Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Brentwood Extended Care & Rehab during CMS and state inspections, most recent first.
The facility did not submit required PBJ staffing data to CMS for a full quarter when 55 residents were present, due to the departure of the employee responsible for the submission and the lack of another staff member able to complete the task.
A facility administrator, who was new and untrained in abuse investigation procedures, failed to properly investigate an allegation of physical abuse involving a resident with intact cognition. The administrator did not conduct required interviews, failed to restrict the accused staff member's contact with the resident, and did not notify authorities within mandated timeframes, resulting in a deficient investigation.
A resident with intact cognition reported being slapped by a staff member, but the facility did not notify OSDH within the required timeframe and failed to contact law enforcement. The administrator stated these actions were not taken due to lack of training and awareness of reporting requirements.
A resident with intact cognition reported being slapped by a staff member, but the facility did not conduct timely interviews with staff or other residents as part of its abuse investigation. The administrator, who was new and untrained in the process at the time, acknowledged the investigation was incomplete.
A resident who was severely cognitively impaired and dependent on staff for bathing did not receive scheduled baths as required by facility policy. Over a three-month period, only six baths were documented, with multiple scheduled bath days lacking any record of completion or refusal. Staff interviews confirmed that all baths and refusals should be documented, but no additional records could be found to verify care was provided.
A facility failed to notify the legal representatives of three residents about inappropriate sexual behavior involving a resident with PVD and hypertension. Incident reports documented the behavior, but clinical records lacked family notification. The facility's policy required family notification, but an LPN did not find it necessary.
A resident with a history of CVA and PVD, dependent on staff for transfers, reported being handled roughly by staff, resulting in a red area and pain in the right upper arm. The resident also reported verbal abuse. An investigation revealed improper use of a mechanical lift by a CNA, leading to significant bruising. The CNA was terminated, and another was suspended.
A facility failed to submit the results of an abuse investigation to the SSA within the required timeframe. A resident with PVD and Diabetes Mellitus type two was reported for inappropriate behavior, and while an initial report was made, the final results were not submitted. The administrator admitted the oversight, believing the DON had completed the task.
The facility failed to assess two residents after an allegation of inappropriate sexual behavior by a resident. Despite the facility's policy requiring assessments, there was no documentation in the clinical records of the affected residents, who had conditions such as anxiety, depression, and dementia. Staff interviews confirmed the lack of assessments.
An IJ situation was identified due to the facility's failure to protect residents from falls resulting in major injuries. One resident fell twice, resulting in a broken neck, and another resident fell twice, resulting in a broken back. The facility did not document or implement required fall prevention interventions.
The facility failed to maintain a safe and clean environment, with issues including missing and cracked tiles, unrepaired damage in a resident's room, and leaking washing machines in the laundry room. Maintenance staff were unaware of these issues due to a lack of logged maintenance requests.
The facility failed to ensure that quarterly resident assessments were completed within 14 days of the assessment reference date for two residents. One resident's assessment was delayed by nearly a month, and another's by over a month. The administrator confirmed the assessments should have been timely but could not explain the delays.
The facility failed to document mental health diagnoses in the PASARR for two residents with major depressive disorder, anxiety, and delusional disorders. The administrator confirmed that these diagnoses should have been documented and OHCA notified.
The facility failed to ensure that baths were given as scheduled for two residents and that assistance with eating was provided for one resident. One resident did not receive documented showers for nearly a month, and another resident went one to two weeks without a shower. Additionally, a resident with hemiplegia and hemiparesis was observed eating with their hands in a dark dining room without staff assistance or supervision.
A resident with COPD and chronic pain did not receive prescribed pain medication and nebulizer treatments due to a mix-up in medication delivery and lack of coordination with hospice. Staff confirmed the absence of necessary medications, and the resident reported missing treatments since admission.
A resident with chronic pain and opioid dependence did not receive their prescribed pain medication for five doses due to a delay in receiving the medication from the pharmacy. The resident experienced severe pain and was unable to perform usual activities. The facility's policy to reorder medication in advance was not followed.
The facility failed to administer insulin and blood pressure medication per physician's orders for two residents, leading to significant medication errors. One resident received insulin despite low blood sugar levels, and another was prepared to receive Metoprolol despite a low diastolic blood pressure reading. Staff admitted to not following prescribed guidelines.
The facility failed to ensure proper infection control measures, including disinfecting a blood pressure machine between residents, preventing soiled linens from being placed on the floor, and correctly storing a nebulizer mouthpiece. Additionally, the facility lacked an infection surveillance system and a water Legionella prevention program.
The facility failed to implement a system to assess residents for infections using standardized tools before initiating antibiotics. Despite having a policy and new assessment forms, the facility had not tracked antibiotic use since December 2023, and it was unclear if the tools were used for residents administered antibiotics in early 2024.
The facility failed to provide a SNF ABN to a resident who was discharged from skilled services but remained in the facility. The MDS Coordinator confirmed that the resident was not given the required ABN form.
The facility failed to complete a significant change resident assessment within the required 14-day timeframe. The assessment, dated October 19, 2023, was not signed until November 9, 2023. The administrator acknowledged the delay but could not provide an explanation.
The facility failed to ensure accurate resident assessments for two residents. One resident was incorrectly documented as being on an anti-coagulant instead of an anti-platelet medication. Another resident was inaccurately documented as requiring restraints despite assessments indicating otherwise.
The facility failed to refer a resident with new mental health diagnoses to OHCA for a PASRR level II evaluation. The resident had a history of traumatic brain injury and was later diagnosed with a mood disorder and major depressive disorder with psychotic symptoms. The facility did not notify OHCA as required.
A facility failed to document hospice services and pain management interventions in a baseline care plan for a resident with chronic pain. The resident did not receive pain medication due to a delivery error, and the administrator confirmed the oversight.
The facility failed to assist a resident with limited range of motion in wearing their splint. The resident, with left-sided hemiplegia and contractures, reported that staff did not help with exercises or applying the splint, which had not been worn for about two months. Observations and interviews confirmed the lack of assistance, despite the resident's desire to wear the splint to prevent further contracture.
The facility failed to have physician orders for maintaining an indwelling urinary catheter for a resident admitted with urinary retention and kidney calculus. The facility's policy required a physician's order for catheter and bag changes at 30-day intervals, but no such order was present, and the catheter had been in place for over 30 days. The administrator confirmed the oversight.
The facility failed to follow the physician's orders for oxygen therapy for a resident with acute respiratory failure and tracheostomy. The resident's oxygen was consistently set at 2.5 liters per minute instead of the prescribed 3.5 liters per minute, and an LPN was unaware of the correct setting.
The facility failed to document and retain the required staffing information. White boards at each nursing station displayed the facility name, date, census, and staff titles, but did not include staffing hours worked. The administrator was unaware of the requirements and identified 49 residents in the facility.
A resident with ESRD was prescribed Eliquis with an incorrect diagnosis of hypertension. Despite a pharmacy review and physician concurrence, the diagnosis was not updated. The administrator confirmed the medication was for preventative use due to a dialysis fistula.
The facility failed to maintain a functional microwave for heating resident food after hours. A resident reported the issue, and dietary staff confirmed the lack of a working microwave. An attempt to replace it with a dirty, unusable microwave was made, which the administrator acknowledged should not be used.
A facility failed to provide a call light in the room of a resident with mobility issues, despite the facility's policy requiring every resident to have a functioning bedside call light. The resident confirmed the absence of the call light since moving into the room, and the administrator acknowledged the oversight.
Failure to Submit PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required Payroll-Based Journal (PBJ) staffing data to CMS for the second quarter of fiscal year 2025. Record review showed that no staffing data was provided for the period from January 1, 2025, through March 31, 2025, despite 55 residents residing in the facility during that time. During an interview, the office manager explained that the employee responsible for submitting the PBJ data was no longer employed at the facility, and at the time, there was no one available who could complete the submission.
Administrator Lacked Training, Leading to Inadequate Abuse Investigation
Penalty
Summary
The facility failed to ensure that the administrator was knowledgeable about and followed the facility's abuse policy, resulting in a substandard investigation of an abuse allegation involving one resident. The facility's policy required staff to be informed about abuse prevention, intervention, detection, and reporting requirements. A quarterly MDS assessment indicated that the resident involved had intact cognition at the time of the incident. An incident form documented an allegation of physical abuse, but the investigation records provided by the administrator did not include interviews with staff or other residents regarding the alleged abuse. During interviews, the administrator confirmed that they were responsible for conducting abuse investigations but admitted to being unaware of all investigation requirements at the time, as they were new to the organization and had not received training. The administrator did not conduct interviews with staff or residents, did not suspend or otherwise restrict the accused staff member from contact with the resident during the investigation, and failed to notify the state health department and local law enforcement within the required timeframes. These omissions resulted in a deficient response to the abuse allegation.
Failure to Timely Report Alleged Abuse and Notify Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse by a staff member against a resident to the Oklahoma State Department of Health (OSDH) within the mandated timeframe and did not notify local law enforcement as required. According to the facility's policy, any suspected abuse, neglect, or exploitation must be reported to OSDH and other relevant agencies. Documentation showed that the incident involving the resident was reported to OSDH the day after the allegation was made, as evidenced by the fax receipt. The incident form also lacked documentation indicating that law enforcement had been contacted regarding the allegation. The resident involved had an intact cognitive status, as indicated by a recent BIMS score of 15. During an interview, the administrator acknowledged that the abuse allegation was not reported to OSDH within the required two-hour window and that law enforcement was not contacted. The administrator attributed these failures to a lack of training and awareness of the reporting requirements at the time of the incident.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of physical abuse involving one resident. According to the facility's policy, all allegations of abuse, neglect, and mistreatment are to be investigated in a timely and objective manner. Documentation showed that a resident with intact cognition reported to the activities director that a staff member had slapped them. The incident was reported to the state health department, but the facility's investigation records did not include interviews with staff or other residents regarding the alleged abuse at the time it was reported. Further review revealed that the investigation materials provided by the administrator only included interviews conducted much later, and not around the time of the incident. The administrator acknowledged that, at the time of the investigation, they were new to the organization and had not received training on the abuse investigation process. As a result, the investigation did not include essential steps such as interviewing relevant staff and residents or addressing concerns about the alleged perpetrator.
Failure to Provide Scheduled Bathing and Documentation for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for bathing received baths as scheduled. According to facility policy, residents are to be bathed three times weekly and as needed, with refusals documented in the electronic medical record and on a refusal form signed by the resident, CNA, and charge nurse. Review of the resident's records over a three-month period showed that the resident received only six documented baths, with multiple scheduled bath days lacking any documentation of completion or refusal. The resident, who was severely cognitively impaired with a BIMS score of 99 and dependent on staff for bathing, reported not having received a bath in a while and was unsure of the scheduled days. Interviews with the DON and CNA confirmed that all completed baths should be documented and refusals recorded with appropriate forms. However, no additional bath sheets or refusal forms could be located for the resident, and the DON acknowledged there was no way to prove the resident was bathed more than six times in the last three months. The lack of documentation and missed scheduled baths constituted a failure to provide care and assistance with activities of daily living as required by facility policy.
Failure to Notify Families of Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to notify the legal representatives of three residents about inappropriate sexual behavior involving a resident with diagnoses of peripheral vascular disease (PVD) and essential hypertension. An incident report dated 12/01/24 documented that this resident was sexually inappropriate with two female residents, who had diagnoses including anxiety disorder, depression, dementia, and major depression disorder. The clinical health records for these residents did not contain documentation of family notification regarding the inappropriate behavior. The facility's policy required the charge nurse to complete an incident report and notify the physician and family, but this was not adhered to. The administrator acknowledged that the LPN did not feel it was necessary to notify the families.
Resident Abuse Due to Improper Handling by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a resident who reported being handled roughly by staff during assistance in bed. The resident, who had a history of cerebrovascular accident and peripheral vascular disease, was dependent on staff for transfers and had intact cognition. The resident reported that staff told them they were going to die in the facility, and a red area was noted on the resident's right upper arm, with the resident experiencing pain rated at 6 out of 10. This incident was documented in an Initial Incident Report, and staff were suspended pending investigation. Further investigation revealed that a CNA used a mechanical lift improperly, causing harm to the resident's right upper arm. The resident, who was alert and oriented, reported that the CNA purposefully put the straps on wrong, resulting in significant bruising. The CNA involved was terminated, and another CNA was suspended and educated on reporting suspected abuse. The administrator acknowledged the lack of formal Quality Assurance involvement in the incident, although steps were discussed to prevent further occurrences.
Failure to Submit Abuse Investigation Results Timely
Penalty
Summary
The facility failed to ensure the results of an abuse investigation were submitted to the State Survey Agency (SSA) within five business days for a resident involved in an abuse allegation. The incident involved a resident with diagnoses including Peripheral Vascular Disease (PVD) and Diabetes Mellitus type two, who was reported to have been sexually inappropriate with multiple female residents. An initial report was faxed to the state on December 1st, documenting the allegation and the immediate action of placing the resident under one-on-one supervision during the investigation. However, there was no documentation that the final results of the investigation were submitted to the SSA. The facility's administrator acknowledged the oversight, stating that they believed the Director of Nursing (DON) had completed the final report, but it was not done.
Failure to Assess Residents After Allegation of Sexual Misconduct
Penalty
Summary
The facility failed to assess two residents after an allegation of inappropriate sexual behavior. The facility's policy on managing suspected abuse/neglect requires a complete assessment of both residents involved, to be conducted by the charge nurse. An incident report documented an allegation of sexual misconduct by a resident towards multiple female residents. However, there was no documentation in the clinical records of the two affected residents, who had diagnoses including anxiety disorder, depression, dementia, and major depression disorder, being assessed following the allegation. Interviews with facility staff confirmed the absence of assessments in the clinical records, indicating that the assessments were not conducted.
Failure to Prevent Falls Resulting in Major Injuries
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified due to the facility's failure to protect residents from falls resulting in major injuries. One resident had a non-injury fall on 04/11/24, but hourly checks were not documented as completed. This resident subsequently fell again on 04/14/24, resulting in a broken neck. Additionally, on 05/17/24, the resident's call light was found unplugged and placed on top of a dresser, out of reach. Another resident experienced a fall with minor injury on 04/20/24, but no interventions were developed following the fall. This resident fell again on 04/23/24, resulting in a broken back. The intervention to move the resident closer to the nurse's station was not implemented due to room availability, and no new interventions were put in place. The facility's fall policy required nurses to complete an incident report and initiate fall interventions for fall prevention. However, the records showed that these steps were not followed. For the first resident, the hourly checks were not documented, and the call light was not kept within reach, as required by the care plan. For the second resident, there was no incident report or updated care plan following the initial fall, and the intervention to move the resident closer to the nurse's station was not documented or implemented. The deficiencies were confirmed through observations, record reviews, and interviews with staff. The Director of Nursing (DON) identified that 51 residents resided in the facility. The facility's failure to develop and implement appropriate fall prevention interventions led to significant injuries for the two residents involved. The Oklahoma State Department of Health was notified, and the IJ situation was verified and communicated to the facility's administrator.
Removal Plan
- Placing all residents on checks relating to prevention of falls it will be documented on TAR's
- Call light for Res #1 has been secured so it cannot be unplugged.
- Resident #2 have relocated her room across from nurse station.
- All staff has been in-serviced on new policy and procedure for fall prevention and falls.
- All nurses have been in-serviced on development and implementation of fall interventions and updated fall procedure.
- Every resident will have a new Fall Risk Assessment completed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents. Observations revealed multiple issues with the flooring, including missing and cracked tiles in the dining room, hall entrance, common area, and resident halls, creating uneven surfaces that posed a trip hazard. Maintenance staff acknowledged the problem, noting that the tiles had been in disrepair for two to three months, but no maintenance requests had been logged. Additionally, a resident's room was found to have missing sheetrock, broken window blinds, and torn wheelchair armrests, none of which had been reported for repair. Maintenance staff confirmed they were unaware of these issues, as no maintenance requests had been submitted by the staff responsible for logging such concerns. Further deficiencies were noted in the laundry room, where two washing machines were leaking, and the area behind the machines was not cleaned. The washers had been leaking for an extended period, with one reported to have been leaking for at least a year. The drywall behind the washers was damaged, and the area was dusty and cluttered with laundry detergents and other items stored directly on the floor. Missing tiles were also observed in front of and between the washers and dryers. These conditions indicate a failure to maintain the facility in good repair and free from hazards, as required by the facility's maintenance policies.
Failure to Complete Quarterly Resident Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly resident assessments were completed within 14 days of the assessment reference date for two residents. One resident's quarterly assessment, dated October 12, 2023, was not completed and signed until November 9, 2023. Another resident's quarterly assessment, dated October 22, 2023, was not completed and signed until November 28, 2023. The administrator confirmed that the assessments should have been completed and signed within 14 days and could not provide an explanation for the delay.
Failure to Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to ensure the PASARR for two residents with mental health diagnoses was filled out correctly and referred to the OHCA. Resident #18, admitted with major depressive disorder and anxiety, had a PASARR Level I dated 03/04/20 that did not document the mental health diagnosis. Similarly, Resident #41, admitted with delusional disorders and major depressive disorder, had a PASARR Level I dated 06/14/21 that also did not document the mental health diagnosis. The administrator confirmed that the mental health diagnoses should have been documented and OHCA should have been notified.
Failure to Provide Scheduled Baths and Assistance with Eating
Penalty
Summary
The facility failed to ensure that baths were given as scheduled for two residents and that assistance with eating was provided for one resident. Resident #15, who had diagnoses including chronic obstructive pulmonary disease, neuropathy, and rheumatoid arthritis, was supposed to receive showers on Mondays and Thursdays. However, there was no documentation that Resident #15 received a shower from March 1 to March 22, 2024. The resident complained about not receiving a shower for the entire month and reported going three to four weeks without a shower before. The MDS Coordinator and the administrator confirmed that Resident #15 frequently refused baths, but these refusals were not documented, and no alternative days or times were offered to make up for missed showers. Similarly, Resident #16, who had diagnoses including Parkinson's disease, neuralgia, and pain, was supposed to receive showers on Tuesdays and Fridays. There was no documentation that Resident #16 received a shower from March 1 to March 22, 2024. The resident reported not receiving showers on scheduled days and going one to two weeks without a shower. The administrator confirmed that refusals were not documented and no alternative days or times were offered for missed showers. Additionally, the facility failed to provide assistance with eating for Resident #18, who had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease. An assessment documented that Resident #18 had moderately impaired cognition, limited range of motion, and required supervision or touching assistance for eating. On March 20, 2024, Resident #18 was observed eating their meal with their hands in a dark dining room without any staff assistance or supervision. Staff members walked through the dining room but did not turn on the lights or encourage the resident to use utensils. The administrator eventually found a staff member to move the resident to a lighted area, but the resident continued to eat with their hands until a CNA arrived and assisted another resident. The administrator acknowledged that staff had not provided the necessary supervision during lunch on that day.
Failure to Coordinate Care with Hospice and Ensure Medication Availability
Penalty
Summary
The facility failed to ensure care was coordinated with hospice to ensure a resident's medications were available for administration. The resident, who had diagnoses including COPD and chronic pain, was admitted to the facility with orders for Albuterol Sulfate Inhalation Nebulization Solution and oxycodone-acetaminophen oral tablets. However, the resident did not receive their pain medication or nebulizer treatments as prescribed. The pain medication was delivered to the wrong facility, and the nebulizer medication was not available in the building. Staff members, including a CMA and LPN, confirmed the medication mix-up and the lack of administration of the prescribed treatments. The hospice nurse stated that they were notified about the missing medications after the resident had already missed several doses. The facility's policies required reordering medications in advance and coordinating care with hospice, but these protocols were not followed. The resident reported not receiving any nebulizer treatments since admission, and staff confirmed the absence of the necessary medications. This lack of coordination and failure to ensure medication availability led to the resident not receiving essential treatments for their conditions.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that pain medication was administered as ordered for a resident with chronic pain and opioid dependence. The resident was admitted with six oxycodone/acetaminophen tablets and had a physician's order to receive the medication every four hours. However, the resident's clinical record did not contain a pain assessment, and the baseline care plan did not document interventions for chronic pain. The resident missed five doses of their pain medication due to a delay in receiving the medication from the pharmacy, which was sent to the wrong nursing home. The resident reported severe pain and was unable to perform usual activities due to the lack of pain management. The Director of Nursing (DON) acknowledged the delay and stated that the pain medication was on the way. The hospice nurse confirmed that they were notified about the medication shortage the previous day. The resident finally received their pain medication after a significant delay, which caused them considerable discomfort. The facility's policy required reordering medication four days in advance, but this was not followed, leading to the deficiency in pain management for the resident.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure insulin and blood pressure medication were administered per physician's orders for two residents. Resident #31, who had diagnoses including hypertension and diabetes, received insulin Detemir on multiple occasions despite their blood sugar being below the threshold of 100, as specified in the physician's order. Additionally, Metoprolol ER was incorrectly held for this resident when their vital signs did not meet the criteria for withholding the medication. The errors were acknowledged by the staff involved, who admitted to not following the prescribed guidelines and making mistakes in medication administration. Resident #46, diagnosed with hypertension, was also subject to medication administration errors. The resident's blood pressure was recorded with a diastolic reading below the threshold specified in the physician's order for holding Metoprolol Tartrate. Despite this, the medication was prepared for administration. The CMA involved admitted to not reading the blood pressure parameters on the medication label due to nervousness and failing to see the hold directions in the computer. These actions led to significant medication errors, compromising the residents' safety and well-being.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by multiple deficiencies observed during the survey. A blood pressure machine was not disinfected between residents, leading to potential cross-contamination. Specifically, a CMA used the same wrist blood pressure monitoring device on three residents without disinfecting it before or after each use. The CMA admitted to only cleaning the device a couple of times a day and was unaware of the need to disinfect it between each resident. Additionally, soiled linens were found on the floor in a resident's room, and the CNA responsible acknowledged that they did not bring a big enough bag for the linens and were aware that placing soiled linens on the floor was against protocol. Furthermore, a nebulizer mouthpiece was improperly stored on top of the nebulizer machine instead of in a bag, as confirmed by an LPN who stated it should have been stored correctly to prevent cross-contamination. The facility also lacked a comprehensive infection surveillance system, as evidenced by the absence of infection tracking and trending since December 2023. The administrator confirmed that infections had not been tracked, and the IP admitted that although three residents had clostridium difficile infections in March, there was no documentation of monitoring staff for proper PPE use and handwashing. Additionally, the facility did not have a water Legionella prevention program in place, and the maintenance personnel were unaware of any such program. The administrator confirmed the lack of documentation related to the facility's water system management for Legionella prevention.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to have a system in place to assess residents for infections using standardized tools and criteria for the initiation of antibiotics. The facility's undated policy indicated that nurses should perform and document a comprehensive assessment using established protocols when an infection is suspected. However, the facility had not tracked antibiotic use since December 2023. An undated document titled 'Attention All Nurses' introduced new assessment forms for various infections, but it was unclear if these tools were utilized before initiating antibiotics. The Infection Preventionist (IP) confirmed that they could not determine if assessment tools were used prior to antibiotic administration for 13 residents in January 2024, 12 residents in February 2024, and 15 residents in March 2024.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to one of three sampled residents whose beneficiary notices were reviewed. Resident #23 was admitted to skilled services on January 18, 2024, and discharged from skilled services on February 21, 2024, but remained in the facility. A review documented that an ABN was not provided to the resident. On March 20, 2024, the MDS Coordinator confirmed that Resident #23 was not given an ABN form.
Failure to Complete Timely Significant Change Assessment
Penalty
Summary
The facility failed to ensure a significant change resident assessment was completed within 14 days of the assessment reference date for one of four sampled residents whose assessments were reviewed. The facility's Resident Assessment Instrument policy, revised in October 2010, mandates timely resident assessments when there is a significant change in the resident's condition. However, the significant change assessment for a resident, dated October 19, 2023, was not completed and signed until November 9, 2023. The administrator acknowledged that the assessment should have been signed within 14 days but could not explain the delay.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents. One resident with congestive heart failure was incorrectly documented as being on an anti-coagulant instead of an anti-platelet medication in two quarterly assessments. The administrator and MDS Coordinator were unaware of the correct classification of aspirin. Another resident with type 2 diabetes mellitus, recurrent depressive disorders, and chronic viral hepatitis C was inaccurately documented as requiring restraints in an MDS re-admission assessment, despite a side rail assessment indicating no need for bedrails and the administrator confirming the resident never required restraints.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis to the Oklahoma Health Care Authority (OHCA) for a Pre-Admission Screening and Resident Review (PASRR) level II evaluation. The resident, who was admitted with a diagnosis of diffuse traumatic brain injury with loss of consciousness of unspecified duration, was later diagnosed with a mood disorder due to a known physiological condition and major depressive disorder, recurrent, severe with psychotic symptoms. Despite these new diagnoses, the facility did not notify OHCA as required. This deficiency was identified during a record review and interview, with the administrator acknowledging the oversight.
Failure to Document Hospice Services and Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan included hospice services and interventions for pain management for a resident who was on hospice. The resident was admitted with diagnoses including chronic pain and was on hospice prior to admission. The baseline care plan did not document the resident's hospice status or interventions for pain management. The resident reported not receiving pain medication since the previous day due to a delivery error. The administrator confirmed that pain interventions and hospice services should have been documented in the baseline care plan.
Failure to Assist Resident with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion was offered assistance with splints. The resident, who had cerebrovascular disease with left-sided hemiplegia and contractures, reported that staff did not assist them with exercises for their arms or hands. Observations confirmed that the resident's left hand was closed, and they were unable to open it without a splint. The resident stated that they had not worn the splint for about two months and that staff had not offered to help them apply it recently. Further interviews revealed that the restorative aide was unsure when they last performed range of motion exercises for the resident, as they were working as a CNA. The occupational therapist (OT) mentioned that the range of motion exercises might have been turned over to the nurse aides and confirmed that the resident's hand was very tight. The OT was observed applying the splint, which was found in the resident's drawer. Despite the resident expressing a desire to wear the splint to prevent further contracture, staff did not offer assistance with the splint on the morning of the observation.
Lack of Physician Orders for Indwelling Urinary Catheter Maintenance
Penalty
Summary
The facility failed to have physician orders for maintaining an indwelling urinary catheter for one resident who was admitted with an indwelling urinary catheter and diagnoses including urinary retention and calculus of kidney and ureter. The facility's policy required a physician's order for the catheter and bag to be changed at 30-day intervals, but no such order was present. The resident's nursing notes did not document any catheter and drainage bag changes, and the indwelling urinary catheter had been in place for over 30 days. The administrator confirmed that the catheter and bag should have been changed and that there should have been a physician's order for the change at least monthly and as needed.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow the physician's orders for oxygen therapy for a resident diagnosed with acute respiratory failure and tracheostomy. The physician's order, dated 04/15/23, specified that the resident should receive oxygen at 3.5 liters per minute via nasal cannula or trach mask, with pulse oximetry checks every shift and adjustments to maintain oxygen saturation above 92%. However, observations on multiple dates revealed that the resident's oxygen was set at 2.5 liters per minute, contrary to the prescribed 3.5 liters per minute. Additionally, an LPN was unaware of the correct oxygen setting and had to refer to the orders to verify it.
Failure to Document and Retain Required Staffing Information
Penalty
Summary
The facility failed to document and retain the required staffing information. During the survey, it was observed that the facility had two white boards at each nursing station with the facility name, date, census, and staff titles documented. However, the staffing hours worked were not documented. The administrator, who was unaware of the requirements regarding posted staffing information and the need to keep staffing information for at least 18 months, identified 49 residents residing in the facility.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, a resident with a diagnosis of end-stage renal disease (ESRD) was prescribed Eliquis, a blood thinner, with an incorrect diagnosis of hypertension secondary to other renal disorder. A pharmacy review suggested clarification of the Eliquis diagnosis, noting that it is not used for hypertension. The physician concurred with the pharmacy's recommendation but did not change the diagnosis. The administrator confirmed that the Eliquis was not prescribed for hypertension and should have been updated to reflect its use as a preventative medication due to the resident having a fistula for dialysis.
Failure to Maintain Functional Microwave for Resident Food Heating
Penalty
Summary
The facility failed to ensure the microwave used to heat up resident food after hours was in good repair. A resident reported that they were not allowed to have a microwave in their room and that the staff microwave was broken, resulting in their food not being heated the previous night. Dietary staff confirmed the lack of a working microwave and the inability to heat resident food after hours. An attempt to replace the microwave with one from the maintenance building revealed that the replacement was discolored, stained, and could not be cleaned properly. The administrator acknowledged that the replacement microwave should not be used for heating resident food.
Failure to Provide Call Light in Resident's Room
Penalty
Summary
The facility failed to provide a call activation button in the room of a resident who was admitted with diagnoses of acquired absence of the right leg above the knee and unspecified abnormalities of gait and mobility. During an observation, it was noted that the resident's room did not have a call light, and the resident confirmed that they had not had one since moving into the room. The facility's policy requires that every resident should have a functioning bedside call light, which was not adhered to in this case. The administrator acknowledged that every resident should have a call light regardless of room changes.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — including the 1 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Muskogee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Skilled Nursing And Therapy | 1.5 mi | ★★★★★ | 16 | 0 |
| Muskogee Nursing Center | 3.3 mi | ★★★★★ | 1 | 1 |
| Broadway Care & Rehab Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Pleasant Valley Health Care Center | 4 mi | ★★★★★ | 0 | 0 |
| York Manor Nursing Home | 4.2 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.