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 Beacon Ridge during CMS and state inspections, most recent first.
A facility failed to provide a resident with a 30-day written notice of transfer or discharge, as well as necessary documentation and information about appeal rights. The resident, with multiple diagnoses, was transferred to a hospital without receiving proper notice or assistance in appealing the decision. The facility did not adhere to its policies, resulting in a lack of communication with the resident, their representative, and the ombudsman's office.
A resident with multiple diagnoses was transferred to a hospital without receiving the required bed-hold policy documentation. The resident, who expressed a desire to leave the facility and refused treatment, was aggressive towards staff. The facility failed to document any interventions or referrals to address the resident's behavior. Upon the resident's return, the facility refused to accept them, leaving them in cold weather without proper documentation or notification to relevant parties.
A resident with multiple diagnoses was not allowed to return to the facility after hospitalization due to aggressive behavior and refusal of care. The facility failed to provide necessary documentation for the resident to appeal the discharge decision and did not notify the required parties. The LPN did not provide the resident with transfer forms, and the social service director was unaware of their documentation responsibilities.
The facility did not ensure that three residents were offered the right to formulate an advance directive, as their medical records lacked the necessary documentation. This issue was confirmed by the corporate nurse, who stated that the forms were not completed.
The facility did not conduct a thorough investigation after an abuse allegation, as required by their policy. An incident was reported, but lacked documentation of an investigation. The administrator acknowledged the need for personal statements and safe surveys, but could not find any investigation records.
The facility failed to complete quarterly MDS assessments on time for three residents. The assessments were not completed within the required 14 days after the ARD, with delays ranging from several days to over a month. The MDS coordinator noted that the facility had been without an MDS coordinator for about five months, contributing to the issue.
The facility failed to develop comprehensive care plans for residents, resulting in deficiencies in addressing medical needs. A resident with diabetes and atrial fibrillation lacked care plans for diabetic monitoring and anticoagulant therapy. Another resident's care plan did not document ADLs. A resident with a new pressure ulcer had no care plan for it, and a resident with psychosis had no care plan for their diagnosis or antipsychotic medication. These omissions were acknowledged by the corporate nurse.
The facility failed to conduct entrapment risk assessments and obtain informed consent for bed rail use for several residents. Observations revealed that residents were using bed rails without proper documentation, including physician orders and care plan entries. Interviews with staff indicated a lack of awareness of the facility's policy on bed rail use.
A significant medication error occurred when a resident with adrenocortical insufficiency and hypothyroidism was administered an incorrect dosage of fludrocortisone. The resident was prescribed 0.5mg daily (5 tablets of 0.1mg each), but only one tablet was given daily over multiple administrations. This error was confirmed by the corporate nurse and pharmacy technician, highlighting a failure to follow physician's orders.
The facility failed to store food according to professional standards, with several open bottles of thickened liquids past their discard dates or not dated. The walk-in freezer had significant ice accumulation, indicating improper storage. Additionally, the dish machine failed to sanitize dishes, as shown by multiple tests with no chlorine reaction. The DM acknowledged these issues, affecting the safety and quality of food services for 57 residents.
The facility did not maintain a water management program to prevent Legionella growth, as required by their policy. The maintenance supervisor was unaware of the program and had not monitored the water system, and the corporate nurse confirmed the absence of such a program.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, posing potential safety hazards for residents with conditions like morbid obesity and muscle weakness. Despite a policy requiring routine maintenance, the facility lacked documentation of inspections, as confirmed by the DON.
The facility did not report an abuse allegation involving an LPN to OSDH within the required two-hour timeframe, as per their policy. The incident was documented, but the report was delayed by a day. The MDS coordinator acknowledged the failure to meet the reporting deadline.
The facility failed to complete comprehensive MDS assessments within the required time frame for two residents. A significant change MDS for a resident was delayed by over a month, and another resident's admission assessment was not completed timely. The MDS coordinator acknowledged the facility had been without an MDS coordinator for about five months, contributing to the issue.
A facility failed to develop a baseline care plan within 48 hours of a resident's admission, as required. The MDS coordinator admitted that the facility had been without an MDS coordinator for about five months, resulting in issues with care plans.
A resident with chronic kidney disease, hypertension, and chronic pain syndrome had a care plan that was not updated to include the use of a Hoyer lift for transfers and the presence of an indwelling catheter. Despite a physician's order and a significant change assessment, the care plan remained unchanged, as observed during a survey. A corporate nurse confirmed the care plan should have been revised.
A facility failed to obtain a physician's order for a catheter for a resident with chronic kidney disease, hypertension, and chronic pain syndrome. The resident was observed with a catheter draining to gravity, but their record lacked a physician's order and the care plan did not document the catheter. The corporate nurse acknowledged the need for a physician's order and a care plan.
A facility failed to maintain a medication error rate below 5%, with two errors identified during a medication pass. A resident received incorrect doses of fludrocortisone and vitamin D3, as confirmed by staff interviews and pharmacy verification. The errors resulted in a medication error rate of 6.67%.
The facility did not ensure the QAA committee met quarterly, with the last meeting documented in February 2024. A meeting was missed in August 2024 due to the absence of a DON and staff shortages. The interim administrator confirmed the lack of documentation for the required meetings.
The facility failed to conduct and document a facility-wide assessment necessary to care for 56 residents competently during both day-to-day operations and emergencies. The BOM and the stand-in administrator were unable to provide a facility assessment and were unsure of its requirements.
The facility failed to implement its infection control program effectively during an influenza outbreak, leading to the spread of the virus among residents and staff. Observations revealed inconsistent mask usage, lack of available masks and alcohol gel, and failure to notify the OSDH. Several residents with respiratory symptoms were not placed under droplet precautions, and staff were not adequately trained on precautionary measures. Infection control logs and tracking maps were also found to be blank.
A resident admitted with dental caries and other diagnoses did not have a comprehensive care plan developed for their dental status, including necessary teeth extractions. The DON confirmed the care plan was not completed as required.
The facility failed to maintain complete and accurate medical records for a resident, including documentation of medical appointments, dental extractions, and follow-up care, as confirmed by the DON.
Failure to Provide Proper Transfer/Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a 30-day written notice of transfer or discharge to a resident and their representative, as well as to the ombudsman's office. The resident, who had diagnoses including fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder, was transferred to a hospital without receiving the necessary documentation or information about their rights to appeal the transfer. The facility's policy required that such notices be given in advance, but this was not adhered to in the case of the resident. The resident was initially admitted to the facility from another nursing home and was noted to be pleasant and oriented. However, the resident later expressed a desire to leave the facility and refused treatment, which led to aggressive behavior towards staff. Despite these circumstances, the facility did not provide the resident with the required documentation or assistance in appealing the transfer decision. The facility also failed to contact relevant agencies or make referrals for the resident's intellectual disabilities. Additionally, the facility did not provide the resident with information on how to obtain an appeal form or assist them in completing and submitting an appeal hearing request. The facility's failure to follow its own policies and procedures resulted in a lack of proper documentation and communication with the resident, their representative, and the ombudsman's office. This oversight was further compounded by the facility's inability to provide evidence of any interventions or referrals made to support the resident's care and cooperation.
Failure to Provide Bed-Hold Policy and Proper Discharge Documentation
Penalty
Summary
The facility failed to provide the bed-hold policy to a resident who was transferred to the hospital. The facility's policy requires that all residents or their representatives receive written information about the bed-hold policy at least twice: once in advance of any transfer and again at the time of transfer. However, in the case of the resident in question, there was no documentation that the resident or their representative received this information. The resident, who had diagnoses including fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder, was transferred to a hospital without receiving the necessary paperwork. The resident was admitted to the facility from another nursing home and was noted to be pleasant and alert. However, the resident later expressed a desire to leave the facility and refused treatment, becoming aggressive towards staff. The facility's staff documented incidents of the resident being a danger to themselves and others, including physical and sexual aggression. Despite these issues, there was no documentation of any interventions or referrals made to address the resident's behavior or to assist with their transfer to a more suitable care setting. When the resident was transported back to the facility by an ambulance service, the facility staff refused to accept the resident, leaving them lightly clothed and strapped to a gurney in cold weather. The ambulance service director reported that neither they nor the resident were informed of the reasons for the facility's refusal to accept the resident back, nor were they provided with any paperwork. The facility also failed to notify the resident's representative, the ombudsman, or the State LTC office about the discharge, as required by policy.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating their own transfer and discharge policy. The resident, who had diagnoses including fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder, was transferred to a hospital due to aggressive behavior and refusal of care. The facility's policy states that residents sent to acute care settings are expected to return unless a discharge is initiated based on the resident's status upon seeking return. However, the facility did not permit the resident's return, citing the resident's behavior as a danger to staff and themselves. The facility did not provide the resident with the necessary documentation to appeal the discharge decision, nor did they notify the resident, their representative, the ombudsman, or the State LTC office as required. The facility's administrator admitted that there was no documentation in the resident's clinical record to show that the facility followed its policies regarding the appeal process and notification requirements. Additionally, the social service director and administrator did not contact the local company that provides services for individuals with intellectual disabilities, nor did they reach out to DHS for assistance. The LPN responsible for the transfer packet stated that the resident did not receive a copy of the transfer forms, and the social service director, who was new to the position, was unaware of their responsibilities in documenting the resident's clinical records. The facility's failure to adhere to its policies and procedures regarding resident transfers and discharges resulted in the resident not being allowed to return to the facility, and the necessary appeal process was not facilitated.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to ensure that residents were offered the right to formulate an advance directive, as evidenced by the absence of such documentation for three of the six sampled residents. Specifically, the medical records for residents #107, #32, and #7 did not contain an advance directive or an acknowledgment form indicating that the residents had been offered the opportunity to create one. This deficiency was identified during a review of the residents' medical records and confirmed through an interview with the corporate nurse, who acknowledged that the forms were not completed.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse, as required by their Abuse, Neglect, and Exploitation policy. This policy mandates an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation, including identifying and interviewing all involved parties and providing complete documentation. An incident reported on 10/04/24 documented an allegation of abuse, but the report to the OSDH lacked supplemental documentation of an investigation. On 11/19/24, the administrator acknowledged responsibility for abuse investigations and stated that the investigation should include personal statements and safe surveys, as well as statements from those making the allegations. However, they were unable to locate any documentation of an investigation for the incident in question.
Delayed Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments in a timely manner for three residents. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, quarterly assessments must be completed no later than 14 calendar days after the Assessment Reference Date (ARD). However, for one resident, the assessment with an ARD of October 15, 2024, was not completed until November 18, 2024. Similarly, another resident's assessment with the same ARD was also completed on November 18, 2024. A third resident had an ARD of October 14, 2024, but the assessment was not completed until November 12, 2024. The MDS coordinator acknowledged the issue, stating that the facility had been without an MDS coordinator for about five months, which contributed to the delay in completing the MDS assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. One resident with type II diabetes mellitus and atrial fibrillation did not have documented care plans for diabetic monitoring or anticoagulant therapy, despite having physician orders for insulin and anticoagulant medications. Another resident with shortness of breath, weakness, and chronic kidney disease lacked documentation of activities of daily living (ADLs) in their care plan, which was confirmed by the MDS coordinator. Additionally, a resident with chronic kidney disease, hypertension, and chronic pain syndrome developed a new pressure ulcer, but no care plan was created to address this condition. Furthermore, a resident with an unspecified psychosis diagnosis was prescribed Risperdal, an antipsychotic medication, yet their care plan did not document the psychosis diagnosis or the antipsychotic medication therapy. These omissions were acknowledged by the corporate nurse, indicating a failure to ensure that care plans were comprehensive and reflective of the residents' medical needs.
Failure to Conduct Bed Rail Assessments and Obtain Consent
Penalty
Summary
The facility failed to perform necessary assessments and obtain required documentation for the use of bed rails for several residents. Specifically, the facility did not conduct entrapment risk assessments for four residents, nor did it obtain informed consent for the use of bed rails for these individuals. Additionally, a physician order was not obtained for one resident, and care plans did not include documentation of bed rail use for two residents. These omissions were identified through observations, record reviews, and interviews. Resident #3, who was admitted with diagnoses including morbid obesity and reduced mobility, was observed using bilateral Halo bed rails without documentation of an entrapment risk assessment, informed consent, or a physician order. Similarly, Resident #5, admitted with weakness and insomnia, had a physician order for bed rails but lacked informed consent documentation. Resident #44, with muscle weakness and reduced mobility, had not had an entrapment risk assessment since June 2022 and also lacked informed consent documentation. Resident #14, with muscle weakness and cerebral infarction, was observed with bed rails but had no documentation of an entrapment risk assessment or informed consent. Interviews with facility staff, including an LPN and the DON, revealed a lack of awareness and adherence to the facility's policy regarding bed rail use. The DON acknowledged that a physician order, entrapment risk assessment, and informed consent should have been completed prior to the use of bed rails for all residents. The DON also stated that entrapment risk assessments should be conducted quarterly and documented in the residents' care plans.
Significant Medication Error Due to Incorrect Dosage Administration
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident with diagnoses of adrenocortical insufficiency and hypothyroidism. The resident was prescribed fludrocortisone, a corticosteroid, at a dosage of 0.5mg (5 tablets of 0.1mg each) to be taken daily. However, the medication administration records revealed that only one tablet was administered daily instead of the prescribed five tablets. This error persisted over multiple administrations, as evidenced by the remaining 71 tablets from a prescription filled for 150 tablets on 09/04/24, indicating that only 79 tablets had been administered over 79 days. The error was identified when CMA #1, responsible for administering the medication, admitted to giving only one tablet during the morning medication pass, unaware of the correct dosage noted on the blister pack. The corporate nurse confirmed that the prescription should have lasted 30 days if administered correctly, acknowledging the significant medication error. The pharmacy technician verified the last refill of the medication, further supporting the discrepancy in administration. This oversight in medication administration was not in accordance with the physician's orders, leading to a significant medication error for the resident.
Deficiencies in Food Storage and Dish Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitation, as observed during an initial tour of the kitchen. Several open bottles of thickened liquids, including nectar thickened water with lemon, nectar thickened orange juice, and honey thickened milk, were found to be past their discard dates or not dated at all. Additionally, the walk-in freezer exhibited significant ice accumulation, with ice on the outside of the door seal, icicles hanging above the door frame, and ice on the floor and back wall. These conditions indicate improper storage and potential safety hazards for food items. Furthermore, the dish machine was found to be ineffective in sanitizing dishes, as evidenced by multiple tests showing no reaction on chlorine strips. The Dietary Manager (DM) confirmed that the dish machine was tested daily, yet it failed to sanitize properly during the survey. The DM acknowledged the issue and mentioned that they would need to use paper products and contact the dish machine service provider. These deficiencies in food storage and dish sanitation could impact the safety and quality of food services provided to the 57 residents receiving services from the kitchen.
Failure to Maintain Legionella Water Management Program
Penalty
Summary
The facility failed to maintain a water management program aimed at preventing the growth of Legionella and other opportunistic waterborne pathogens in the building's water system. The Legionella Water Management policy, revised in September 2022, outlined the need for an interdisciplinary water management team, a detailed description and diagram of the water system, identification of areas prone to Legionella growth, and specific measures to control its spread. However, no documentation of such a program was found during the record review. The maintenance supervisor was unaware of the water management program and had not monitored the water system for Legionella as per the policy, indicating a lack of education on this task. Additionally, the corporate nurse confirmed that the facility had not maintained a water management program.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for residents. This deficiency was identified through observations, record reviews, and interviews, affecting four residents who were reviewed for accident hazards. The facility's policy on the proper use of bed rails mandates correct installation, use, and maintenance, including routine preventative maintenance to ensure safety standards are met. However, the facility was unable to provide documentation of regular inspections and maintenance for the bed rails used by the residents. The deficiency involved residents with various medical conditions, including morbid obesity, muscle weakness, reduced mobility, and cerebral infarction. These residents required assistance with bed mobility and used bed rails for positioning and turning. Despite the presence of bed rails, the facility did not adhere to its policy of ensuring compatibility and safety through regular inspections. The Director of Nursing (DON) confirmed the lack of documentation for these inspections, highlighting a lapse in the facility's maintenance program for bed safety equipment.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe. According to the facility's Abuse, Neglect, and Exploitation policy, all allegations of abuse must be reported immediately, but no later than two hours after the allegation is made. An incident report dated October 16, 2024, documented an allegation of abuse involving an LPN. However, the incident report was not sent to OSDH until October 17, 2024, exceeding the mandated reporting period. On November 19, 2024, the MDS coordinator confirmed that the incident report should have been sent within two hours but was not.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for two residents. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a significant change MDS must be completed no later than the 14th calendar day after determining a significant change has occurred, and an admission assessment must be completed no later than the 14th day of the resident's admission. Resident #15 had a significant change assessment with an Assessment Reference Date (ARD) of October 16, 2024, but the MDS was not completed and signed until November 18, 2024. Resident #109 was admitted to the facility, but a comprehensive MDS was not completed until November 18, 2024. The MDS coordinator acknowledged that the facility had been without an MDS coordinator for about five months, which contributed to the issue with the completion of MDS assessments.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which is a requirement for ensuring immediate needs are met. The resident was admitted to the facility, but as of a specified date, there was no active care plan documented in their chart. The MDS coordinator acknowledged that baseline care plans should be completed within 48 hours of admission and noted that the facility had been without an MDS coordinator for about five months, leading to issues with care plans.
Failure to Revise Care Plan for Resident with New Transfer and Catheter Needs
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was admitted with chronic kidney disease, hypertension, and chronic pain syndrome. A significant change assessment noted the resident was frequently incontinent of bladder and required partial to moderate assistance with transfers, but did not document the presence of an indwelling catheter. A physician's order later specified the use of a Hoyer lift for all transfers. However, the care plan was not updated to reflect the use of the lift or the presence of the catheter. This deficiency was identified during an observation where the resident was seen with a catheter draining to gravity at bedside, and confirmed by a corporate nurse who acknowledged the care plan should have been revised accordingly.
Failure to Obtain Physician's Order for Catheter
Penalty
Summary
The facility failed to obtain a physician's order for a catheter for a resident who was admitted with chronic kidney disease, hypertension, and chronic pain syndrome. During an observation, the resident was seen resting in bed with a catheter draining to gravity at the bedside. Upon reviewing the resident's record, it was found that there was no physician's order for the catheter, and the resident's care plan did not document the presence of the catheter. The corporate nurse confirmed that a physician's order should have been obtained and a care plan for the catheter should have been developed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by observations during a medication pass. Out of 30 medication administration opportunities, two errors were identified, resulting in a medication error rate of 6.67%. The errors involved incorrect doses of medication given to a resident. Specifically, the resident was prescribed fludrocortisone 0.1mg tablets, with a dosage of 0.5mg (5 tablets) daily, and vitamin D3 25mg daily. However, during the medication pass, the resident received only one tablet of fludrocortisone and a vitamin D3 dose of 1,000 IU, which was not equivalent to the prescribed 25mg. The errors were confirmed through interviews with the staff involved. CMA #1, who administered the medications, acknowledged administering only one tablet of fludrocortisone and was unaware of the correct dosage. Additionally, CMA #1 was uncertain about the vitamin D3 dosage equivalence. LPN #1 verified the errors after consulting with the pharmacy and reviewing the resident's medication orders. The corporate nurse was informed of these observations and acknowledged the occurrence of the two medication errors.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly, as required. The last documented QAA meeting occurred in February 2024. A form dated August 22, 2024, indicated that a meeting was not held in August 2024 due to the absence of a Director of Nursing (DON) and staff shortages. On November 21, 2024, the interim administrator confirmed that quarterly QAA meetings should have been conducted and acknowledged that documentation for these meetings could not be found.
Failure to Conduct and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment necessary to care for residents competently during both day-to-day operations and emergencies. The BOM identified that 56 residents resided in the facility. On multiple occasions, the BOM and the stand-in administrator were unable to provide a facility assessment. Initially, the BOM was unsure what a facility assessment was and referred to the stand-in administrator. The stand-in administrator presented an emergency preparedness book, which was not a facility assessment. Despite being informed of the required components of a facility assessment, the stand-in administrator admitted to never having seen one in any of their buildings and was unable to locate it.
Failure to Implement Infection Control Program During Influenza Outbreak
Penalty
Summary
The facility failed to implement its infection control program effectively to prevent the spread of influenza. Observations revealed that staff members were not consistently wearing masks, and there were no masks or alcohol gel available at the facility's entry. Additionally, the facility did not notify the Oklahoma State Department of Health (OSDH) when residents and staff tested positive for influenza. The facility also lacked a surveillance plan for identifying, tracking, monitoring, and reporting signs and symptoms of influenza among residents and staff. This failure affected six of the seven residents sampled for infection control, as well as several staff members who were out sick with the flu. Resident #1, who had diagnoses including influenza type A, COPD, and obstructive sleep apnea, exhibited respiratory symptoms and was later diagnosed with influenza A. Despite this, droplet precautions were not implemented, and staff were not in-serviced on precautionary measures. Similar issues were observed with other residents, such as Resident #4, who had respiratory infection symptoms and was not placed under droplet precautions. The facility also failed to isolate residents with respiratory symptoms from other residents, including during smoking breaks. The facility's infection control logs and tracking maps for October, November, and December 2023, and January 2024 were found to be blank, indicating a lack of proper documentation and monitoring of infections. Staff members, including CNAs and LPNs, confirmed that they had not been in-serviced on how to implement precautionary measures to reduce influenza symptoms, when to isolate residents, and the type of isolation required. This lack of training and implementation of infection control measures contributed to the spread of influenza within the facility.
Failure to Develop Comprehensive Dental Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident's dental status. The resident, who was admitted with diagnoses including diabetes, dental caries, and hypertension, had an admission assessment indicating obvious or likely cavities or broken natural teeth. Despite this, no comprehensive care plan was created or implemented to address the resident's dental issues, including the need for upper and lower teeth extractions. The Director of Nursing confirmed that a comprehensive care plan had not been completed but should have been.
Incomplete Resident Records
Penalty
Summary
The facility failed to ensure resident records were complete for one of three residents whose records were reviewed. Resident #10, who was admitted with diagnoses including diabetes, dental caries, hypertension, right shoulder pain, and atrial fibrillation, had multiple instances of incomplete documentation. Specifically, there was no documentation of the resident's attendance at orthopedic appointments on two separate occasions, nor was there any record of the resident's condition upon return to the facility or any physician orders that may have been given. Additionally, there was no documentation of the resident undergoing upper and lower teeth extractions, nor any follow-up observations or aftercare provided post-extraction. The Director of Nursing (DON) confirmed that the facility's policy requires nurses to document any significant changes in a resident's condition for at least 72 hours, as well as to document when a resident leaves and returns to the facility and any physician orders given. However, this documentation was not completed for Resident #10, as confirmed by the DON. The lack of proper documentation indicates a failure to maintain complete and accurate medical records in accordance with accepted professional standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 101 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sapulpa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Village | 1 mi | ★★★★★ | 10 | 0 |
| The Gardens | 2.1 mi | ★★★★★ | 0 | 0 |
| Covenant Living At Inverness | 6.2 mi | ★★★★★ | 0 | 0 |
| Glenwood Skilled Nursing And Therapy | 7.9 mi | ★★★★★ | 4 | 0 |
| Sherwood Manor Nursing Home | 8.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.