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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Boyce Manor Nursing Home during CMS and state inspections, most recent first.
A resident with a history of psychiatric disorders repeatedly engaged in verbal and physical abuse toward other residents, including threats and assaults, while staff failed to implement new or effective interventions after each incident. The care plan was not updated with new strategies, and another resident expressed ongoing fear and distress as a result of the abuse.
A resident with multiple psychiatric diagnoses was involved in several aggressive incidents, including physical altercations with other residents. Despite these repeated episodes, the care plan was not updated with new interventions, and previously implemented strategies were simply relisted without modification.
The facility failed to bathe two residents according to physician orders, resulting in missed bathing opportunities. One resident, with schizophrenia and thoracic spine pain, missed three out of four showers, with no documentation of showers or refusals. Another resident, needing assistance with personal care, reported not receiving a bath in two weeks, with records showing 12 missed opportunities. The MDS coordinator confirmed the lack of documentation.
The facility failed to ensure RN coverage for eight consecutive hours, seven days a week, as required. The PBJ Staffing Report and facility Time Detail Report documented multiple dates with insufficient RN coverage. The administrator confirmed the lack of documentation for RN coverage on these dates, affecting the care of 48 residents.
The facility did not complete quarterly MDS assessments on time for a resident. An annual assessment was done in November 2024, but no quarterly assessment followed. The MDS coordinator acknowledged the oversight.
The facility failed to accurately code MDS assessments for two residents. One resident with schizoaffective disorder was incorrectly documented as having weight loss, while another with end-stage renal disease was not coded for receiving dialysis, despite receiving it regularly. The MDS coordinator acknowledged these errors.
A facility failed to include a 14-day stop date for a PRN order of lorazepam, an antianxiety medication, prescribed to a resident with anxiety. The order allowed for administration every 12 hours as needed but lacked the required stop date, as confirmed by the corporate nurse consultant.
A resident with a history of alcohol abuse and aggressive behavior assaulted another resident, causing stab wounds. The facility failed to document and address the assailant's behavior in their care plan, leading to an Immediate Jeopardy situation. The victim, who had anxiety and paranoid schizophrenia, was attacked in their sleep, resulting in significant injuries.
The facility failed to report abuse allegations to OSDH within the required timeframe. A resident with schizophrenia was attacked by another resident, resulting in injuries, but the report was delayed. Another resident with alcohol abuse issues was involved in a verbal altercation while intoxicated, which was not reported. The DON admitted to not being aware of the reporting requirements for verbal allegations.
Failure to Prevent Resident-to-Resident Abuse and Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from abuse, specifically failing to prevent repeated resident-to-resident physical and verbal altercations involving a resident with a history of psychiatric diagnoses, including paranoid schizophrenia, mood disorder, post-traumatic stress disorder, and depression. This resident exhibited ongoing aggressive behaviors, including cussing, making threats to kill staff and other residents, and multiple incidents of physical violence such as kicking and hitting other residents. Despite these repeated incidents, the care plan interventions were not updated with new strategies after each event, and instead, previously implemented interventions were simply relisted. Staff interviews confirmed that the resident's aggressive behaviors were unpredictable and had been ongoing since admission. Documentation showed that after each incident, the resident was either placed on observation, sent for psychological evaluation, or returned from the hospital with no new orders. The care plan coordinator acknowledged that no new interventions were added after continued episodes of aggression, even though the resident continued to display both verbal and physical abusive behaviors. The resident's last psychiatric evaluation was several months prior, and there were no scheduled follow-up appointments, indicating a lack of ongoing psychiatric oversight for a resident with significant behavioral health needs. Another resident, who was the victim of one of the physical assaults, reported being verbally and physically abused by the aggressive resident. This resident, who was moderately cognitively impaired, expressed fear and distress following the incident, stating they were afraid of the aggressive resident and hoped they would not return. The care plan for this resident was updated to allow them to verbalize feelings and receive reassurance, but the primary deficiency remained the facility's failure to implement effective interventions to prevent further abuse and ensure resident safety.
Failure to Revise Care Plan After Repeated Aggressive Incidents
Penalty
Summary
The facility failed to review and revise the care plan for a resident with multiple psychiatric diagnoses, including paranoid schizophrenia, mood disorder, post-traumatic stress disorder, brief psychotic disorder, and depression. The resident was involved in multiple incidents of aggressive behavior and abuse toward other residents, as documented in incident reports dated 09/26/24, 10/26/24, and 01/10/25. These incidents included physical altercations such as kicking and hitting other residents, resulting in law enforcement involvement and transfers for psychological evaluation or inpatient treatment. Despite these repeated incidents, the care plan for the resident was not updated with new interventions following the most recent episode of aggression. Instead, the care plan relisted previously implemented interventions without introducing any new strategies to address the ongoing problem of agitation and aggressive behavior. The care plan coordinator confirmed that no new interventions were added after the latest incident, acknowledging that new interventions should have been implemented if the behaviors persisted.
Failure to Bathe Residents According to Physician Orders
Penalty
Summary
The facility failed to ensure that residents were bathed according to physician orders, resulting in a deficiency for two residents. Resident #3, who was admitted with diagnoses including schizophrenia, hypotension, and thoracic spine pain, had a physician's order for bathing twice weekly and as needed. However, the resident missed three out of four shower opportunities over a specified period, and the Assistant Director of Nursing (ADON) reported that showers or refusals were not documented, making it unclear if the resident received the required showers. Resident #29, admitted with diagnoses including the need for assistance with personal care and muscle wasting, also had a physician's order for bathing twice weekly and as needed. This resident reported not receiving a bath in two weeks, and their records showed no baths or showers were given for 12 out of 17 opportunities. The Minimum Data Set (MDS) coordinator confirmed the lack of documentation for showers or baths for this resident.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days a week, as required. This deficiency was identified through observation, record review, and interviews. The PBJ Staffing Report documented the absence of RN hours on several specific dates, including 08/17/24, 08/18/24, 09/01/24, 09/09/24, 09/14/24, 09/15/24, 09/28/24, and 09/29/24. Additionally, the facility's Time Detail Report showed a lack of RN coverage for eight consecutive hours on multiple dates from 08/31/24 to 01/17/25. The administrator confirmed the absence of further documentation to support RN coverage on these dates. The facility housed 48 residents at the time of the survey, as identified by the MDS coordinator.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments in a timely manner for one of the sixteen sampled residents. Specifically, the resident's record showed an annual assessment was conducted in November 2024, but no subsequent quarterly assessment was completed. The MDS coordinator confirmed that the assessments should have been completed, indicating a lapse in the facility's adherence to the required assessment schedule.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of MDS assessments for two residents. One resident, admitted with schizoaffective disorder, PTSD, and persistent mood disorder, was incorrectly documented as having weight loss in their annual assessment, despite records showing a weight gain of 1.69% over six months and 0.42% in one month. The MDS coordinator acknowledged the error. Another resident, admitted with end-stage renal disease and dependent on renal dialysis, was not coded for receiving dialysis in their admission assessment, even though they received dialysis three times a week both prior to and during their stay. The MDS coordinator confirmed the admission assessment was improperly coded.
Failure to Include 14-Day Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN orders for psychotropic medications. Specifically, a PRN order for lorazepam, an antianxiety medication, prescribed to a resident with a diagnosis of anxiety, did not include a required 14-day stop date. The order, dated June 27, 2024, instructed the administration of 1 mg of lorazepam by mouth every 12 hours as needed for anxiety, but lacked documentation of a stop date. This oversight was confirmed during an interview with the corporate nurse consultant, who acknowledged that the PRN order should have included a 14-day stop date.
Failure to Prevent Resident Assault Due to Inadequate Behavior Management
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an Immediate Jeopardy situation. A resident with a history of alcohol abuse and major depressive disorder assaulted another resident, causing stab wounds that required sutures. The assailant had a documented history of verbal outbursts and alcohol intoxication, which were not adequately addressed in their care plan. Despite previous incidents of intoxication and aggressive behavior, there was no documentation of incident reports or investigations, nor were interventions implemented to manage the resident's behavior. The assaulted resident, who had diagnoses including anxiety and paranoid schizophrenia, was cognitively intact and had not exhibited behaviors prior to the incident. The attack occurred when the assailant entered the victim's room while they were asleep, resulting in significant injuries. The facility's policies on abuse and resident conduct were not effectively enforced, as evidenced by the presence of alcohol and a weapon in the assailant's possession. The Director of Nursing acknowledged the facility's failure to report and investigate past incidents involving the assailant. The lack of documentation and intervention in the assailant's care plan contributed to the occurrence of the assault. The facility's inability to prevent the introduction of alcohol and weapons into the environment further compromised resident safety.
Failure to Timely Report Abuse Allegations
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. This deficiency involved two residents. The first resident, admitted with anxiety and paranoid schizophrenia, reported that another resident entered their room and attacked them with a weapon, resulting in visible injuries. The incident occurred around lunchtime, but the report was not submitted to OSDH until the following day, exceeding the two-hour reporting requirement. The second resident, admitted with alcohol abuse and major depressive disorder, was involved in an incident where they were found yelling and cussing in another resident's room. The resident smelled of alcohol, and an empty alcohol bottle was discovered nearby. Despite the altercation and the presence of alcohol, this incident was not reported to OSDH. The Director of Nursing (DON) acknowledged that the incident should have been reported, indicating a lack of awareness that verbal allegations also required reporting.
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 51 citations issued within 25 miles in the last 12 months — including the 10 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 Holdenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartway At Heritage Village Health And Rehab | 1.7 mi | ★★★★★ | 9 | 0 |
| Elmwood Manor Nursing Home | 8.2 mi | ★★★★★ | 6 | 2 |
| Wewoka Healthcare Center | 8.6 mi | — | 29 | 8 |
| Seminole Care And Rehabilitation Center | 20.4 mi | ★★★★★ | 0 | 0 |
| Seminole Pioneer Nursing Home | 20.6 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 July 2026) and official state health department websites.