for employment. However, there was no documentation to confirm that the necessary registry checks were completed or that the employees were enrolled for ongoing criminal history monitoring under the facility. The administrative assistant confirmed that after receiving the provisional employment forms and consent to release forms, they entered the basic information into the background check system, which indicated eligibility for employment. Consequently, no further searches were conducted, and new registry checks were not completed. This oversight affected three employees, potentially compromising the safety and well-being of the 64 residents residing in the facility.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were thoroughly investigated for two residents. Resident #1, who had severe cognitive impairment, was allegedly physically restrained by a CNA, as observed on a video monitoring device. The incident was reported to the ADON, who then informed the DON. The video footage was reviewed, and the police were called. The resident was assessed for injuries, and the CNA was suspended and later terminated. However, there was no documentation of interviews with other residents or staff related to the incident. Resident #2, who had moderate cognitive impairment, was found with scattered bruising and reported being hit by a boy. The incident was reported to the police, and an employee was terminated for violating policy. Similar to the first case, there was no documentation of additional interviews with residents or staff. The DON confirmed that no further documentation was available beyond what was submitted to OSDH.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe. The incident involved a resident with vascular dementia, communication deficit, history of falls with injury, and cerebellar stroke syndrome. The suspected abuse by a Certified Nursing Assistant (CNA) was visualized on a video monitoring device at 3:30 a.m. on 02/28/24. The Licensed Practical Nurse (LPN) reported the incident to the Assistant Director of Nursing (ADON), who then advised to review the footage the next morning. The ADON reported the incident to the Director of Nursing (DON) at 9:30 a.m. on 02/29/24, and the initial report was submitted to OSDH later that day at 12:32 p.m. and 1:01 p.m., well beyond the two-hour reporting requirement. The facility's policy, dated 10/2022, mandates immediate reporting of all alleged violations involving abuse within two hours of occurrence. Despite this policy, the initial report was delayed, and there was no documentation that the incident was reported to OSDH within the required timeframe. The DON confirmed that the report was not submitted within the two-hour window. The resident was assessed for injuries, and none were noted. The CNA involved was placed on suspension pending further investigation.
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Illustrative
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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Nursing homes near Bartlesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Villa Care & Rehab Center | 1.2 mi | ★★★★★ | 5 | 0 |
| Medicalodges Dewey | 1.6 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Adams Parc | 1.7 mi | ★★★★★ | 0 | 0 |
| Forrest Manor Nursing Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Nowata Nursing Center | 16.6 mi | ★★★★★ | 1 | 0 |
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