Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bellevue Health & Rehabilitation Center during CMS and state inspections, most recent first.
Eighteen dietary contract staff members did not receive required abuse prevention and reporting training prior to working, due to an oversight by the dietary contractor and unclear contract terms. The DON and facility leadership confirmed the omission, which affected all dietary contract staff while 141 residents were present.
The facility did not ensure that all dietary contractor staff received required training on abuse prevention and reporting, as mandated by facility policy. Eighteen dietary staff members began working without this training due to an oversight in the contractor's orientation process, leaving 141 residents without the protection of fully trained staff.
Damaged room surfaces and an unlevel bed were observed for two residents. One resident with Alzheimer's disease had chipped paint, damaged sheetrock, and debris on the floor, while a CNA said the room had looked that way for months and the bed was pushed too close to the wall. Another resident with dementia and diabetes was found in a bed with padding under the mattress, unable to lie centered because of discomfort from the bed frame, while the walls around the bed were also damaged; the ADON was unaware of the issue and the administrator stated the bed was not level.
A facility failed to provide enough trained dietary support staff to serve meals on time during multiple dining observations. Breakfast and lunch trays were repeatedly prepared or delivered after the posted meal times, and residents reported cold food, late meals for weeks, and anxiety about not knowing when meals would arrive. The dietary manager stated the kitchen was working with several new staff members and was slower than needed in preparing and serving food.
Food Storage, Labeling, and Sanitation Failures: The facility failed to label and date prepared foods and opened items, discarded expired or spoiled food, complete refrigerator/freezer temperature logs, and maintain a sanitary kitchen environment. Surveyors observed unlabeled drinks and cereal-like items, bread products without dates, moldy cucumbers, discolored lettuce, multiple opened foods without dates, expired items, incomplete sanitizer logs, debris in dining room storage, standing water in an ice machine, and construction debris and haze in the kitchen area while maintenance work was occurring nearby.
Resident-accessible bathrooms lacked working call lights in 2 observed areas. An unlocked bathroom outside the therapy hall was open for mobile residents who could self-transfer, but it had no call light, and the bathroom on hall 500 also had no call light. Medical Records, an LPN, and the DON all confirmed these bathrooms were accessible to residents and should have call lights available.
Improper Handling of Soiled Linen for Contact Precautions: The facility failed to process soiled linen from rooms on contact precautions using required PPE in the laundry area. During observation, no gowns were available, and the laundry manager stated staff wore gloves to transport red biohazard bags but did not wear gowns when opening the bags and placing soiled linen into the washer. The IP stated laundry staff should wear gloves and a gown when handling soiled linen from contact or isolation precautions.
Two residents who required substantial assistance for transfers did not have specific transfer interventions documented in their care plans, despite staff consistently using devices such as a slider board and sit-to-stand lift. Assessments and therapy plans indicated the need for these supports, but the care plans lacked this information, as confirmed by staff and administrative review.
The facility failed to administer oxygen according to physician orders and did not label O2 tubing for two residents. One resident with SOB had unlabeled O2 tubing, and another was receiving O2 at 1.5 LPM instead of the ordered 2 LPM, with unlabeled tubing. An LPN confirmed the discrepancies in O2 administration and labeling.
A facility failed to conduct required pre and post-dialysis assessments for a resident with end-stage renal disease, as mandated by their policy. Despite physician orders for monitoring and progress notes, documentation was missing for several dates, indicating non-compliance with the assessment requirements. The DON confirmed the assessments were not completed as required.
The facility failed to follow infection control protocols for residents on transmission-based and enhanced barrier precautions. Staff did not wear required PPE or sanitize equipment for a resident with MRSA, and two CNAs did not use PPE for a resident with a gastrostomy. Additionally, a CNA did not change gloves during incontinent care, compromising infection control.
A facility failed to provide a resident with double portions as ordered by a physician. The resident, with a history of Type 2 Diabetes Mellitus and hemiplegia, was observed receiving a meal tray with single portions instead of the prescribed double portions. A CNA confirmed the absence of double portions and admitted not noticing the requirement on the meal ticket.
A facility failed to label an enteral tube feeding bottle for a resident with dysphagia and gastrostomy status. The resident's feeding and H2O bags were not marked with staff initials, date, or time, contrary to facility policy. An LPN confirmed the oversight during an observation.
A resident with respiratory care needs did not receive medications as ordered by the physician. The resident was prescribed loratadine and guaifenesin, but the MARs showed incomplete administration of guaifenesin and no documentation of loratadine administration. The resident reported a respiratory infection and sinus drainage, and the facility's DON and ADON were informed of the medication discrepancies. Guaifenesin was a house stock medication, while loratadine was delayed in delivery, with poor communication among nursing staff about its status.
Failure to Provide Abuse Training to Dietary Contract Staff
Penalty
Summary
The facility failed to ensure that all 18 dietary contract employees received required training on abuse prevention, identification, and reporting prior to working. According to the facility's Abuse Prevention Program policy, mandated staff training on abuse is required for all staff, including contract employees. However, record review and interviews revealed that the dietary contractor was responsible for providing this training but did not include the necessary abuse training in their orientation or supplemental materials for dietary staff. The DON confirmed that the dietary staff had not been trained on identifying and reporting abuse before starting their duties. Interviews with human resources, the regional director of operations, and the administrator indicated that there was confusion regarding the responsibility for abuse training. The facility expected the dietary contractor to provide the training, but the contractor omitted the abuse training supplement. The contract between the facility and the dietary contractor did not clearly specify the requirement for abuse training, leading to the oversight. At the time of the survey, 141 residents resided in the facility, and none of the 18 dietary contract staff had received the mandated abuse training.
Failure to Train Dietary Contractor Staff on Abuse Prevention and Reporting
Penalty
Summary
The facility failed to implement its abuse prevention policy by not ensuring that all dietary contractor staff received training on identifying and reporting abuse. According to the facility's Abuse Prevention Program policy, all staff are required to undergo mandated training on abuse prevention, identification, and reporting. However, record review and interviews revealed that none of the 18 dietary contractor staff members had received this training prior to working in the facility. The dietary contractor was responsible for providing this training, as outlined in the Management Service Agreement, but the abuse training was omitted from the orientation process for these staff members. Interviews with facility leadership, including the DON, human resources, regional director of operations, and the administrator, confirmed that the dietary contractor was expected to provide abuse training to their employees, but this requirement was either overlooked or not included in the contract. As a result, 141 residents resided in the facility without assurance that all staff interacting with them were trained to identify and report abuse, neglect, or mistreatment, as required by facility policy.
Damaged Room Surfaces and Unlevel Bed
Penalty
Summary
The facility failed to ensure that walls and paint were in good repair for Resident #6 and Resident #3, and that Resident #3's bed was in good repair. Resident #6, who had a diagnosis of Alzheimer's disease and a BIMS score of 08, was observed in a room with chipped and peeled paint, deep scratches in the sheetrock behind the bed, and sheetrock debris on the floor. The resident's family representative stated the damaged wall bothered both the resident and the family representative. A CNA stated the wall damage had been present since 10/2025 and made the room look like it was not taken care of and maintained. The maintenance supervisor stated there were no outstanding work orders for the room and observed that the bed was pushed too close to the wall, contributing to damage on two walls, with chipped paint and sheetrock dust on the floor. Resident #3, who had diagnoses including dementia and diabetes, was assessed as cognitively intact with a BIMS score of 14 and dependent for bed mobility. The resident was observed in bed with padding added under the mattress and positioned at the side of the bed rather than in the center. The wall at the foot of the bed and the wall the bed was pushed against were damaged, with missing paint and deep scratches in the sheetrock. A CMA stated the resident could not sit in the middle of the bed because they felt the bars under it, and the family had placed padding under the mattress to make it more comfortable. The resident stated they could feel a bar or something under their bottom when lying in the middle of the bed. The ADON stated they were not aware of any residents with a broken bed or repositioning issues, and the administrator later stated the bed was not level and needed to be lowered and readjusted.
Late Meal Service and Inadequate Kitchen Staffing
Penalty
Summary
The facility failed to provide enough trained support personnel to safely and effectively carry out food and nutrition services for 4 of 4 dining observations. Survey observations showed breakfast trays being prepared at 8:48 a.m. when the posted breakfast time was 8:00 a.m., lunch trays delivered to a hall at 12:51 p.m. while dining room residents had not yet been served lunch despite a posted lunch time of 12:00 p.m., breakfast trays delivered to another hall at 9:00 a.m. while dining room residents had not yet been served breakfast, and lunch trays being delivered to the dining room at 12:50 p.m. with a posted lunch time of 12:00 p.m. An undated facility document listed meal times as breakfast at 8:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m. A resident stated they ate in their room and did not eat breakfast because they received cold pancakes that were not appetizing and said meal times had been late for the last several weeks. A CNA stated meal trays had been late since the new company took over the kitchen and that residents became anxious when they did not know when meals would arrive. The dietary manager stated they were working with several new staff members, not everyone knew their roles yet, and the kitchen was slower getting food prepared and served than needed.
Food Storage, Labeling, Temperature Monitoring, and Kitchen Sanitation Failures
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in accordance with professional standards. During kitchen observations, prepared drinks and cereal-like items in the hot food holding box were found without labels or preparation/use-by dates. In the food preparation area, multiple bread products were observed without manufacturer best-by dates or facility-marked dates, and the dietary manager stated they did not label and date bread products when they came in or when they were opened. In the walk-in refrigerator and freezer, surveyors observed fresh cucumbers that were soft to touch and had visible mold, opened shredded lettuce that was discolored and soft, and multiple opened or stored food items without labels, dates opened, or use-by dates, including ham, tomato sauce, tator tots, French fries, chicken tenders, sausage patties, and a bag of fajita chicken with a use-by date of 11/30/25. In dry storage, opened food items such as pancake mix, cornstarch, and refried pinto bean constitute were not sealed, labeled, or dated, and a bag of croutons had a use-by date of 11/30/25. The dietary manager stated opened items should be stored in sealed containers and items past the use-by date should be discarded. The facility also failed to complete temperature monitoring logs for the reach-in freezer and walk-in refrigerator on the morning of the observation. A 3-compartment sink was being used for dishwashing because the dishwasher was out of service, but the sanitizer dispenser log was not completed. Additional sanitation concerns were observed when salt and pepper storage containers in the dining room drawers had a moderate amount of debris, and an ice machine had brown standing water in the drainage tray. On 12/18/25, the kitchen area where the dishwasher was being repaired had a foggy haze, debris from construction and leaves on the floor, with maintenance workers present and no separation between the work area and food storage and preparation areas; the air curtain between the exit door and work area was not in use.
Resident-Accessible Bathrooms Lacked Call Lights
Penalty
Summary
The facility failed to ensure that resident-accessible bathrooms had working call lights in 2 of 2 bathrooms observed. On 12/16/25, a bathroom outside the therapy hall was observed unlocked, with the door open and a sign reading "restroom for patients only," yet it did not have a call light. At 1:15 p.m., the bathroom on hall 500 was also observed to be accessible to residents and did not have a call light. The DON identified that 141 residents resided in the facility. During interview, Medical Records stated the bathroom outside the therapy room was an unlocked and open bathroom that mobile residents who could self-transfer could use without supervision, and that there was not a call light in the bathroom. Medical Records stated a resident could have a slip and fall and would not be able to call for help. LPN #1 stated all resident-accessible bathrooms should have a call light and identified that the bathroom by the therapy room was accessible to residents and did not have one. The DON stated resident-accessible bathrooms should have handicap rails, grab bars, and call lights, and confirmed that the bathroom on hall 500 was accessible to residents and did not have a call light.
Improper Handling of Soiled Linen for Contact Precautions
Penalty
Summary
The facility failed to handle and process linens to prevent the spread of infection for residents on contact isolation in the laundry room. On 12/18/25 at 3:00 p.m., an observation of the laundry area found no gowns available. The facility policy titled "Laundry and Bedding, Soiled," dated September 2022, stated that hand hygiene products and appropriate PPE, including gloves and gowns, are available and used while sorting and handling contaminated linen. At 3:04 p.m., the housekeeping/laundry manager stated staff wore gloves to transport the red biohazard bags to the laundry area, opened the bags, and placed the soiled linen in the washing machine, but did not wear gowns when placing the soiled linen in the washing machine. At 3:12 p.m., the infection preventionist stated laundry staff should wear gloves and a gown when handling soiled linen from a room with contact precautions or isolation precautions to prevent the possible spread of infection.
Failure to Document Transfer Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plan interventions for transfers for two residents who were dependent on staff assistance for mobility. Both residents had documented needs for substantial to maximal assistance with transfers, as indicated by their assessments and physical therapy evaluations. Despite this, their care plans did not include specific interventions for transferring, such as the use of a slider board, gait belt, or sit-to-stand lift, even though these methods were observed being used by staff during transfers. Staff interviews confirmed that these transfer methods were consistently used, but not documented in the residents' care plans. The deficiency was identified through observations, record reviews, and staff and resident interviews. The MDS coordinator and DON both acknowledged that interventions for transfers should have been documented in the care plans, but were not. The residents involved had significant physical limitations, including one with an acquired absence of the right leg below the knee and another with Parkinson's disease and schizophrenia, both requiring assistance for safe transfers. The lack of documented interventions in the care plans was contrary to facility policy and regulatory requirements for comprehensive, person-centered care planning.
Failure to Administer Oxygen According to Orders and Label Tubing
Penalty
Summary
The facility failed to administer oxygen (O2) according to physician orders and did not label O2 tubing for two residents reviewed for respiratory care. One resident had a diagnosis of shortness of breath (SOB) and a physician order for oxygen at 2 liters per minute (LPM) via nasal cannula as needed to maintain O2 saturations. An O2 concentrator was observed in the resident's room, but the O2 tubing was not labeled. A Licensed Practical Nurse (LPN) confirmed that the O2 tubing should be changed weekly and labeled, but it was not. Another resident, also diagnosed with SOB, had a physician order to administer O2 at 2 LPM via nasal cannula every shift and to change the O2 tubing weekly on Wednesdays with a date label. The resident was observed receiving O2 at 1.5 LPM instead of the ordered 2 LPM, and the O2 tubing was not labeled. The LPN verified the incorrect O2 setting and acknowledged that there was no indication of when the O2 tubing was last changed, stating it should have been labeled.
Failure to Conduct Required Dialysis Assessments
Penalty
Summary
The facility failed to complete ongoing assessments for a resident requiring dialysis services, as outlined in their Dialysis Care/Arterial-Venous Fistula policy. This policy mandates that all residents receiving dialysis must be monitored before and after their treatment to ensure stability, with evaluations conducted by the Charge Nurse. The resident in question was admitted with diagnoses including dependence on renal dialysis and end-stage renal disease, with physician orders specifying monitoring for complications and completion of pre and post-dialysis progress notes. However, documentation was missing for several dates in May 2024, indicating that pre-dialysis assessments were not conducted on five occasions, and post-dialysis assessments were not conducted on two occasions. The Director of Nursing confirmed that these assessments were required but not completed on the specified dates.
Infection Control Deficiencies in PPE Usage and Sanitization
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols for residents on transmission-based and enhanced barrier precautions. Resident #93, diagnosed with MRSA bacteremia and osteomyelitis, was under contact precautions. However, staff members, including an LPN and a CMA, were observed entering the resident's room without wearing the required personal protective equipment (PPE) such as gowns and gloves. Additionally, the CMA did not sanitize the blood pressure cuff after use, nor did they wash or sanitize their hands, despite clear signage indicating the need for such precautions. Resident #56, who had a gastrostomy and was on enhanced barrier precautions, also did not receive care in accordance with the facility's policies. Two CNAs provided care without wearing the necessary PPE, such as gowns and gloves, even though they were aware of the resident's precautionary status. Furthermore, during incontinent care for Resident #52, a CNA failed to change gloves after providing care and before touching other items in the resident's environment, such as a cup and a light cord, which compromised infection control practices.
Failure to Provide Ordered Double Portions for Resident
Penalty
Summary
The facility failed to provide double portions as ordered for a resident during meal service. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, hemiplegia, and hemiparesis following a cerebral infarction affecting the right dominant side, had a physician's order dated 10/13/23 for a low concentrated sweets (LCS) diet with mechanical soft texture, regular consistency, and double portions for heart health. On 06/02/24 at 12:07 p.m., the resident was observed receiving a meal tray with single portions instead of the ordered double portions. A Certified Nursing Assistant (CNA) confirmed at 12:12 p.m. that the tray did not contain double portions and stated they had not noticed the double portion requirement on the meal ticket.
Failure to Label Enteral Tube Feeding Bottles
Penalty
Summary
The facility failed to ensure proper labeling of an enteral tube feeding bottle for a resident with dysphagia and oropharyngeal phase gastrostomy status. The resident had a physician order for Vital AF 1.2 Cal to be administered at 55 ml/hr via PEG-tube every shift, along with an order for enteral H2O to auto flush the PEG-tube with 23 cc of H2O every hour. During an observation, it was noted that the resident was receiving 55 ml/hr of Vital AF 1.5 Cal via PEG-tube, but the formula bottle and H2O bag were not labeled with staff initials, date, or time as required by the facility's policy. An LPN confirmed that the protocol was not followed, as the tube feeding was not labeled.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician for a resident with respiratory care needs. The resident had diagnoses including congestion and allergic rhinitis, and was prescribed loratadine and guaifenesin. The physician ordered loratadine to be given as needed and guaifenesin to be administered every 12 hours for seven days. However, the Medication Administration Records (MARs) showed that guaifenesin was administered only 12 out of 14 times. Additionally, there was no documentation that loratadine had been administered to the resident. The resident reported having a respiratory infection and sinus drainage over a holiday weekend, during which they were unable to take their prescribed medication. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware of the discrepancies in medication administration. It was revealed that guaifenesin was a house stock medication and should have been available, while loratadine was delayed in delivery from the pharmacy. The ADON confirmed that loratadine was delivered late at night, and there was a lack of communication among nursing staff regarding the medication's status during shift changes.
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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 Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Ignite Medical Resort Okc, Llc | 0.1 mi | ★★★★★ | 9 | 0 |
| Northwest Nursing Center | 1.2 mi | ★★★★★ | 0 | 0 |
| The Lodge At Brookline | 1.3 mi | ★★★★★ | 0 | 0 |
| North Winds Living Center | 2 mi | ★★★★★ | 0 | 0 |
| Warr Acres Nursing Center | 2 mi | ★★★★★ | 0 | 0 |
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